What science says about perimenopause, menopause and mood swings — minus the hype

After decades of relative neglect, menopause is suddenly everywhere — in the news, on social media and in conversations among friends. Some are calling it the “meno-boom,” and booms attract business. The Canadian menopause wellness market — meaning the products, treatments and services designed and sold to help women manage symptoms before, during and after menopause — is projected to reach a revenue of US$784.9 million by 2030. But alongside the marketing are sensational claims and outright misinformation, including about how the menopausal transition affects mental health. That’s exactly what my research team has been studying for more than a decade. And as a woman now navigating perimenopause myself, I have a personal appreciation for why these conversations matter. I’m far from being in a minority: the Canadian Institutes of Health Research estimates that about 10 million people in Canada are currently navigating some stage of perimenopause, menopause or post-menopause transition. So let’s cut through the noise. Here’s what the evidence actually says about menopause and mental health. The Canadian menopause wellness market is projected to reach a revenue of US$784.9 million by 2030. (Unsplash) Before you know you’re in perimenopause The increased risk of depressive mood arises early in what researchers call the early menopause transition. This stage is marked by menstrual cycles that are consistently seven days shorter or longer relative to a woman’s usual cycle. Someone whose cycle used to average 30 days, for example, might start having 23- or 37-day cycles. So unless you’re tracking your cycle very closely, it can be easy to miss any connection between mid-life mood changes and perimenopause. It also doesn’t help that depressive symptoms have been shown to fluctuate considerably in perimenopause, making it a moving target. Not just about depression and mood swings Though a lot of research on the menopause transition has focused on depressed mood, there’s growing recognition that other psychological symptoms can show up too. For example, a recent study by our team, following perimenopausal women for three months, found that more than half struggled with moderate-to-severe anger and irritability. Weekly changes in sleep quality, hot flash severity, as well as hormones, predicted weekly changes in anger. Estrogen fluctuation in perimenopause has also been associated with greater sensitivity to interpersonal rejection, highlighting that psychological changes in the menopause transition can involve more than just feeling down. This fits with anecdotes from women that say they just “don’t feel like themselves.” Read more: Perimenopause usually begins in your 40s. How do you know if it has started? Hot flashes don’t explain everything Hot flashes are no fun, and they are extremely common in mid-life, with 60 to 80 per cent of women experiencing them in the years leading up to and following their last menstrual period. But as much as hot flashes may negatively impact quality of life, they don’t fully account for the increase in low mood that we see in perimenopause. For one thing, the timing doesn’t line up. Across the population, mood symptoms begin to increase well before hot flashes emerge. And by the time hot flashes reach their peak severity, depressive symptoms are already declining. At an individual level, this translates to many women experiencing depressive mood in the absence of hot flashes and many others experiencing hot flashes in the absence of mood changes. Hormone therapy isn’t a cure-all Menopausal hormone therapy is highly effective in treating hot flashes and night sweats. Vaginal estrogen cream is also a safe and effective treatment for vaginal dryness and sexual difficulties at any age. The benefits for cognitive difficulties (memory and thinking), sleep and low mood are less well-established. Multiple rigorous trials have confirmed that menopausal hormone therapy doesn’t prevent cognitive decline. And though it has been shown to improve sleep difficulties in women experiencing night sweats, evidence for its benefits in women without these symptoms is less conclusive. As for mood, the overall benefits of menopausal hormone therapy have been found to be quite modest, although some women may benefit more than others. Cognitive behavioural therapy and serotonin-based antidepressants remain the first-line treatments for depressive symptoms, including during perimenopause. Future research may help us better pinpoint who stands to benefit most from hormone therapy. In the meantime, it’s worth keeping both its proven benefits and the limits of the current evidence in view. Cognitive behavioural therapy and serotonin-based antidepressants are current first-line treatments for depressive symptoms during perimenopause. (Unsplash+) Not everyone struggles with the transition The increased attention paid to menopause and perimenopause is long overdue, and it stands to greatly improve mid-life care. Women should not have to suffer in silence or go untreated. But we should be mindful about how we discuss it. Women have long been dismissed as “hormonal” — meaning less logical, rational and level-headed than men. Careless narratives or conversations about menopause risk reinforcing that stereotype. Our research consistently finds enormous individual differences in how sensitive women are to the hormonal changes occurring in the menopause transition. For some, rapid shifts in hormone levels can trigger a host of negative mood symptoms. For others, the effects are negligible. Women experiencing difficult symptoms deserve recognition and effective treatment. But mid-life can also bring greater confidence, autonomy and opportunities for personal and professional growth. For some, menopause also means welcome freedom from menstruation and concerns about pregnancy. The “meno-boom” has brought perimenopause out of the shadows, and that’s worth celebrating. But attention isn’t the same as understanding. The research reveals that this period is more complicated (and more individual) than pop culture and business marketing can capture. Taking women’s mid-life mental health seriously means resisting easy answers.