In my first appointment with a new therapist this summer, she told me the highest rates of suicide in women occur during the perimenopausal years. Unfortunately, there is a paucity of research on perimenopausal women, despite this phase of a woman’s life lasting anywhere from 4 to 10 years and beginning as early as the late 30’s. This is even more shocking when considered with the statistics from recent studies showing that middle-aged-women are at increased risk of suicidal ideation and “deaths of despair” (drugs, alcohol, liver disease, suicide) during this perimenopausal transition (1), (2). Recent studies have also pointed to the exclusion of women from clinical trials and the gross underfunding of research into diseases and health issues predominantly affecting women (3), (4).
A study of 2,000 women in the UK states that 1 of 10 women in perimenopause experience suicidal thoughts. And a staggering 9 of 10 perimenopausal women experience mental health issues. This same research states that one-third of women do not seek help for these issues and another staggering 8 of 10 women don’t even discuss these difficulties with their partners (5). So many women are suffering in silence, largely due to a lack of cultural and scientific knowledge about this significant life experience that can impact a full quarter of a woman’s adult reproductive years.
Aside from suicidal ideation and depression, perimenopausal women also report increased anxiety, decreased self-esteem, isolation, irritability/hostility, paranoia, feelings of worthlessness, brain fog and anhedonia (6), (7). These symptoms have real impacts on women’s lives and the lives of those around them. Women have reported quitting their jobs in perimenopause due to brain fog, decreasing sense of capacity and reduced ability to deal with day-to-day pressures. It causes tension within marriages, in friendships, among families and has far-reaching impact into the wider culture.
Physiologically, perimenopause is marked in early stages by imbalances in estrogen and progesterone and in later stages by significantly lower levels of both hormones. In addition to its impacts on mental health, estrogen has profound impacts on many body systems including cardiovascular, musculoskeletal, urinary, reproductive and neurological. Specifically, estrogen is anti-inflammatory, maintains tissue integrity in the vagina and other mucus membranes, protects the heart and bones and plays many other crucial roles in maintaining health. Progesterone helps promote deep, restful sleep, can decrease body aches and pains and is also protective of cardiovascular function. Both hormones impact mood and mental health in profound ways.
While many traditionally trained doctors are keen to offer SSRIs and other anti-depressant, anti-anxiety medications, these are not always the best first line of defense with perimenopausal mental health symptoms. Fortunately, good options for treatment and education are becoming available in the wider market. Some options include bioidentical hormone replacement, lifestyle changes, acupuncture and herbal medicines that regulate and balance hormones.
Hormone replacement therapy was vilified due to one study in the 1990’s linking HRT with breast cancer and heart attacks. The Women’s Health Initiative was later found to be flawed, but damage was done to the public’s perception of HRT. Notably, the HRT being used at that time was synthetic HRT, which can absolutely be dangerous to women. Many more options for safe bioidentical HRT are available to women now, and there appears to be a sea change happening as perimenopause gets more time in the spotlight. One option is Winona (8), a company offering a simple online questionnaire that gives women access to a doctor and high-quality bHRT shipped to her home. Quicksilver Scientific also has a line of hormone products, as well as an accessible training program available to certified health practitioner (9).
Lifestyle changes in perimenopause involve prioritizing self-care and stress reduction, something many of us struggle with throughout our lives as we navigate the fast pace of the modern world. Better nutrition, sleep and rest, tools for regulating nervous system and working through unresolved trauma, psychotherapy; all can be extremely helpful. Acupuncture also has a long track record of supporting overall body function through various life transitions, including perimenopause. It does this by supporting liver function through both herbs and needling (10).
Some women believe that adding bHRT is a less natural way of managing the perimenopausal transition and opt for herbs. Herbs can be helpful to support the many changes occurring in a woman’s body at this time. As with any approach, it’s important to find someone well-versed in understanding hormonal shifts and patterns and how to target herbal therapies to the individual. Vitex, schisandra, and others can all be helpful in the early stages of perimenopause.
It’s important to shine light into the dark corner of perimenopause. The majority of women will have some symptoms, many of them severe, many unrecognized by conventional doctors and many of them lasting for years. It is time for us to stop suffering in silence and get access to the support and education we need to live full, healthy, empowered lives through all the transitions we navigate.
- Nakanishi, Miharu, Endo, Kaori, Yamasaki, Syudo, Stanyon, Daniel, Sullivan, Sarah, Yamaguchi, Satoshi, Ando, Shuntaro, Hiraiwa-Hasegawa, Mariko, Kasai, Kiyoto, Nishida, Atsushi, Miyashita, Mistsuhiro. Association between menopause and suicidal ideation in mothers of adolescents: A longitudinal study using data from a population-based cohort. Journal of Affective Disorders, 2023 (pages 529-534). https://www.sciencedirect.com/science/article/pii/S0165032723010340
- “Deaths of Despair and the Future of Capitalism”. Case, Anne and Deaton, Angus. Princeton University Press, 2020.
- Smith, Kerri. Women’s health research lacks funding – these charts show how. 2023. https://www.nature.com/immersive/d41586-023-01475-2/index.html
- Liu, Katherine A, Dipietro Mager, Natalie A. Women’s involvement in clinical trials: historical perspective and future implications. Pharmacy Practice, 2016. 14(1): 708. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4800017/
- O’Reilly, Kate, McDermid, Fiona, McInnes, Susan, Peters, Kath. “I was just a shell”: Mental health concerns for women in perimenopause and menopause. International Journal of Mental Health Nursing, 2023. https://onlinelibrary.wiley.com/doi/full/10.1111/inm.13271
- Kulkarni, Jayashri. Perimenopausal depression – an under-recognized entity. Australian Prescriber, 2018. 41)6): 183-185. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6299176/
- Lozza-Fiacco, Serena, Gordon, Jennifer Lee, Anderson, Elizabeth Helen, Kozik, Rachel Grace, Neely, Olivia, Schiller, Crystal, Munoz, Maria, Rubinow, David R, Girdler, Susan S. Baseline anxiety – sensitivity to estradiol fluctuations predicts anxiety symptom response to transdermal estradiol treatment in perimenopausal women – A randomized clinical trial. Psychoneuroendocrinology, 2022. (143)
- https://bywinona.com/hormone-replacement-therapy
- https://www.quicksilverscientific.com/pages/qsi-information
- In the House of the Moon: Reclaiming the Feminine Spirit of Healing. Elias, Jason, Ketcham, Katherine. Warner Books, 1995.