As part of our ongoing deep dive into perimenopause, we chatted to Dr Jenny Hill from the menopause-specific clinic, Dr Menopause. She talks us through why perimenopause and menopause are such a vulnerable time for female mental health – and why we often get misdiagnosed.
It is not uncommon, says Dr Jenny Hill, for patients to start crying during their first appointment at Dr Menopause. Based in Tauranga, it’s a clinic dedicated to the experience of menopause and perimenopause, which opened last year.
Due to the ongoing lack of understanding about perimenopause and menopause, chances are that by the time a patient reaches the clinic, they are already approaching the ‘last resort’ stage of seeking help.
“These women – they don’t know what’s going on or don’t feel listened to,” says Jenny. “All of a sudden, their lives are completely derailed. They’re wondering: ‘Who have I become? Who is this person?’ As women, we’re very good at justifying why we feel like this.”
‘It can be up to a decade of hormonal chaos’
By the time women reach the stage of perimenopause, they’re in the thick of life. They may have young children, they may be in the busiest years of their career, they might be caregiving for family members, they might have teenagers. Hell, they might have all of those things and more going on.
“There are a lot of balls to juggle, so they think ‘Oh well, I’m not sleeping, or I’m not feeling great, because I’m worried about all of this, but when life calms down, I’ll feel better.’”
With all that noise, the insidious symptoms of perimenopause can often just buzz along in the background for a while – until that buzz gets louder. Until it becomes a scream.
If you are someone whose knowledge of perimenopause is cursory at best, you might just associate it with hot flashes and dwindling periods. But those are symptoms that often come up at the tail-end of the perimenopause journey, Jenny says.
The average age for a woman to reach menopause is 51, and menopause is defined as the day in your life where you haven’t had a period for a year. But that’s just one day. Perimenopausal symptoms can exist for five to 10 years before that.
It can be up to a decade, Jenny says, of “hormonal chaos”. And it’s very hard to avoid, with 80-85% of women experiencing menopausal or perimenopausal symptoms. And the first canary in the mine often isn’t the physical symptoms we’re told to expect, it’s the emotional ones.
‘I Feel Like I’m Losing My Mind’
“After you’ve had a baby, and then perimenopause and post-menopause are some of the riskiest times in a women’s life for mental health and suicide,” Jenny says. “Often the mood symptoms [of perimenopause] are the very first symptoms, because our brains are so estrogen sensitive.”
Estrogen is a neuroactive steroid, meaning it’s crucial for both chemical and hormonal pathways in our brain. When perimenopause starts, our estrogen levels fluctuate widely – so our mood is affected, but so is our cognitive performance.
Brain fog can be one of the first signs of perimenopause, Jenny says. “People will come to me and say they’ve Googled the symptoms to early onset Alzheimer’s, telling me, ‘I feel like I’m losing my mind.’”
‘Perimenopause is a real window of vulnerability for mental health’
The symptoms are also inconsistent – some months are fine, some are dire. “Often, it’s only when people look back that they realise that there were five, six years where they weren’t firing on all cylinders,” she says. “It’s quite terrifying for women. Perimenopause is a real window of vulnerability for mental health.”
The prescription of antidepressants, Jenny says, absolutely skyrockets for women in their early to mid 40s, “because that’s what women present with” when they first reach out for help.
‘the highest rates of suicide in women is around menopause’
And there’s another statistic that’s even more chilling – the highest rates of suicide in women is around menopause. So that decade of hormonal chaos can really be a matter of life or death.
Baby brain or perimenopause?
When asked what the early warning signs of perimenopause are, Jenny lists the following: increased irritability, difficulty falling to sleep or waking up and feeling wired in the middle of the night, brain fog and difficulty remembering things, and lower energy levels.
Yes, you might also read that list and be like, “Well, shit” because to be honest, that sounds like a normal day for many of us. When I immediately flag that I have all those symptoms, I ask her if it’s post-partum or perimenopause. Turns out, breast-feeding is “like a mini menopause” Jenny says, because it’s another time in your life when your estrogen bottoms out and the brain fog sets in. Good to know!
But if you’re not post-partum, and you’re wondering if perimenopause has started arriving for you, Jenny says getting a blood test can help to work out what’s going on.
Not to look at hormone levels, which in most situations are unhelpful due to the fluctuating course and can look normal, but to check things like iron levels, thyroid function, a full blood count and a diabetes screen.
“I like to think of this as a mid-life warrant of fitness, because women aren’t good at going to see the doctor when there isn’t something drastically wrong. So, it’s a good opportunity to make sure nothing else is going on.” An under or overactive thyroid, for example, can cause anxiety, night sweats, heart palpitations – all the kind of things that can also come with perimenopause.
In terms of emotional side of things, it can be harder to work out what’s going on – hence the sudden rise in antidepressant prescriptions that present in the early 40s.
A GP doesn’t have time to get into the nitty-gritty in a standard 15-minute appointment and, also, antidepressants can be a great help for many. But to treat what is a menopausal or perimenopausal symptom, rather than a mental health crisis, that’s when seeking more specialized help can separate the wood from the trees.
“For women who have never had a problem [with mental health] before, and nothing has changed in their life in terms of major stressors, you’ve got to think there might be something internal or hormonal that’s going on,” Jenny says.
“They’ll say ‘I used to be the fun one; I’d never say no, in case I missed out on something.’ And now they’re making excuses to stay at home and not see anyone.”
“It’s often quite a different presentation of anxiety and depression as well – these women come well-dressed, with their make-up on, still fully functioning,” she continues. “Whereas someone with depression, they’re very flat, they don’t care about their appearance. It’s the subtle differences you want to look for.”
A lot of women can also suffer from sudden, vicious spikes of anxiety. “I had one client who got to the point where she was thinking, ‘I can’t do my job anymore,’” Jenny says. Her patient had been working for 30 years and was in a top role – competent, accomplished, experienced. But then came the crippling anxiety, waking her up at 3am, leaving her speechless and panicked at big presentations. “She told me, ‘This isn’t me. But it’s completely out of my control.’”
Jenny also recommends reading through this list of perimenopausal symptoms to help you work out what’s going on.
The Life-Changing Power of HRT
In the early 2000s, a study came out in America that drastically changed how HRT – hormone replacement treatment – was both viewed, and then prescribed. Run by the Women’s Health Initiative, the study was flawed – there’s a great article on the NY Times here – but basically, it tested the wrong kind of HRT on the wrong kind of control group and the results weren’t accurate.
The resulting, incorrect message was that HRT could have negative health repercussions, including a heightened risk of breast cancer and stroke. Before the study came out, 40% of menopausal aged women in the US were taking HRT for their symptoms; afterwards, HRT couldn’t shake its bad reputation, even though the study was discredited and has since been updated.
As a result, Jenny says, “there is a whole generation of women who have really missed out and are now suffering from things like osteoporosis and heart disease, or had horrific menopauses. Because 25% of women have absolutely debilitating menopauses.”
The right hormonal treatment for women can be “completely life-changing,” Jenny says. “Treatment doesn’t have to be HRT if that’s not what someone wants, but it’s important for women to know what their options are, that when they’re ready, and if they want to give it a go, then it’s there.”
The Global Estrogen Patch Shortage
This is where we must break the other bad news – while there are great hormonal treatments out there, there is also currently a global estrogen patch shortage. Ever since lockdown, there has been supply issues and a current worldwide shortage and here in NZ, doctors have commented that Pharmac haven’t necessarily helped things. It’s hard to overestimate just how much of an impact this is having on Kiwi women.
“It’s awful, because we know we have a very safe and effective treatment for perimenopausal and menopausal women who have symptoms, which are causing significant impacts on their health and wellbeing… and we can’t get access to it,” Jenny says.
She describes the current availability in Aotearoa as “a lottery”, saying that a reasonable portion of her work week is spent responding to women who can’t get their prescriptions or repeats filled, ringing around different pharmacists, trying to find what’s available or altering existing scripts.
Because pharmacies are limited in how many patches they can dispense each month, and the correct ones are not always in stock, women are currently either having to go without, wear weaker patches, cut patches, or pay more money to just stay on a functional equilibrium. As well as that, alternative oestradiol gels aren’t funded… now there are supply issues with those as well.
Is this just another example of women’s health being undervalued and under resourced? Well, you won’t be surprised, for instance, to know there’s never been a global shortage of Viagra. And the consequences of no Viagra are considerably less, hmm, urgent than a global shortage of menopausal treatment.
“I’ve decided there aren’t enough menopausal women on the board at Pharmac,” Jenny says. She points out that at the Australasian Menopause Society Conference in Queenstown last year, the difference between what is available for women in Australia versus in New Zealand was stark. “Half the time, when presenters were talking about different treatments, they were like ‘…sorry New Zealand, you can’t get this.’”
But there is light at the end of the tunnel. There is a growing interest in perimenopause and menopause – the symptoms, the suffering and the treatments. There are clinics like Dr Menopause, and an increasing number of medical professionals learning about the ins and outs of menopause – plus, a better-informed population of women entering their menopausal years.
What’s important, Jenny says, is to get to know your options and know that there will be a treatment out there for you – suffering is not an inevitability. “There’s no badge to say, ‘I had the shittiest menopause out of all my friends,’” she says.
“We should be aiming to be feeling great, loving life, thriving in the here and now but also promoting our long-term health. We want our bodies and our minds to be in the right state to take us there.”
