Menopause and Mental Health

Overview

This Guidelines summary aims to help nurses provide women with information on living well and how to positively manage the menopause. This summary only includes key recommendations for nurses; for a complete set of recommendations, refer to the full guideline.

Note: the term ‘women’ is used throughout this text, noting that as a gender-diverse society the guidance can, and should, be used by and/or applied to people who identify as non-binary, transgender, or gender fluid.

For information on the definition of the menopause, causes, signs and symptoms, and myths, refer to the full guideline.

Reflecting on your Learnings

Reflection is important for continuous learning and development, and a critical part of the revalidation process for UK healthcare professionals. Click here to access the Guidelines Reflection Record.

Key Points for Nurses

• Think about menopause or hormone-related issues in women you see
• When you meet a woman with menopausal symptoms, suggest they see their GP, practice nurse, or specialist—use the British Menopause Society specialist finder
• Be skilled and confident to ask questions relating to wellbeing, mood, symptoms, vaginal dryness, and sexual issues in a compassionate and supportive way
• Think about how menopause could have an impact on existing expression or mental health and understand the differences in hormonal low mood and depression and the different treatment pathways
• Assess whether a presentation is related to menopause and offer holistic support—do not assume it is depression
• Be aware of the common menopausal treatments and any interactions with medication
• Be aware of evidence in side effects and myths around hormone-replacement therapy (HRT)
• Make a diagnosis from history and not blood tests
• Think menopause and its treatment, not depression and antidepressants
• Women with a strong history of reproductive depression respond well to oestrogens.
• Think not only about symptoms, but long-term health; think bones and cardiovascular disease (CVD) and what can you do to optimise health
• Be aware of diagnostic overshadowing for women with menopause
• Challenge myths around HRT
• Be positive—menopause is natural.

Keeping Healthy at the Menopause and Living Well

• Menopause marks a transition to the next phase of life, and offers the possibility to refocus on growth and reconsider priorities
• Some women experience minimal symptoms and medical intervention is not needed. It is important to optimise health with good diet, weight management, and increasing exercise (especially weight bearing) to help with CVD, bones, and minimise symptoms
• The experience can vary across cultures and there are suggestions that the cultural differences can shape the experiences. Some cultures celebrate the menopause as an achievement of wisdom and ageing, while Western culture often portrays it as negative, with a stigma around menopause and women’s experience
• This can have a negative impact and stop women asking for help, clarifying needs, sharing experiences, and receiving healthcare. It is often hidden, and attitudes are not challenged. Women may avoid interactions due to flushes and feel this ages them. Women should be encouraged to:
  • celebrate: keep a diary of the positives and challenge the negative thoughts. Make time to laugh as humour can help with tension, stimulate immune systems, help with coping, and enhance memory, learning, and help women to feel connected
  • connect: support of others who have been through similar experiences, such as women in a support group or menopause café
  • challenge: the normal and the way menopausal women are treated in society and in the workplace.

Mental Health and Menopause

• Mid-life is a time of transition, and stressful life events, from divorce to a second career, combined with physical changes can result in feeling overwhelmed. A number of studies have identified that menopause significantly impacts mood and mental health, including higher stress levels and depression
• Anxiety and panic attacks are also reported during menopause, with hormonal changes and physical symptoms, such as sleeplessness, affecting biological functioning—especially for women with bipolar illness. Women with schizophrenia may be at increased risk of an episode as their production of oestrogen decreases, and some antipsychotic medications like sulpiride and risperidone may cause periods to stop, which can be misdiagnosed as menopause
• It is important to encourage women to talk about mental wellbeing and encourage them to seek the right support and help
• Some women with previous hormonal-related issues, such as postnatal depression and/or premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD), may be at higher risk of developing issues around the menopause.

Treatment of Menopause

Treatment Algorithm

How to Positively Manage the Menopause

• Diet and lifestyle: advise patients to reduce both caffeine and alcohol, stop smoking, and keep a food diary for flush triggers. Simple measures can help, such as wearing layers so when a flush occurs they can be taken off. To manage night sweats, patients should keep a glass of cool water nearby and keep the room slightly cool if able. Advise patients to ensure there is enough calcium and vitamin D in the diet, eat a diet rich in fibre and wholegrain foods, and try and maintain a healthy body weight. Patients should also avoid hot drinks before bedtime, and keep alcohol to a minimum as it can trigger flushes
• Exercise can be beneficial: yoga has been proven to improve sleep; weight-bearing exercise, such as walking and running, is essential to maintain bone health
• Holistic management: can include diet, lifestyle, meditation, cognitive behavioural therapy (CBT), counselling, and support groups.

Herbal and Alternative Therapies

• NICE (2015) states that herbal remedies are not regulated by a medicine authority and there can be a wide variety in their potency and effectiveness
  • black cohosh can help hot flushes but does not help with anxiety or low mood. It can interact with other medicines, so caution is needed
  • red clover is a weak plant oestrogen that has some research for the vasomotor symptoms
  • soya is another weak plant oestrogen that may help vasomotor symptoms in some women
  • St John’s Wort helps relieve vasomotor symptoms of flushes and sweats and can be beneficial to women who have had breast cancer. It does, however, make tamoxifen ineffective. It can prolong the effect of some sleeping tablets and anaesthetics, trigger high mood, and should not be taken at the same time as other antidepressants as it can lead to serotonin syndrome
• Patients should check with their healthcare professional prior to starting any supplements.

Prescribed Alternatives

• Prescribed alternative to HRT include:
  • clonidine
  • SSRIs
  • gabapentin (off licence and mainly for women who cannot take HRT; for example, those with a history of some cancers)
• Prescribed alternatives only work on vasomotor symptoms and on mood, but do not have an impact on other symptoms or protect bones or the heart
• These are not first line treatments and should only be used in women who cannot take HRT
  • some SSRIs and serotonin and noradrenaline reuptake inhibitors (SNRIs) can improve hot flushes for some women. Paroxetine seems to be the most effective, but may interact with tamoxifen, so venlafaxine is generally used. These may give some women side effects such as gastrointestinal disturbances, and can decrease libido
  • gabapentin may help flushes and sweats—can also help with sleep, but can cause daytime sleepiness, and may help with joint pains
  • clonidine is licensed for the treatment of hot flushes; however, only a few women will get a significant benefit from it
• HRT: oestrogen and progestogen if the women has a uterus, and oestrogen if not. Replacing oestrogen with HRT is the most effective treatment for menopausal symptoms
• HRT taken as sequential (with a bleed) for perimenopause and continuously (without a bleed) for postmenopausal women
• It is available as tablets, patches, gel, transdermal spray, intrauterine progestogen, or vaginal oestrogen for local treatments.

Benefits and Risks of HRT

• Symptom management
• Side effects—breast tenderness, headaches, bleeding, mood changes
• Slight increase in risk of breast cancer (with combined HRT)
• Strokes, blood clots (less with transdermal)
• HRT within specialist care only if previous thrombosis, hormone-dependent cancer, undiagnosed vaginal bleeding, liver disease
• CBT: can help alleviate the symptoms of low mood, anxiety, hot flushes, and sweats.

Medication and its Impact on Menopause

• Some medications can have an impact on the menopause or can mimic the symptoms, making a diagnosis difficult or confusing. Some studies suggest that premenopausal women have a better response to some medications than postmenopausal women. Medications given from gynaecology, such as gonadotropin-releasing hormone analogues, induce a medical menopause. Many medications (SNRIs) can have a negative impact on sexual function
• Medications given in mental health that can have an impact are:
  • moclobemide: hot flushes, but improved anxiety and sleep
  • toloxatone: increase in anxiety
  • sulpiride: amenorrhoea and galactorrhoea
  • risperidone: amenorrhea and galactorrhoea
  • antipsychotic medications: amenorrhea and prolactinaemia
  • imipramine: hot flushes
  • sertraline: night sweats.

Anxiety, Depression, and Sleep

• Anxiety, depression, and sleep are interlinked, as anxiety and depression can trigger sleep problems, and sleeplessness can make anxiety and depression worse
• Lack of sleep can affect mental wellbeing, cognitive function, and cardiac health. Sleep disturbances are common throughout the perimenopause, menopause, and postmenopause. These can include: difficulty getting to sleep; difficulty staying asleep; poor quality sleep; waking early; and fatigue during the day. Night sweats can make sleep uncomfortable and can cause regular waking
• Sleep disturbances can be caused by lack of oestrogen, causing hot flushes and sweats. Mood can also be affected, and anxiety can lead to difficulty getting to sleep and early morning wakening. Other consequences of oestrogen decline, such as bladder problems and joint aches and pains, can also cause sleep disturbance
• Progesterone decline at menopause may also contribute to sleep disturbances, as it can be sleep inducing and can have calming relaxing effects—the lack of this can contribute to anxiety and restless agitation. Melatonin is another important hormone for sleep, and this decreases with age. It is also influenced by oestrogen and progesterone levels
• Treatments for poor sleep include adequate exercise (not before bed), healthy diet, and managing stress. Maintaining a regular bedtime and trying not to nap in the day can also help. CBT can reduce menopausal symptoms such as low mood, anxiety, and sleep disturbance. HRT can improve sleep, particularly for women who are having hot flushes and sweats and these are affecting sleep
• Menopause is not a high risk for new onset of mental health conditions such as bipolar; it is a time of psychological stress. For example, depression is more common in women than men, resulting from hormonal changes such as:
  • PMS or PMDD
  • postnatal depression
  • those occurring around the menopause. It seems to be worse in the few years before periods stop
• Women who have a history of reproductive depression are more susceptible around the menopause, and it is important to note that oestrogens are good for treating these women. Sadness, low mood, and mood swings can also occur during the menopause, but are distinct from depression, which is a diagnosable condition
• It is normal to feel emotional about physical changes like getting older, the impact of poor sleep and the loss of fertility, role changes like children leaving home, looking after ageing parents or other relatives, or facing the loss of parents. Menopause can signal a time to take stock of life and focus on the next stage
• Emotions related to life course are different to clinical symptoms of depression, which may include:
  • low mood lasting 2 weeks or more
  • feeling hopeless or flat
  • feeling tired
  • changes in appetite (comfort eating or losing appetite)
  • feeling worthless
  • changed or troubles sleep patterns
  • feelings of dread, unease, or agitation
  • trouble concentrating or making decisions
• Women should be encouraged to seek help, and if a woman has thoughts of harming herself, seek help straight away.

Sex and the Menopause

• The onset of the menopause does not mean that sexual activity has to cease. Many couples enjoy a fulfilling sex life during and after the menopause. Some women find that no longer having the fear of an unintended pregnancy quite liberating
• However, the loss of oestrogen and testosterone following menopause can lead to physiological and emotional changes in a woman’s body that can impact on their sex life, including:
  • painful or uncomfortable sex due to reduced vaginal secretions and thinning of the vagina
  • loss of libido (lower sex drive)
  • mood swings and hot flushes
  • urogenital ageing symptoms resulting in continence problems
  • vulval irritation and itching
  • higher incidence of Candida albicans (thrush) and bacterial vaginosis (BV)
  • body changes that lower self-esteem, such as thinning hair and breast changes
• Not all women experience problems but for those who do they should be encouraged to discuss their worries with their partners and work together on finding the right treatment options, including:
  • lubricants and moisturisers obtainable from pharmacies and supermarkets
  • vaginal oestrogen creams can be prescribed and used in conjunction with lubricants
  • HRT
  • avoid precipitants that exacerbate vaginal dryness and increase the incidence of BV and thrush, such as vaginal deodorants or tight, restrictive clothing
  • promote continence by encouraging pelvic floor exercises or referral to continence services
  • take time with love making to become more aroused and explore new ways to enjoy sexual pleasure with their partner
  • some women may need to be prescribed testosterone (off licence for libido).

For further information, support, and referrals, refer to the full guideline.