Why can the menopause trigger anxiety?

Anthea*, 51, started to experience anxiety and low mood when her periods began to get more erratic and heavy, before they stopped completely. She stopped sleeping and had to be signed off work five times in a year.

However, it was only when she began to read about the menopause and its effects that she realised it might be contributing to her mental health problems. "I felt tearful all the time," she says.

After speaking to several different healthcare professionals, Anthea eventually started counselling and hormone replacement therapy (HRT), which eases the symptoms of the menopause by replacing hormone levels that have dropped. After six months, her mental health had improved and she was sleeping again, seeing friends and back at work.

Anthea is far from alone in her experience. Research has shown that the menopause and perimenopause - the time leading up to the complete stopping of periods - can have a significant affect on women's mental health. One study found that up to one quarter of women going through the menopause had experienced anxiety¹.

Dr Radhika Vohra, a medical advisor for the The Menopause Charity and an NHS and private GP in Surrey.

"We know that the hormone levels of oestrogen, progesterone and testosterone - all produced by the ovaries - start to decline up to seven years before menopause starts and this is called the perimenopause," she says. "The changes in hormone levels and the drop in them have varying effects on the brain and body. There are so many recorded symptoms and anxiety, along with low mood and brain fog, is a very common one."

How hormone changes affect mental health during menopause

Shifts in the levels of female hormones are one of the key causes of mood changes for many women.

"The falling levels of oestrogen, progesterone and testosterone influence women's brains," Vohra explains. "The resulting imbalance of lower chemicals such as serotonin and endorphins - and increased ones such as cortisol and adrenaline - can lead to feelings of anxiousness and irritability."

Serotonin, a neurotransmitter that carries signals between nerve cells, is linked to mood regulation, the body's stress response and memory. Endorphins are chemicals which increase feelings of wellbeing and pleasure, while easing pain and discomfort.

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The menopause is the time when your ovaries stop working to make an egg each month - it occurs 12 months after your last period. The perimenopause is the time when your periods are getting less regular and you are said to be in the postmenopause when your last period was more than 12 months ago, and this is not due to your periods stopping for another reason such as the use of a contraceptive that stops your periods.

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On the other hand, cortisol and adrenaline are hormones linked to our stress response. Normally, progesterone and oestrogen can ease the effect these stress hormones have on the body, but once their levels drop during perimenopause, this weakens. The result can be sustained high levels of stress hormones, which can harm our mental health.

Often, psychological symptoms can appear during the change to menopause too. "During the perimenopause, whilst still having periods, even if irregular, women may find that their mood changes during the second half of their cycle," Vohra adds. "This again is due to the lower levels of oestrogen at this stage."

Other causes of anxiety during menopause

On top of hormonal changes, the physical symptoms of menopause such as hot flushes, body aches, skin irritation and sleep disturbance can trigger anxiety and low mood. Women may not feel like themselves and struggle with low self-confidence.

"Women are often juggling many roles with home and work, and trying to carry the burden of all these expectations whilst not feeling themselves is a source of anxiety for many," says Vohra.

"There are other psychological symptoms too, including, low self-esteem, lack of motivation, panic attacks, poor concentration, anger and low energy. These can be really debilitating despite not being visible. This can result in a lack of pleasure in normal life."

As a result, women may lose interest in activities that once made them happy, such as exercise or socialising. This can worsen feelings of anxiety and low mood.

How to cope with anxiety during menopause

Speak to a health professional

"Speak to a health professional if you are feeling these symptoms, as seeking help can start the process to differentiate symptoms of menopause affecting your mental health from depression," says Vohra. "Some women who have a past history of sensitivity to their own hormone changes, such as premenstrual syndrome or postnatal depression, may be more likely to experience these types of symptoms during the menopause."

A doctor is a good place to start if you are struggling with anxiety, as they will be able to recommend different treatment options. "Understanding the pattern of your mood and anxiety with all of the above, will help you share these concerns with a doctor or health professional," says Vohra. "Prepare and take a deep breath before you consult and know that you know your mind and body best."

Explore hormone replacement therapy (HRT)

It can also help to read up on HRT, which can help ease symptoms such as hot flushes, night sweats, vaginal dryness, reduced sex drive and mood swings. It can also help prevent weakening of the bones, known as osteoporosis. Some types of HRT can increase your risk of breast cancer, but the benefits of HRT are believed to outweigh the risks for many women.

"The risks are smaller than previously published, but your history, risks and family history all need to be taken into account," says Vohra. "If your anxiety is hormone-related, then replacing the hormones with HRT should help. Do consider what medications or contraception you are taking - this includes over-the-counter medication as it can help your health professional evaluate your need."

Access therapy

Talking therapies and CBT (cognitive behavioural therapy) can help you change problematic thought patterns, while helping you think through any problems. "You can in many areas self-refer for CBT through your local mental health service or consult a doctor or health professional to refer you," says Vohra.

"If you are experiencing anxiety during your perimenopause or menopause, first feel reassured that you are not alone. So many women feel like you and the more this is talked about and understood, the more likely it is you can work through this stage of life."

Keep a mood diary

Keeping a mood diary can also help you track your feelings and identify any triggers. "Record how you are feeling in a journal or app, either as a word, a scale out of five, or any other way," says Vohra. "Track what your periods are doing - are you missing them? Are they heavier? This will help piece the jigsaw together."

Make time for self-care

Menopause is a tough time, so it's important to look after yourself and make time for things you enjoy or find relaxing. Exercise can boost feel-good endorphins, but if you aren't feeling up for strenuous activity, try a daily walk. "Enjoy music, read, have a bath, talk to your partner or family, and be open and honest. It's good to take the support of others," adds Vohra.

Further reading

1. Huang et al: Anxiety disorder in menopausal women and the intervention efficacy of mindfulness-based stress reduction.