Variable estrogen levels impact mood, says Dr. Maki, who co-authored the first guidelines to identify and treat depression in perimenopause. She says that “elevated depressive symptoms” (where you may feel depressed but don’t meet a clinical definition of depression) “reliably increase in the perimenopause regardless of whether a woman has a history of depression.”
There’s also research that shows some women become depressed during the perimenopause transition for the first time, suggesting some of us might carry a “predisposing factor to getting depressed at the time of a withdrawal from estrogen,” says Dr. Maki; it’s an avenue for future research into other times of estrogen withdrawal, including the postpartum period and the late luteal stage of the menstrual cycle.
Sometimes, symptoms are short-lived. In the setting of menopause, the brain rewires and women's cognitive abilities commonly resolve, says Dr. Maki. Yet, some women’s symptoms linger, and while some data suggests who might be more vulnerable to longer-lasting issues (more on that later), Dr. Maki says “much of that science is nascent.”
Of course, hormones aren’t solely to blame for mental health-related symptoms. Sleep disturbances—common around menopause and other times of fluctuating estrogen levels like pregnancy—can affect a whole group of cognitive functions, too, Dr. Maki explains, and hot flashes—another common menopause symptom—can also contribute to sleep issues.
Stress can also play a role. “When you have estrogen variability in the presence of a significant life stressor, those stressors will have a more negative effect,” says Dr. Maki. Those with significant life stressors during perimenopause are also disproportionately at risk for becoming depressed, she adds.
How to feel better during hormonal changes
Fortunately, there are ways to take care of your brain and mental health throughout your cycle, perimenopause, and menopause. Here are seven strategies, according to experts who study estrogen.
First: Know your symptoms are real.
Too often, women are not heard or believed in medical appointments, but research on measurable hormonal changes regularly matches women’s stories. In other words: “Women's complaints of forgetfulness correlate with performance on tests of verbal learning and memory,” explains Dr. Maki. “The subjective complaint is, in fact, related to objective performance on these tests.” Adds Dr. Daniel: The research is clear that symptoms are not in your head. “These are real symptoms, and the loss of estrogens is likely one contributor,” says Dr. Daniel.
Find a provider who understands menopause.
Historically, physicians are not given extensive training on menopause. “It’s a woman's rights issue that we do not have these practitioners trained; it’s a huge gap,” says Dr. Maki. She recommends considering getting your general medical care from an ob-gyn (vs a primary care provider or family medicine doctor), who may have a deeper understanding of menopause-related changes in your midlife. The Menopause Society and Let’s Talk Menopause also have databases of specially trained providers—because not all ob-gyns are trained specifically in menopause care. Working with a trained provider, even before menopause, is important as research suggests that depression and other brain-related symptoms can occur throughout perimenopause. Says Dr. Maki: “We may need, scientifically, to move our spotlight earlier in women's lives to make sure we're seeing when the onset of these symptoms is.”
Look back on your life to get an idea of what could lay ahead.
Felt depressed when you were first pregnant? That could be an indicator that you’re sensitive to the onboarding of hormones, explains Dr. Maki. Struggled postpartum? It could be that you are more sensitive to a drop off in hormones. According to research, about 59 percent of women with a past history of clinical depression also experience a recurrence of their depression during perimenopause, she says, noting that the recommended treatment for women with a history of depression who experience a recurrence is what worked in the past for them. Other stressors such as a culture focused on beauty and youthfulness that doesn’t embrace aging, or fertility issues, could also present added stress at times of estrogen fluctuations, says Dr. Maki. “You have to personalize your treatment.” A big part of that is understanding yourself and your history.
Consider hormone therapy.
In the early 2000s, The National Institutes for Health published a large clinical trial called the Women's Health Initiative, which, among other things, found that women on hormone therapy (sometimes called hormone replacement therapy or HRT) had an increased risk of dementia and other negative outcomes, such as blood clots and stroke. “The recommendation, then, was that women shouldn't take hormones,” explains Dr. Daniel. But there was backlash against the research because of its design—namely that it included giving women in their 60s and 70s HRT. “That's not how women use hormones,” says Dr. Daniel. “As people look back at the data, what’s most evident is that the women in their 50s, the younger postmenopausal women, were fine taking the hormones.”