Overview
There was no history of depression in her family. Nothing to worry about - no anxiety disorders, no psychiatric hospitalizations, and no pattern of mental illness in the family. It was dark [when he was] 47. The obsessive thoughts, the sudden and unexpected panic, and the mood swings that made her unrecognizable to her family, let alone herself. She was referred to psychiatry by her GP. She was diagnosed with Major Depressive Disorder and generalized anxiety, prescribed antidepressants and Benzodiazepines. No one inquired about her menstruation. None of these were linked to the onset of her irregular periods and hot flushes. It was assumed that she had some psychiatric illness and was treated as such rather than a menopausal one.
She is a case in many. Psychiatric symptoms during the perimenopausal transition are seen in women without a psychiatric history that warrant routine screening but are not. Women without a psychiatric history who do develop psychiatric symptoms during the perimenopausal transition should be screened routinely but are seldom screened. Symptoms are very real, very severe, and disabling but not always a result of primary psychiatric disease and instead manifest from hormonal shifts. The difference is significant about care. Hormone therapy may be more effective and can help. Benzos can be used to control anxiety, but all the hormonal turmoil goes on
The Hormonal Psychiatric Emergency
Perimenopause brings the brain the same neurochemical chaos that is seen in all acknowledged psychiatric crises. Estrogen isn't just about reproduction; it's also about serotonin, dopamine, norepinephrine, and GABA systems, those that help control our mood, anxiety, and emotional regulation. These neurotransmitter systems may become unstable when estrogen is in dramatic swings, which is what happens during perimenopause, resulting in real psychic symptoms.
The onset pattern is not the same as the onset of primary psychiatric illness. Symptoms are de novo and present in the mid to late 40's, around the time of menopausal irregularities. They can change according to hormonal changes, which do not occur with pure psychiatric disorders. Chemical changes in the body during breast cancer treatment can cause mood changes, but they also frequently involve hot flashes and sleep disturbances, which are not apparent in psychiatric assessments unless a history of the menstrual period and menopause is taken.
It can be serious and significant. Depression can become an issue during perimenopause, with extreme symptoms appearing as suicidal thoughts. Being anxious can be debilitating. In some women, rage, dissociation, or psychiatric symptoms like those of more severe psychiatric disorders occur. When the hormonal environment of the brain becomes enraged, the brain actually goes haywire.
Dr. Sundus Amena says the perimenopause can really cause psychiatric emergencies in women who have never had prior mental health conditions, and we're failing to recognize the neuroendocrine, or the hormonal contribution. The first question that should be asked is about her menstrual cycle and her menopausal status: if a woman becomes profoundly depressed or panicky, usually she will be referred directly to psychiatric treatment without ever wondering about her mood and menstruation; she may be put on psychiatric meds before other treatment options are considered; she will be told she has a psychiatric disorder when what she actually has is a deficit in her brain caused by her lack of corporeal hormones.
The Trauma Reactivation
Not all symptoms of menopause are new, but sometimes, trauma that has lain dormant for decades can resurface. The hormones released during the change of life could cause these experiences to re-emerge in women who endure such trauma during childhood in the form of intense and overwhelming experiences, which can be surprising for the patient and provider.
Biological and psychological processes play a role in the mechanism. Estrogen, along with the function of the HPA axis as well as regulation of cortisol, is influenced by the stress response system. If it's irregular, the nervous system is less likely to be able to regulate the threat response. When the neurobiological containment system is weakened, or triggers can affect the body, traumatic memories from implicit body memory might appear.
With menopause, the body undergoes changes that can, in themselves, trigger trauma associations. When a woman's traumatic experiences include loss of her body, she can experience panic failure when she experiences a hot flash. Sexual trauma can be triggered as the vagina atrophies and changes in sexuality occur. The person may trigger attachment wounds or body trauma from viewing the aging process in the mirror.
During symptomatic menopause, sleep deprivation, so common during this stage, only worsened by its effects on the mind, is nearly universal and further enhances the psychological resources available for working with trauma material. The woman who achieved her trauma integration over the past few years by maintaining stability in both of these areas may notice that a diminishing level of stability in both areas may lead the integration to come undone.
Women may have lived through trauma that hadn't been addressed for years, and this can cause it to resurface, which can be mistaken for a new psychiatric problem, Dr. Sarah Boss says. Trauma doesn't always need to be treated with medication for psychiatric conditions; sometimes, it might require hormone stabilization combined with a somatic treatment of the trauma itself, as the body has been storing what the conscious mind has been capable of processing.
The Diagnostic Failure
Most often, reproductive status does not play a role in current psychiatric practice. Normal intake forms do not tend towards these questions regarding menstrual patterns or menopausal symptoms. The DSM diagnoses of depression and anxiety do not differentiate between presentations of hormonal etiology and of other etiology. Psychiatrists do not receive much training in the field of reproductive psychiatry.
The result is misclassifications that are systematic. Without an etiological consideration, psychiatric diagnoses such as major depression, generalized anxiety disorder, bipolar disorder, or even borderline personality disorder are given to women who present with perimenopausal symptoms. These diagnoses attach to women like graduation rings, once they are given your medical history, so are they.
Treatment follows diagnosis. Major depression becomes an indication for SSRIs for the woman. For the woman who has anxiety, benzodiazepines or Buspirone are used. While these treatments may offer some relief, they don't target the hormonal factor. Some women undergo dozens of psychiatric medications being changed in an effort to find one that works, only to not respond – but as often happens, women are not resistant to illness; they are result-proof examples of ill treatment.
On the other hand, gynecology is often oblivious to the psychiatric symptoms affecting menopause. The specializations are vasomotor symptoms, bone health, and urogenital changes. The mood symptoms can be recognised and/or referred out, although not treated. Each specialty focuses on its own specialization; the problem is that no one sees the complete picture.
The Treatment Integration
It is necessary to acknowledge the link between hormones and psychiatric problems, and treat both at the same time to manage this optimally. This is not either/or; it's both/and.
For perimenopausal psychiatric symptoms, hormone therapy might be very effective. The neurotransmitter systems that are modulated by estrogen are stabilized by stabilizing estrogen levels. For some women, the improvement in mood, anxiety, and cognitive symptoms was dramatic and occurred with hormone therapy alone, but not with psychiatric medications.
If these medications are necessary, they must be selected to take into account the hormonal status. There are antidepressant medications that are more effective in the perimenopausal population than others. Adjustments may be necessary because of changes in hormonal status. The drugs that have been useful during the hectic transition to menopause may be no longer needed once menopause phases out.
If trauma is being re-inflicted, it is important to treat the somatic aspect of trauma. Styles such as Somatic Experiencing, which connect with trauma in the body, can be especially important if the body is destabilized in the process of hormonal change. The Safe and Sound Protocol may offer some regulation of both the traumatic and menopausal autonomic nervous systems.
Hormone and mental health support, optimizing sleep, exercise, stress management, and nutrition all serve more than one function. The integrative approach takes into account the interplay between reproductive, neurological, and psychological systems.
The Advocacy Imperative
Ironically, when these two crises happen simultaneously in the lives of women, they tend to be unable to speak for themselves. You can't treat what's hurting you with the very thing that's hurting you. May receive a psychiatric diagnosis and take it at face value without concern for contribution from hormones. They might not recognize the need to ask inquiries that your providers would not have specifically touched on.
Family members and partners may be important resources to the process of reaching full evaluation. These steps can help facilitate the care women need from multiple providers that is not being naturally provided, and thus a better way to accompany women to appointments, ask about hormonal assessment, and request consultation between the gynecology and the psychiatry departments.
Eventually, the woman (who had a psychiatric crisis, but in fact a perimenopausal one) was seen by a provider who took the whole context of the situation into account. Antidepressants had only partially kept it under control; that was where hormone therapy helped. Trauma focus therapy dealt with what psychiatric medication has not. It took a while to reword her diagnosis from psychiatric disorder to "hormonal transition with psychiatric symptoms," which impacted her experience of self as much as a change in treatment. She wasn't mentally ill. She was menopausal. The difference mattered.
