Hot flashes and mood swings: why perimenopausal symptoms are misdiagnosed – and how to treat them
IIn her forties, Karen Cummings began to notice a shift in her menstrual cycle. The New Yorker’s usually mild and consistent symptoms had been replaced by bloating, emotional swings and overwhelm before she entered menopause five years ago, at age 52.
She thought maybe she should change her birth control. Her doctor suggested an antidepressant. But the symptoms seemed to be related to her menstrual cycle. “I’m not depressed,” she remembers thinking. “I’m using the wrong contraception.”
Dr. Brittanny Keeler, a gynecologist in Buffalo, New York, often has patients show up with menopausal symptoms feeling hopeless. It can feel like falling off a cliff, she said. “They don’t understand what’s happening to them.” They are often told to wait until their periods stop before they can start treatment.
In the US, the average age of menopause, or the period of a person’s life when reproductive hormones decrease and menstruation ceases, is 51 years. Perimenopause can start seven to ten years in advance. People who menstruate may notice symptoms such as insomnia, hot flashes and mood swings in their late 30s and early 40s. These add to other pressures in life, including a career in full swing and family obligations. “The divorce rate peaks for this group” said Keeler. Perimenopause “is definitely a contributing factor.”
Many doctors do not fully determine the cause of these symptoms. Keeler, who has just been certified as a Certified Menopause Practitioner by the North American Menopause Society, said: “We are seeing a huge increase in the amount of antidepressants being prescribed around the mid-2040s. Many women do not get the treatment they really need.”
Many people benefit from mental health medication. But it’s not the full story when it comes to treating perimenopausal symptoms, nor does it adequately address hormonal fluctuations. It is very common to receive a negative diagnosis and then write an SSRI prescription for depression and anxiety, without any acknowledgment of perimenopause.
Cummings found a new doctor and shared the same information: symptoms and her curiosity about other birth control options. Her doctor said, “You still need birth control. You’re on the wrong side.” Her doctor assured her that they would keep trying until they found the right birth control for her current needs. Cummings said: “It was such a simple thing.”
What are the most common symptoms of perimenopause?
Menopausal symptoms can occur much earlier than people think. “Perimenopausal women are actually among the most symptomatic people because of the wild swings in their hormones,” Keeler said.
“When someone is in perimenopause, the ovaries are still working, but not in that nice, predictable way as before, when you had your monthly cycles,” she said. “They send out some estrogen and don’t get the response they want, so they send out even more.” This can result in no ovulation at all in some months or twice in others; the latter is known as experiencing an out-of-phase cycle.
Symptoms are different for everyone, but can include mood swings and irregular bleeding, such as shorter, lighter cycles or heavier, longer cycles. Hot flashes and night sweats can also occur closer to menstruation. Insomnia is also common. It may not be difficult to fall asleep, but sleeping through the night is a challenge.
Perimenopause is clinically defined by a seven-day variance in the menstrual cycle and typically lasts four years. “It’s a gradual shift,” says Dr. Katie Unverferth, director of the Women’s Life Clinic at UCLA and a psychiatrist who focuses on reproductive psychiatry and women’s mental health. But fluctuations in ovarian function can begin long before that level of variance.
“This hormonal dysregulation can lead to many mood symptoms,” Unverferth said. It is quite common to experience mood swings, colloquially called premenstrual symptoms or PMS, during the luteal phase, which lasts longer as women age.
Patients can feel ‘all over the place’. Anxiety, depression, insomnia and cognitive complaints such as memory problems may occur. “Many say they don’t feel like themselves, and it’s very difficult to pinpoint why,” Unverferth said.
“The greater the hormonal changes, the greater the risk of depression,” Unverferth said. These severe fluctuations in hormones are also manifested in premenstrual dysphoric disorder (PMDD) and during pregnancy and postpartum. “But once you enter menopause and that change has been made, the risk of depression decreases again.”
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How do you treat symptoms during perimenopause?
“Menopause is easier to treat than perimenopause because during menopause we simply give you back what you don’t deserve,” says Keeler. Menopausal hormone therapy (MHT), previously called hormone replacement therapy (HRT), replaces the progesterone and estrogen that decrease during menopause. This can help relieve symptoms such as hot flashes, night sweats, brain fog, vaginal dryness, and mood swings. It also lowers the risk of heart disease, osteoporosis, diabetes and dementia.
But in some circumstances, MHT is not a sufficient treatment for people in perimenopause. “Not only do we need to control the symptoms, but we also need to support the uterine lining to prevent erratic bleeding caused by fluctuating hormones, which can sometimes happen at menopause because the dose is too low, and some women also have always need contraception. Keeler said.
“Birth control pills are actually great for people who experience (perimenopause symptoms), especially mood swings, because birth control pills will suppress ovulation,” she said, and the ovaries will no longer try to move the body through the menstrual cycle.
But not everyone is a candidate for hormonal treatments, such as those who have had a heart attack or blood clots. Treatment should be individualized and developed through consultation with a healthcare provider.
Additionally, people with existing mental health problems or a low tolerance for subtle health changes may really struggle with perimenopausal symptoms, such as hot flashes in public or sleep problems, and may think they are “embarrassing and embarrassing,” Unverferth said. “Cognitive behavioral therapy specifically for perimenopausal symptoms can be very helpful.”
Research has shown that antidepressants can be effective when it comes to emotional symptoms. According to Unverferth, one from 2011 study found that, for example, the anti-anxiety and antidepressant Lexapro and hormone therapy together helped with hot flashes, night sweats, sleep and quality of life. “Typically, antidepressants are still the first choice for depression and perimenopause, but for someone who has treatment-resistant depression or very severe depression, or someone who also has insomnia or night sweats, we would certainly consider hormone therapy,” she said .
Awareness and access to treatment options are essential, but MHT, contraception and non-hormonal options such as antidepressants are not a panacea. “If you don’t take care of yourself — eat well, prioritize your sleep, exercise — you won’t get as much benefit from this as you hope,” says Keeler. She emphasized strength training for people in their 30s and for those in perimenopause and menopause because it can counteract the loss of muscle mass and decline in bone health during menopause.
Reproductive health, especially in terms of perimenopause and menopause, is not solely the responsibility of gynecologists. “The entire healthcare system is flawed. We just don’t get enough time to focus on patient prevention,” Keeler said. Not all doctors can specialize in everything, but they should recognize perimenopausal symptoms and know where to send patients for care. Those beginning this transition should consult their primary care physician and consider speaking to an endocrinologist and even an orthopedist. “This (transition) affects all organ systems, and so all physicians, regardless of their field, have a responsibility to at least recognize the symptoms, even if they are not equipped to treat them,” Keeler said.