Menopause and Mental Health: Cognitive Changes of a Key Transition Period

In tandem with the growing interest around perinatal maternal mental health, researchers and physicians have broadened their attention towards other aspects of women’s health over the life course. Across the lifespan, the changes that take place during the perimenopausal period are increasingly a key priority for both reproductive and mental health.

I know what menopause is, but what is perimenopause?

While most people are familiar with the phrase menopause, when a woman stops menstruating permanently, perimenopause might be less familiar. Similar to the word perinatal referring to the time around pregnancy, perimenopause refers to the time leading up to menopause. This is the period where the ovaries start to produce less or varied amounts of estrogen as it moves towards no longer sustaining regular menstrual cycles [1]. Because this hormonal transition can happen gradually around 8-10 years before menopause begins, perimenopause typically occurs around the mid-40s, although it can begin earlier. Some might be in this stage for a few months, some might be in it for years. Because perimenopause can start at different points for different women, it can be hard to predict its onset and associated symptoms. 

What are some ways to recognize I’m in perimenopause?

Although irregular periods can be the result of many different conditions, an irregular period may also be an initial sign of perimenopause. For someone who has consistently regular periods, a switch to spotting or missing periods may be a good indication to speak to a physician about perimenopause concerns. Some of the other symptoms can mimic what people encounter during menopause itself, such as hot flashes, low sex drive, hot flashes, night sweats, sleep issues, and vaginal dryness [1]. In addition to these physical symptoms, someone might notice changes to their mental wellbeing. This article focuses on the current research around cognitive implications of perimenopause.

How does perimenopause relate to mental health?

The most common mental health and cognitive symptoms of perimenopause are mood disturbances, including depression, anxiety, and irritability. While only a few studies review anxiety specific to perimenopause, many people encounter more anxiety during this period, which may coincide with physical symptoms like sweating, nausea, or muscle tension. Cognitive issues can feel like “brain fog,” forgetting things more, feeling fatigued and having challenges with concentration. The root cause of these can sometimes be difficult to differentiate for people already encountering this hormonal shift. [2] Regarding prevalence, depressive symptoms are reported by approximately 25–30% of perimenopausal women, with anxiety symptoms present in about 12–20% depending on the population studied [3]. One study with a large cohort and survey data indicated that over 60% of perimenopausal women report cognitive symptoms at least half the time [4]. Because of the burden of these mental health challenges within this population, this is an area that warrants more study and careful evaluation by healthcare providers. For many women, it may simply feel as if they don’t “feel like themselves” but these psychological changes can be reflective of a larger neuroendocrine process.

How can people go about addressing mental health symptoms during perimenopause?

The mental health and cognitive symptoms above commonly begin in the early perimenopausal years and often intensify as women progress through the transition, with some evidence suggesting the onset of perimenopause is temporally associated with the emergence and escalation of these mental health issues [7]. This makes it even more pertinent for healthcare providers to be able to provide compassionate care that takes into account both physical and mental symptoms. Firstly, being able to rule out potential other causes is a priority, since symptoms may be environmentally-driven. Screening for mental health issues, such as bipolar disorder, which may have reemerged, could also be a necessary step before beginning direct care for perimenopausal mental health issues. Ultimately, when started before menopause, within 10 years of their last period, people may benefit from menopausal hormone therapy, also known as hormone replacement therapy (HRT) [5]. This can range from reductions in cardiac risk, lower lung and colon cancer rates, and improved bone density in a population that faces heightened risk of osteoporosis and serious fractures. Some patients describe HRT treatments as helping them return to their sense of self. 

While this article should not be read as medical advice, it may be worthwhile to advocate to a medical provider about potential treatment avenues for mental health challenges with perimenopausal onset. Dr. Karen Adams at Stanford Medicine described how expert menopause care is one of the aspects of women’s mental health that suffers from poor accessibility and availability of care [5]. These shortages of care can prevent people from seeking help for an already stigmatized issue in reproductive health. The medical providers that do offer support for the issue may not have sufficient training on these issues. In fact, one cross sectional survey study of resident physicians in 20 programs across the nation reported that only twelve residents self-reported feeling adequately prepared to manage women experiencing menopause [5]. Evidently, addressing this multifaceted issue requires both further research on the neuroendocrine changes of perimenopause and the gaps in medical education that can be reduced to better serve women’s mental and physical wellbeing.