Menopause and the years leading up to this transition can take women on an emotional roller coaster of mood swings and mental health concerns including depression and often anxiety. Irritability, tension, and nervousness may be present in as high as 51% of women age 40-55 years old (1). Menopause may even trigger a new-onset of panic disorder, or worsen a preexisting panic disorder (2). These experiences can be distressing, and even scary at times.
Why is mental health compromised during menopause?
Hormonal changes, debilitating hot flashes, and lack of sleep creates a vicious cycle that puts mental health in a precarious position. Not to mention the fear around going through such a pivotal life transition.
Female hormone changes in estrogen and progesterone begin during the years leading up to menopause known as peri-menopause. Menopause is defined as the cessation of menses for 12 months, but fluctuations in estrogen and progesterone begin years prior to this. During this peri-menopausal period, progesterone levels begin to drop, while estrogen (or estradiol) levels fluctuate up and down creating a relative estrogen dominance and progesterone deficiency.
This progesterone deficient state plays into anxiety and sleep issues. Progesterone is important for mental health, particularly anxiety, since it increases activity of the neurotransmitter GABA (3). GABA is an inhibitory neurotransmitter meaning it is involved in calming the mind. Therefore, a deficiency in progesterone created during peri-menopause puts women at risk of anxiety. Progesterone is also required for healthy sleep for similar reasons. The calming actions of GABA means it helps sedate the body to promote sleep. Estrogen contributes to sleep as well by metabolizing, or breaking down, the neurotransmitters norepinephrine, serotonin, and acetylcholine, which allows for increase in REM cycle sleep (4). Difficulty initiating sleep is associated with further anxiety, and 40-50% of women in the menopausal transition experience insomnia (5).
You can start to see this domino effect between hormones, sleep, and anxiety. And then we throw hot flashes into the mix.
Anxiety can actually be a trigger for hot flashes, often preceding that sudden rush of warmth. One study looking at over 400 women found that women with moderate anxiety are 3x more likely to experience hot flashes, while women with severe anxiety are 5x more likely to experience hot flashes than those women with mild anxiety (6). After controlling for factors such as body weight, estrogen levels, and smoking, among others, anxiety still remained strongly associated with hot flashes. Furthermore, anxiety scores were higher in those women with more severe and frequent hot flashes (6).
What about feelings of depression?
Some women going through menopause are plagued by low, depressive feelings rather than anxiety. Hormonal changes as well as sleep disturbances may play into this. During the menopausal transition, higher testosterone levels may contribute to higher rates of depression (2). Women experiencing symptoms of depression may be unable to achieve restorative sleep, which is associated with depression (5).
How can you support mental health during menopause?
During this life transition, experiencing feelings of anxiety and depression is common, but not necessarily normal: your mental health doesn’t have to suffer.
Conventionally, medical doctors will prescribe antidepressants and/or hormone replacement therapy for mood disorders in menopause (2).
Naturopathic doctors aim to treat the underlying cause, which in this case, is the hormonal fluctuations. Therefore, hormone replacement therapy may be useful for some women. For those women looking for an alternative to hormone therapy, naturopathic therapies such as herbal medicine and nutrition can be powerful tools in addressing the underlying cause as well as helping with symptom management.
Note: because some of these tools can be powerful and may be contraindicated for some people, they should only be used under the supervision of a healthcare practitioner such as a naturopath.
Getting to the Root Cause: Hormone Modulators
Isoflavones. Both soy and the herb Red Clover contain a compound called isoflavones. Isoflavones act as phytoestrogens in the body meaning they have a structure similar to our own estrogen. Therefore, they have the ability to bind estrogen receptors in the body to help modulate estrogenic activity. Because they bind estrogen receptors in a weaker manner than actual estrogen, this has the potential to decrease estrogenic activity when estrogen levels are too high. As mentioned above, during the peri-menopausal phase is when we often see this relative estrogen dominance. Red Clover isoflavones have been shown effective in reducing symptoms of anxiety (and depression) in menopausal women (7).
Chaste Tree. This is another herb that has the potential to modulate hormone levels, specifically progesterone. Chaste Tree may indirectly increase progesterone production through promoting secretion of the hormone LH, which then stimulates the ovaries to produce progesterone (8). Because this requires activity of the ovaries, Chaste Tree may only be useful in those women that have not yet reached full cessation of menses indicating that their ovaries are still capable of producing progesterone. More studies are required to determine if this herb is useful in anxiety specifically, but Chaste Tree has been found to alleviate symptoms of PMS (8).
Tools for Symptom management
Kava. When used in combination with hormone therapy, those menopausal women taking Kava extract had a reduction in anxiety symptoms greater than those taking hormone therapy on its own (9). As far as we know, this herb does not modulate estrogen and progesterone, but has significant amounts of research on its use in anxiety and sleep. Many other sedative herbs exist that can be used to promote sleep and therefore potentially break the cycle between anxiety and lack of sleep.
Dietary triggers for hot flashes. We know that anxiety is a trigger for hot flashes, but avoiding dietary triggers may also reduce this burden. Dietary triggers for hot flashes include spicy foods, alcohol (specifically nitrite containing wine), coffee and other hot beverages (I know, all the good things!).
Naturopathic tools for addressing anxiety and other mood changes during menopause are plentiful. The beauty of naturopathic medicine, is that all treatments are individualized specifically for your needs. Not all herbs/supplements and people are created equally, so talk to a naturopath or other healthcare practitioner before embarking on complementary therapies.
1. Bromberger, J., Kravitz, H., Chang, Y., Randolph, J., Avis, N., Gold, E., Matthews, K. (2013). Does risk for anxiety increases during the menopausal transition? Study of women’s health across the nation (SWAN). Menopause, 20(5), 488-495. doi:10.1097/GME.0b013e3182730599
2. Bhatt, N. (2019). Menopause and mood disorders. Medscape: https://emedicine.medscape.com/article/295382-overview#a1
3. Reddy, D., O'Malley, B., Rogawski, M. (2005). Anxiolytic activity of progesterone in progesterone receptor knock out mice. Neuropharmacology, 48(1), 14-24. doi:10.1016/j.neuropharm.2004.09.002
4. Tal, J., Suh, S., Dowdle, C., Nowakowski, S. (2015). Treatment of insomnia, insomnia symptoms, and obstructive sleep apnea during and after menopause: therapeutic approaches. Current Psychiatry Reviews, 11(1), 63-83. doi:10.2174/1573400510666140929194848
5. Terauchi, M., Hiramitsu, S., Akiyoshi, M., Owa, Y., Kato, K., Obayashi, S., Matsushima, E., Kubota, T. (2012). Associations between anxiety, depression, insomnia, in peri- and post-menopausal women. Maturitas, 71(1), 61-65. doi:10.1016/j.maturitas.2012.01.014
6. Freeman, E., Sammel, M., Lin, H., Gracia, C., Kapoor, S., Ferdousi, T. (2005). The role of anxiety and hormonal changes in menopausal hot flashes. Menopause, 12(3), 258-266. doi:10.1097/01.GME.0000142440.49698.B7
7. Lipovac, M., Chedraui, P., Gruenhut, C., Gocan, A., Stammler, M., Imhof, M. (2010). Improvement of postmenopausal depressive and anxiety symptoms after treatment with isoflavones derived from red clover extracts. Maturitas, 65, 258-261. doi:10.1016/j.maturitas.2009.10.014
8. Van Die, M., Burger, H., Teede, H., Bone, K. (2009). Vitex agnus-castus (chaste-tree/berry) in the treatment of menopause-related complaints. The Journal of Alternative and Complementary Medicine, 15(8), 853-862. doi:10.1089/acm.2008.0447
9. De leo, V., la Marca, A., Morgante, G., Lanzetta, D., Florio, P., Petraglia, F. (2001). Evaluation of combining kava extract with hormone replacement therapy in the treatment of postmenopausal anxiety. Maturitas, 39(2), 185-188. doi:10.1016/S0378-5122(01)00197-9