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The Emotional Roller Coaster of Menopause


Many women describe experiencing ‘brain fog’ during menopause and think that symptoms such as forgetfulness and increased anxiety are signs of them getting old or ‘going mad’. However, many of these symptoms can be attributed to the hormonal changes that take place during menopause.

We spoke with one of our BHRT specialists, Dr Ruslana Popelyuk, to find out more about these symptoms and how our hormones are involved. The role of hormone therapy and lifestyle factors for improving psychological symptoms are also discussed, with guidance from naturopath, Vera Martins.

What psychological symptoms are associated with menopause?

Women can experience many different psychological symptoms during menopause. These include feelings of depression, anxiety, a lack of motivation, fatigue, insomnia, and cognitive dysfunction, for example difficulty concentrating or forgetfulness. Women also report feeling ‘useless’, having a lack of confidence and a low libido.

Are these symptoms a normal part of menopause?

These symptoms are very much a part of menopause and it is something that we often see in clinic.

The risk of developing mental health problems, particularly depressive symptoms, increases up to threefold for women during the menopausal transition. The same is true even for women with no history of mental health problems.

These emotional symptoms can be compounded by the physical symptoms of menopause, for example, hot flushes that disrupt sleep. Also, menopausal women are often going through other significant life changes, for example children leaving home, or caring for elderly parents, which can further impact their mental health.

What is important is that women do not feel that they are alone in having these feelings. It is a normal part of menopause that most women will experience, and there is help available.

What hormones are responsible for these symptoms?

During menopause, levels of estrogen, progesterone and testosterone decline, and these changes have a direct impact on the way our brain functions.

Estrogen and progesterone both play important and varied roles within the central nervous system (CNS) by regulating chemicals, known as neurotransmitters. Neurotransmitters are responsible for regulating our moods, behaviours and overall cognitive function (i.e. our ability to remember and learn).

Role of estrogen

Estrogen promotes the activity of serotonin, a neurotransmitter associated with feelings of happiness, by preventing its degradation and increasing the amount available in the brain.

Estrogen also increases the amount of dopamine in the brain, which is responsible for regulating pleasure, motivation and learning.

Estrogen also plays an important role in neurogenesis. This is the process by which new cells are produced in the brain and it is important for learning and memory.

Role of progesterone

Progesterone is commonly known as having calming effects. This can be explained by its relationship with the neurotransmitter, GABA. GABA balances the activity of different chemicals in the brain. Any changes to the activity of GABA can cause anxiety, and since progesterone promotes the action of GABA, it has anti-anxiety effects.

Progesterone also suppresses the action of another neurotransmitter, glutamate. This is an excitatory neurotransmitter that stimulates brain activity, and high levels of glutamate have been linked with increased anxiety.

Role of testosterone

Testosterone is the hormone responsible for our sense of well-being; it gives us confidence, energy and the ability to withstand stress. Since testosterone levels decline during menopause, this can explain some symptoms, including low confidence, motivation and fatigue.

How can BHRT help?

The balance of chemicals in our brain and, therefore, our moods and behaviours, are dependent on hormones.

Balancing hormone levels with hormone replacement therapy can help to improve psychological symptoms. Personalised bio-identical hormone replacement therapy offers the additional benefit of being tailored exactly to patients’ needs.

A recent clinical trial studied the effectiveness of transdermal estrogen (TE2) and micronised progesterone (MP) for preventing depressive symptoms in pre-menopausal and peri-menopausal women. Depressive symptoms were found in 17% of the women who received treatment with TE2 + MP, compared to 32% of women who received a placebo.

Another study examined the effect of bio-identical estrogen in peri-menopausal women with symptoms of depression. A reduction in depressive symptoms was observed in 68% of women receiving estrogen, compared to only 20% of patients who received a placebo.

What other advice do you offer to women experiencing psychological symptoms?

Living a healthy lifestyle, with regular exercise and a balanced diet is good advice for all patients, regardless of the menopause.

Research has shown that certain lifestyle modifications can have a positive impact on cognitive function during menopause.  A recent study found that cognitive training, for example, doing puzzles or learning a new skill, improved people’s memory. Practising mindfulness and doing exercises, such as yoga and Tai Chi have also proved to be effective for improving cognitive function, partly through their stress-reducing qualities.

A balanced diet, low in sugar, caffeine and alcohol, is also recommended. Studies have shown that the Mediterranean diet, full of ‘good fats’ and fresh produce, is particularly beneficial for cognitive function.

We spoke to our naturopath, Vera Martins, to find out more about these ‘good fats’, their effects on brain function, and the use of supplements.

What are ‘good fats’?

Fats have developed a bad reputation, but it is important to change that mentality and understand their importance. “Good fats”, known as unsaturated fats, include polyunsaturated essential fatty acids (PUFAs) and monounsaturated essential fatty acids (MUFAs). They are called essential as they cannot be produced by the body and therefore, you need to have them through food, or alternatively supplements.

The two main types of PUFAs, omega-3 and omega-6, have extensive health benefits. The desired ratio of omega-3 and omega-6 in our bodies is 1:4, but modern Western diets tend to be richer in omega-6 and deficient in omega-3.

Saturated fats should be consumed with moderation and trans fats (also known as hydrogenated fats) should be avoided.

How do good fats improve cognition and brain function?

Omega-3 fatty acids play an important role in learning, memory, and mood as they help building and repairing brain cells. Both omega-3 forms, EPA and DHA, are known to have antioxidant properties, reduce cellular stress, improve blood flow to the brain, and influence neurotransmitters. DHA is an essential building block of brain cells.

The benefits of fats go far beyond brain health. They also play an important role in the absorption of fat-soluble vitamins (A, D and E), cardiovascular health, reducing inflammation and hormone function.

What foods do you recommend to boost our intake of these good fats?

The best source of omega-3 essential fatty acids is wild, oily fish, for example, mackerel, sardines, salmon, herring, and anchovies. This is the form best absorbed by the body. Plant-based foods rich in omega-3 include chia seeds and flaxseeds.

Food sources of MUFAs include avocado, nuts, such as almonds and Brazil nuts, and extra virgin olive oil.

Processed foods labelled as “low fat” should be avoided as they usually contain high levels of sugar and unnecessary additives.

Are there any supplements that you would recommend to help brain function?

The best way to get your essential fatty acids, as with any nutrient, is through a balanced diet. However, if you have a low-fat diet or a health condition, you may need an extra boost by supplementing. In these cases, consider taking a good quality omega-3 EPA:DHA supplement. The best absorbable sources are oily fish or algae. Make sure to check the label for purity (free of contaminants such as PCB and heavy metals) and stability.

Other brain-boosting supplements to consider are antioxidants, such as vitamin C and grapeseed extract, and the herbs Gingko and Bacopa.

Remember that good sleep, managing stress, exercise, and staying hydrated are all very important self-care aspects of looking after your brain.

References
Rossler, W. et al. (2016). Does menopausal transition really influence mental health? Findings from the prospective long-term Zurich study. World Psychiatry.
Hickey, M. et al. (2016). Depressive symptoms across the menopause transition: findings from a large population-based cohort study. Menopause.
Soares, C.N. (2017). Depression and Menopause. Current Knowledge and Clinical Recommendations for a Critical Window. Psychiatric Clinics of North America.
Maki, P.M. (2016). Cognition and the menopause transition. Menopause.
Marin, R. and Diaz, M. (2018). Estrogen Interactions with Lipid Rafts Related to Neuroprotection. Impact of Brain Ageing and Menopause. Frontiers in Neuroscience.
Del Rio, J.P. et al. (2018). Steroid Hormones and Their Action in Women’s Brains: The Importance of Hormonal Balance. Frontiers in Public Health.
British Menopause Society. (2019). Testosterone Replacement in Menopause. Available: https://thebms.org.uk/publications/tools-for-clinicians/testosterone-replacement-in-menopause/ [Accessed October 2019].
Fischer, B. et al. (2015). Effects of Hormone Therapy on Cognition and Mood. Fertility and Sterility.
Gordon, J.L. et al. (2018). Efficacy of Transdermal Estradiol and Micronized Progesterone in the Prevention of Depressive Symptoms in the Menopause Transition. JAMA Psychiatry.
Soares C.N. et al. (2001). Efficacy of Estradiol for the Treatment of Depressive Disorders in Perimenopausal Women. Archives of General Psychiatry.
Lehert, P. et al. (2015). Individually modifiable risk factors to ameliorate cognitive aging: a systematic review and meta-analysis. Climateric.
Di Pasquale, M.G. (2009). The Essential of Essential Fatty Acids. Journal of Dietary Supplements.
Amen, D.G. et al. (2017). Quantitative Erythrocyte Omega-3 EPA Plus DHA Levels are Related to Higher Regional Cerebral Blood Flow on Brain SPECT. Journal of Alzheimer’s Disease.

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