Insight: Perimenopause, menopause and your mental health and wellbeing

By Dr Haleema Sheikh, a specialist in integrative women’s health and bioidentical hormone balancing for the Marion Gluck Clinic.

Perimenopause refers to the menopausal transition phase in women’s lives when the levels of reproductive hormones become more variable, and they can start to experience physical and mental symptoms related to these changes.

Menopause is diagnosed when a woman has not had a period for 12 consecutive months, and this usually happens between the ages of 45 and 55.

Hormones are our bodies chemical communication messengers which are carried in the blood stream around the body and are responsible for modulating and regulating activity in all our organs and tissues.

Women have receptors for the reproductive hormones produced in the ovary and adrenals (estrogen, progesterone and testosterone) in every tissue in the body including the brain. Thus, the hormonal imbalances during perimenopause and loss of hormones during menopause can have significant far-reaching consequences on our mental health.

Women are more susceptible to hormonal mental health issues as there is a complex interplay of reproductive hormones which need to be in sync to have a regular menstrual cycle.

This delicate interplay is often disrupted during perimenopause with estrogen not being balanced by progesterone (our soothing calming sleep supporting hormone) and then as we progress into menopause, we also lose the supportive effects of estrogen on the brain.

Women’s ovaries have a finite lifespan and during perimenopause which can start on average 6 years before menopause there can be significant hormonal disruption.

Women may start to have anovulatory cycles where they don’t ovulate each month and this results in estrogen being dominant as there is no progesterone rise in the second half of the cycle without ovulation. The lack of progesterone will also impact sleep quality and length which can further disrupt our mental health.

Progesterone enhances the activity of gamma-aminobutyric acid (GABA), a neurotransmitter that promotes relaxation and reduces anxiety. This is why low progesterone levels can contribute to increased stress, irritability, and anxiety which are often seen in perimenopause.

Progesterone is generally the first hormone to be lost in perimenopause. Unfortunately, many women are diagnosed with depression and anxiety at this time and are given antidepressants which may be helpful but do no tackle the root cause which is hormonal disruption.

Estrogen has powerful positive effects on the female brain, affecting mood, memory, cognition, and emotional well-being. It
plays a key role in neurotransmitter activity and boosts serotonin (the happiness hormone) and dopamine which help regulate mood and motivation. Estrogen also enhances the stress response; it modulates cortisol, the stress hormone, helping women cope with pressure more effectively.

By regulating sleep patterns through its influences on melatonin and circadian rhythms it also improves sleep quality and resilience which are key for mental health.

Coming onto Testosterone – it is not just a male hormone and it plays a crucial role in women’s brain health, energy levels and mood. Though women have lower testosterone levels than men, this hormone is essential for mental clarity, motivation, emotional resilience, and overall well-being.

Testosterone levels can be maintained by some women till later in menopause, but a significant proportion of women will have symptomatic loss of testosterone in perimenopause and so it is important to be aware of symptoms and test blood levels if considering support.

Testosterone has a mood stabilising effect and improves emotional wellbeing. It is also involved in neurotransmitter regulation and thereby reduces mood swings, stress and depressive symptoms. It also helps with enhanced confidence and motivation which gives women a sense of self assurance and emotional resilience in their lives.

The brain also receives feedback from the body and the gut and brain are deeply connected through the gut-brain nerve axis.

Changes in the gut microbiome (the friendly bacteria which reside in the large intestines) during menopause can significantly affect mood, mental health, and cognitive function.

As estrogen declines, the composition of the gut microbiome shifts, leading to inflammation, neurotransmitter imbalances, and increased stress response, which ultimately can contribute to anxiety, depression, and mood swings.

The gut communicates with the brain ‘telling’ it that the body is in a hostile environment and puts the brain into a high alert mode which can trigger hypervigilance and anxiety.

Ninety per cent of serotonin (the ‘happiness hormone’) is produced in the gut. Gut dysbiosis (an imbalance of good and bad bacteria) which is more common in menopause can disrupt serotonin and dopamine production, leading to depression, anxiety, and mood swings.

Low estrogen also leads to increased gut permeability (leaky gut), allowing inflammatory molecules and toxins to enter the bloodstream. This triggers neuroinflammation, which is linked to brain fog, fatigue, and low mood.

Healthy gut bacteria help regulate cortisol, the stress response hormone. An unbalanced microbiome can lead to higher cortisol levels, making women more prone to stress, panic, and emotional ups and downs.

The gut microbiome also influences melatonin (our sleep hormone). Dysbiosis can lead to insomnia, night wakings, and poor sleep quality, worsening irritability and emotional instability.

There are many signs and symptoms that may indicate the need to support hormonal balance which make sense now that we understand the impact of the hormones on the brain and body

• Frequent emotional ups and downs that disrupt daily life.
• Overwhelming anxiety or panic episodes.
• Difficulty focusing or remembering simple things.
• Persistent sadness or loss of joy.
• Chronic fatigue and lack of motivation.
• Feeling disconnected or unlike yourself.
• Irritability
• Low self-esteem and loss of confidence

There are many ways to restore balance, and a multipronged approach often works well:

• Lifestyle changes – Regular exercise, a healthy diet, and stress management are key to happy hormonal balance.
• Hormone therapy or Supplements – can be very helpful to help cushion the loss of ovarian function. Body identical and bioidentical hormones have the same molecular and chemical structure to our own hormones and have been shown to support the mental health issues that many women face
• Mental health support – Therapy, mindfulness, or journaling can be helpful to process the changes and build resilience.
• Sleep hygiene – Create a relaxing bedtime routine to improve rest is key to remaining high functioning and rebalance the system.
• Social support – Connecting with friends, support groups, or loved ones is protective for women going through this period.

Perimenopause and menopause often hit women during a time in their lives when they are juggling many balls including challenging careers, teenage children, spouse/partner, running a house and possibly looking after elderly parents.

The reproductive hormones provide resilience in the system which diminishes at this time. It is helpful for women to understand what is going on in their bodies during this transitional time and be kind to themselves as they recalibrate to lower hormone levels which can most certainly be done successfully.

The Marion Gluck Clinic is a UK-based medical clinic which uses bioidentical hormones to treat menopause, perimenopause and other hormone related issues.