New York psychotherapist Colette Dowling, LMSW, author of the following article on menopausal depression, has written eight books on women's issues, including the international best-seller, The Cinderella Complex: Women's Hidden Fear of Independence, which was published in 23 languages.
Menopausal depression has long been the subject of controversy. The question has been: Do women have a vulnerability to becoming depressed at menopause, or don't they?
Menopausal depression is a complicated subject because so much happens to women at mid-life. Certainly they undergo dramatic hormonal changes, and sometimes--for example, after hysterectomy--with shocking abruptness. Hysterectomies are hormonally disruptive even when the ovaries are left intact. However, when ovaries are removed, depression is virtually predictable. The estrogen levels plummet rapidly--within a matter of hours--after hysterctomy, and this leaves women vulnerable. Why? Because serotonin, a hormone that's of major importance in maintaining good mood, requires estrogen for its production in the brain. When estrogen levels drop abruptly, so does serotonin, and mood changes can be fairly sudden and dramatic.
However, it doesn't take a hysterectomy for menopause to produce the surprisingly wide range of physical and mental symptoms associated with menopausal depression. It was only when I was a year past menopause that I began to address the sleep problems I was having, as well as the loss of energy and libido. I had also been having odd lapses in memory. For six months or so I stumbled a lot, and had a hard time focusing on my work. I felt depressed and anxious and needed frequent naps. I can joke, now, about the bleak fantasies on which I'd obsess as I lay awake at night, but at the time I was worried about how long I'd be able to keep on supporting myself. My freelance income had dropped as my ability to plan and think ahead was compromised. I was stuck in this pattern for many many months, and it became hard not to think: Is this it, the end of my vitality and productivity?
It took far longer than it should have for me to learn that menopausal depression, related to a drop in estrogen, was causing my symptoms, and to get the treatment that put me back on track. Estrogen levels begin dropping in the mid-thirties, making pregnancy less likely. In a woman's early forties, menstrual cycles become shorter and FSH (follicle stimulating hormone) may be elevated. By then, the perimenopause has begun, and while pregnancy isn't out of the question, it's unlikely. By the late forties, menstrual cycles become irregular and periods can produce heavy bleeding. Irregularity is the harbinger of menopause. Some women miss a period or two and then it's all over. For others, the irregularity goes on for a year or longer.
That is but the briefest outline of the menopausal trajectory. Things become more complicated when we contemplate the effects of hormones and other body chemicals on each individual woman. Estrogen isn't the only thing acting on the woman at midlife. Who gets hit with hot flashes, insomnia, and mood changes--and when, and how severely, and for how long--has to do, in part, with brain neurotransmitters like serotonin.
Serotonin regulates sleep, energy, mood and libido, and is central to our well-being. Women (like men) vary in the amounts of serotonin they have available in the brain. Researchers have suggested that women who have low serotonin to start out with (largely a genetic matter) may become more symptomatic than other women at menopause.
The hormones in the endocrine system all interact with one another, so that when one hormone is off it can affect many systems in the body. For example, it's a good idea, if you're suffering from depression, to have your thyroid levels checked, since lowered estrogen can pull down thyroxine levels. A low thyroid condition (hypothyroidism) mimics, perfectly, depression.
The low serotonin levels caused by menopausal loss of estrogen can sometimes be offset by vigorous exericise,or by daily use of a lightbox that emits 10,000 lux of light. This is another example of hormone interaction, since melatonin is affected by light, and melatonin affects serotonin production. (Lightboxes can be found on the internet.)
Finally, and not least, the low serotonin levels produced by lowered estrogen can be treated with antidepressant medication. The SSRIs, the newest category of antidepressant, work directly on the serotonin in the brain.
Certainly there are social and cultural stressors that can occur at mid-life--job changes, care of elderly parents, and the loss of husbands and children among them. When you add to such stressors the radical hormone shifts that occur at mid-life, it's easy to see why women become vulnerable to menopausal depression.
Some women treat their menopausal depression and other symptoms with hormone replacement therapy. Such treatment should be brief since estrogen has been connected with breast cancer and heart disease. For this reason, antidepressant medication may be the safer bet when treating menopausal depression.
Women at mid-life often feel guilty about their mood changes and avoid seeking treatment. "This will pass," they think, and while that may be true, depression can seriously affect the quality of life, including one's ability to make a living. There is nothing less serious about depression at menopause than there is at any other time of life. And, just as at any other time of life, depression at menopause can be effectively treated. If you're not quite sure what's going on, speak to your regular physician or gynecologist. A depression screen will quickly establish whether or not you're clinically depressed and need treatment.
New York psychotherapist Colette Dowling, LMSW, is best known for uncovering women's psychological conflicts with independence in her best-selling The Cinderella Complex: Women's Hidden Fear of Independence. She has written many other books on women's issues, including Red Hot Mamas: Coming Into Our Own at Fifty, and "You Mean I don't Have to Feel this Way?": New Help for Depression, Anxiety and Addiction.
Ms. Dowling is a graduate of The Smith College School for Social Work, where she received a masters in social work degree. She has done advanced training at The Institute for Contemporary Psychotherapy, and has a private therapy practice in New York.
Colette specializes in the treatment of women. For a consultation with her, call 718-594-0201, or write firstname.lastname@example.org.
See description of Colette Dowling's therapy practice at Psychology Today.
To hear Colette speaking on what it's like beginning therapy with someone new, click the audio button.
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