Menopause Transitions

Imagine everyone tells you that there's going to be a storm for your whole trip. So you pack for it, cancel your outdoor plans, brace yourself. And then you get there and the weather is... fine. Maybe a few grey days. Not the storm you were promised.

That's basically what this episode is about, except the trip is the menopause transition, and the forecast is a cultural narrative that's been building since 1816.

We're working from a major Lancet review that looked at whether menopause actually causes the universal mental health decline it's been blamed for. Turns out, for most people, it doesn't. We get into what the research actually found, who's genuinely at higher risk and why, and what happens when you believe a bad forecast that was never accurate for you in the first place.

This one's for anyone approaching menopause, anyone going through it, or anyone who's ever been told to expect the worst about a life stage before they'd even lived a day of it.

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Imagine you're about to travel somewhere new, and everyone who's been there tells you the same thing. Pack for storms, it rains the whole time, the weather's terrible, so you pack accordingly. You cancel plans that involve being outside, you brace for it, you arrive, and you spend the whole trip watching the sky. And for some people, it does rain. Genuinely, it does. But for most people, the weather turns out to be fine. Maybe a few gray days, but not the storm they were promised. The forecast was wrong, and following a wrong forecast has its own costs. You spend the trip anxious about weather that never came, you interpreted a few clouds as the beginning of something much worse, you made decisions based on a prediction that didn't apply to you. That is what the research is now saying about menopause and mental health. The forecast most people receive doesn't match the weather most people actually experience. But some people do hit real storms. Knowing whose forecast actually says rain and why is the point of today's episode. Today's paper is Brown It All, Promoting Good Mental Health over the Menopause Transition, published in The Lancet in 2024. Okay, so before we look at what the research actually says, let's talk about where the forecast came from, because it didn't come from nowhere. The menopause transition usually starts around age 47, which changes to the menstrual cycle, and it ends at the final menstrual period. And since 1916, clinicians have been associating this transition with psychological distress. By 1959, medical texts were calling it a rather unpleasant and possibly dangerous period of life. The first widely used menopause symptom checklist developed in the 1950s included psychological symptoms like melancholia and nervousness as defining features of the menopausal experience. That checklist informed the clinical frameworks that followed, and the framing stuck. Anxiety, depression, mood instability, irritability, paranoia, even psychosis have all been attributed to menopause in medical and popular literature, often without rigorous evidence to back up the claims. The result is a forecast that has been handed to people approaching this life stage for decades. A survey of over 7,000 European and Australian women found that about half of European respondents and 56% of Australian respondents were concerned about managing menopause, and most did not feel well supported going into it. UN data cited in the paper shows 90% of people globally hold gender-based biases that are shaping these narratives. And there's a clinical consequence of all of this. Only 6.8% of training physicians in one US survey felt adequately prepared to address menopause. So people are receiving a forecast of storms from a culture that's been broadcasting it for over a century, and then going to clinicians who haven't been trained to give them a more accurate one. The paper makes a point I think is important. Misattributing psychological distress to menopause rather than to its actual causes harms people in a specific way. It delays accurate diagnosis, it delays effective treatment, and the negative expectation itself. Believing a storm is coming can make you experience a drizzle of downpour. Believing you're vulnerable to depression because of menopause can contribute to depression in a way that has nothing to do with your hormones. The researchers reviewed 12 perspective studies on depression and the menopause transition. Perspective means they actually followed people over time, measuring mental health before, during, and after the transition, rather than asking people to look back and remember. Their conclusion, there is no compelling evidence for a universal or uniform increased risk of major depressive episodes or depressive symptoms over the menopause transition. The storm that most people were forecasted, most people's weather just didn't match. Only a minority, somewhere between 5 and 9% of people, actually experienced increasing depressive symptoms over midlife. And 8 to 11% actually experience decreasing depressive symptoms. The majority are somewhere in the middle, neither dramatically better nor dramatically worse than before the transition. And I want to be clear about what these numbers are measuring because the paper makes this distinction carefully. Major depressive disorder is a clinical diagnosis affecting about 6% of the global population in any given year, requiring sustained symptoms assessed through a clinical interview. Depressive symptoms are broader, measured through self-report scales, and can include things like disrupted sleep and fatigue that have many possible causes. During the menopause transition, hot flashes and night sweats can disrupt sleep in ways that push up scores on a depressive symptom scale, even when someone isn't experiencing a depressive episode. It's important not to confuse elevated scores with clinical disorders. The most consistent finding across the prospective research is this: the clearest predictor of depression during the menopause transition is having had depression before. The study of women's health across the nation followed over 3,000 people for 13 years and found a 2.67-fold increased risk of major depressive disorder recurrence for people with a prior history, but no increased risk for first lifetime onset in people without that history. The clouds are most likely to gather if they were already there, basically. Studies that did find increased risk were largely finding it in specific subgroups, not across the board. People with both vasomotor symptoms and stressful life events in the preceding six months, people with a longer duration of menopause transitions, people who had surgical menopause. Not everyone. The storm, where it happens, has identifiable causes. So the question becomes whose forecast actually says rain? The paper breaks this down into two categories: established risk factors that exist independently of menopause, and menopause specific factors that are part of transition itself. The established risk factors are familiar. A lifetime history of major depressive disorder is the strongest single predictor. Adverse childhood experiences, financial difficulties, unemployment, lack of social support, high neuroticism, sedentary lifestyle, these aren't new weather symptoms that menopause creates. They're existing conditions in the atmosphere that menopause transitions can interact with. The transition doesn't generate the storm, it can activate a system that was already primed. The menopause specific factors are where it gets more interesting because they're more modifiable. Vasomotor symptoms, meaning hot flashes and night sweats, are bidirectionally associated with depressive symptoms. A systematic review of 33 publications found the relationship runs both ways. Vasomotor symptoms disrupt sleep, and disrupted sleep drives mood disturbances, and low mood and stress can make vasomotor symptoms feel more severe. The humidity in the forecast is bidirectional. Sleep disturbances is the key mechanism. A pooled analysis of longitudinal data from over 20,000 people found that sleep disturbance largely accounted for the association between vasomotor symptoms and depressed mood. It's often not the hormonal shift itself that drives mood change. It's the accumulated effect of nights that don't restore you, compounded over months and years. Estradiol variability matters for some people. Studies with frequent hormone measurements found that greater fluctuations in estradiol, not absolute levels, were associated with worse moods, particularly in people who are mood sensitive to hormonal changes. This is a subgroup phenomenon. Some people's symptoms are more sensitive to shifts in estradiol than others. The way some people feel temperature changes more accurately than others do. And when you layer high estradiol variability on top of stressful life events, the risk of depressive symptoms rises significantly. Negative attitudes towards menopause and aging independently predict worse outcomes. People who enter the transition expecting difficulty, who frame it as decline, who hold the forecast of storms as a certainty, tend to have more depressive symptoms than people with more neutral or affirming views. This is the forecast making the weather worse. Believing the storm is coming changes how you experience the clouds. There's something I find hopeful in this. Even though it can also sound frustrating, if attitudes shape outcomes, attitudes can be shifted. The cultural forecast hasn't been handed to people over a century. It's not fixed, it's a story. And it's one that can be told differently with evidence behind it. The paper covers several other mental health conditions and the menopause transition. I want to go through each one quickly because the picture is quite different depending on which one you're looking at. Anxiety. Four perspective studies found mixed results. Two found no increase in anxiety symptoms over the transition at all, and two found association only in specific subgroups, mainly people with severe vasomotor symptoms. The overall conclusion: no consistent evidence of a universal increase. Worth noting that vasomotor symptoms themselves, like sweating, the racing hard, the rapid breathing, can look like anxiety symptoms. Clinicians need to be careful not to conflate the two or to assume anxiety is hormonal when it might be a separate condition that needs separate treatment. Bipolar disorder. There are no prospective studies on this specifically. The available evidence is largely retrospective, meaning it relies on people's memories rather than real-time measurement. One small study found increased depressive episodes during the transition in people with bipolar disorder. A systematic review of retrospective studies suggested a possible symptom increase, but the evidence base is genuinely thin. This is an area where more research is needed and where the current clinical guidance is cautious. Psychosis and schizophrenia. No prospective studies exist on psychosis rates during the menopause transition. There's a theoretical basis for concern. The estrogen hypothesis, suggesting declining estrogen might trigger psychotic episodes in some people. But the empirical evidence is described in this paper as scarce. This is a claim that has been widely repeated in both clinical and popular context without adequate prospective data behind it. Finally, suicidality. Recent media and clinical claims have suggested women are at elevated suicide risk over the menopause transition. The paper's assessment is direct. There is no substantive evidence of an association between attempted or completed suicide and the menopause transition. One large longitudinal study, which is the most significant data point here, found that menopausal hormone therapy was actually associated with a significant increased risk of suicide attempts and completion. The reason for this association are not yet understood, but it's a finding that warrants serious investigation, not dismissal. The fact that some of these claims aren't well evidenced doesn't mean the experiences they describe aren't real. It means that research hasn't caught up yet, or the studies that exist have found have significant limitations. The honest scientific position in some of these areas is that we don't know. And that's different from the answer of being no. Okay, so if you know whose forecast actually says rain, the next question is, what do you actually do about it? The paper's position here is clear. Depressive symptoms and major depressive disorders during the menopause transition should be treated the same way they would be at any other life stage, not as menopause problem requiring a menopause solution, but as a mental health problem requiring evidence-based mental health treatment. Cognitive behavioral therapy is the most well-evidenced approach. It's recommended by NICE guidelines for depression across adulthood. It's effective for anxiety, and it has specific evidence for reducing vasomotor symptoms and improving sleep disturbances, which means CBT is doing multiple things at once in this context. It addresses the mental health symptoms directly and it also works on the menopause-specific weather conditions that are driving them. Mindfulness-based stress reduction, MBSR, are also promising evidence specifically for this life stage. In one randomized controlled trial of 104 people in menopause, MPSR effectively prevented the development of depressive symptoms, while also promoting higher resilience and lower stress and anxiety. The benefits were particularly pronounced in the highest risk group. People with previous major depressive disorder, stressful life events in the preceding six months, and increased mood sensitivity to ostrial fluctuations. So BSR appears to work best exactly where the most rain is expected. Antidepressants, specifically SSRIs and SNRIs, are effective for major depressive disorder during menopause transitions, as at other life stages. For people approaching menopause who are already on active treatment for major depressive disorder, the paper recommends continuing that treatment rather than discontinuing it, given the elevated risk of recurrence during this period. Menopausal hormone therapy, this probably the area of highest public confusion right now, and let me be honest, MHT is not approved by regulatory agencies in Europe or the US as a treatment for major depressive disorders. Trial results have been small and mixed. However, MHT does improve concurrent depressive symptoms when troublesome vasomotor symptoms are present. If the pathway to low mood runs through vasomotor symptom disrupting sleep, treating the vasomotor symptoms treats a cause, not just the surface. The weather changes when you fix the humidity. One well-designed randomized control trial found that high-dose transdermal ostrageol with progesterone half the risk of emergent depressive symptoms in at-risk perimenopausal women, with an incidence of 17.3% compared to 32.3% in the placebo group. The effect was strongest in people with stressful life events and ostragel mood sensitivity. So there is a subgroup for whom MHT genuinely changes the forecast, but it doesn't show the same protective effect in people who had already experienced major depressive episodes. The paper's overall position on MHT for mental health is measured. It may help with concurrent depressive symptoms when vasomotor symptoms are present and significant. It's not a first approach for depression in the absence of vasomotor symptoms, and the association with increased suicide risk in one large study is a finding that needs to be taken seriously and investigated further. Okay, so that was a lot of information. Let's put it all together. The forecast most people received before menopause says to expect storms, depression, anxiety, decline, instability, and when researchers followed thousands of people through the transitions over more than a decade, most people's weather didn't match up. Only 5 to 9% experienced increasing depressive symptoms. And the storm is not universal. But some people do hit genuinely rough weather. People with a prior history of depression, people with severe vasomotor symptoms, keeping them up at night, people navigating major life stressors at the same time, people who had surgical menopause, these groups are at real risk, and that risk has real identifiable causes. And the wrong forecast has its own cost. When you believe you're heading into a storm, you read every cloud as the beginning of something worse. You misattribute things that have other causes, you delay getting help for what's actually happening because you assume it was just menopause. And here's what I want to leave you with. The conditions in your forecast are mostly modifiable. Sleep can be treated, vasomotor symptoms can be managed, therapy works, the tools are there. The question is knowing which tools apply to which weather. The Benopause transition doesn't have to be the forecast you were handed. It can be one that's actually accurate for you. Leave a review if you have a minute. And I'll see you in the next one.