Dr. Heidi Queen, MD | Energize Health & Hormones

For many women, the most unsettling part of the menopause transition isn’t a hot flash. It may be the sudden feeling that something about them has changed. They may feel more irritable than usual, emotionally fragile, anxious, exhausted or simply unlike themselves. Sleep may become more difficult at the same time, making everything else harder to manage. A new study adds to growing evidence that the hormonal changes of menopause can affect much more than reproductive symptoms—and that treating those changes may have benefits beyond hot flashes and night sweats.

Menopause can change the way you feel, not just the way you feel physically

Mood disturbances are common during the menopause transition. Depression, anxiety, irritability and mental exhaustion can occur alongside the more familiar symptoms of changing hormones. Research cited in the new study suggests that 45% to 68% of women experience some degree of mood disturbance during the menopause transition. Women may also be two to four times more likely to experience depressive symptoms during perimenopause or early postmenopause than during other stages of life. That doesn’t mean every emotional change in midlife is caused by menopause. Mood is influenced by many factors, including stress, relationships, sleep, physical health and previous mental health history. But fluctuating estrogen levels appear to be one important piece of the picture.

And that piece is particularly interesting because estrogen doesn’t act only on reproductive tissues. Estrogen receptors are found throughout the brain, and research has linked changing estrogen levels with alterations in brain activity, neurotransmitter systems and blood flow.

What did the new study find?

Researchers at NYU looked at 260 women who had not previously used hormone therapy and who began systemic HT for FDA-approved menopause-related indications. The women completed the Menopause Rating Scale before and after treatment, allowing researchers to look at changes in psychological, physical and genitourinary symptoms. Sleep, including insomnia symptoms, was also evaluated. The results were notable.

Across the group, psychological and sleep symptoms improved after hormone therapy. Most strikingly, the percentage of participants classified as having severe mood symptoms fell from 62.3% before treatment to 24.6% afterward. Women who started with the most severe mood symptoms tended to experience the greatest improvement.

The researchers also found that the response did not appear to depend on whether a woman had a previous psychiatric diagnosis, was taking antidepressants, her age, or where she was in the menopause transition. That’s an important finding because it suggests that significant mood symptoms during menopause shouldn’t automatically be dismissed as simply a recurrence of depression or anxiety—or as something a woman just needs to tolerate.

Why might hormones affect mood and sleep?

There is a biological reason researchers are interested in this connection. Estradiol, the predominant estrogen during the reproductive years, interacts with systems involved in mood regulation. Experimental research has found effects on serotonin and norepinephrine, as well as other signaling pathways involved in brain function. Lower estrogen status has also been associated with changes in brain structure and activity, while estrogen replacement has been associated with improvements in cortical blood flow and certain patterns of brain activation.

Sleep adds another layer to the story. Sleep disturbances affect an estimated 40% to 60% of women during menopause. Hot flashes and night sweats can interrupt sleep, but hormonal changes may contribute to sleep difficulties in other ways as well. Poor sleep can then contribute to fatigue, difficulty concentrating, anxiety, irritability and the familiar experience many women describe as “brain fog.” In other words, mood and sleep don’t necessarily exist in separate boxes. A woman who isn’t sleeping well may feel emotionally worse, while emotional symptoms can make restful sleep more difficult.

This doesn’t mean hormone therapy is a treatment for depression

This is an important distinction. The study found an association between systemic hormone therapy and improvements in mood and sleep in women who were already using HT for FDA-approved indications. Hormone therapy is not FDA-approved specifically to treat mood disorders, and there is still no standardized approach for using HT as a treatment for mood symptoms during the menopause transition.

The researchers also describe the existing evidence as mixed. Some earlier randomized trials found benefits from transdermal estradiol in perimenopausal women, while other studies have found neutral effects. Research has also suggested that timing may matter, with some evidence of benefit during perimenopause that isn’t necessarily replicated after menopause. That’s why this new study is interesting without being the final word. It supports the idea that mood deserves to be part of the menopause conversation—not an afterthought once hot flashes have been addressed.

What if you simply don’t feel like yourself?

That may be one of the most useful questions to bring to a menopause-focused appointment. Changes in mood, sleep, energy, concentration and emotional resilience can have a substantial effect on quality of life. They can also be easy to overlook because midlife often comes with plenty of legitimate sources of stress. A comprehensive evaluation can help distinguish hormonal symptoms from other possible contributors and look at the whole picture rather than assuming every symptom has a single cause.

For some women, hormone therapy may be an appropriate part of that picture. For others, a different approach—or several approaches working together—may make more sense. The right decision depends on individual health history, symptoms, timing, risks and goals. The larger message is encouraging: you don’t have to assume that feeling unlike yourself is simply something you have to accept because you’re going through menopause.

Dr. Queen takes a personalized approach to women’s health through perimenopause and menopause, looking at symptoms and long-term health together. If changes in mood, sleep, energy or other aspects of midlife health are affecting how you feel and function, schedule a consultation with Dr. Queen to explore what may be contributing—and what options may be appropriate for you. Call (415) 548-7901 to learn more and to schedule your appointment today.