Not just hot flushes: how menopause can destroy mental health - The Guardian

At her lowest point, Karen Arthur came within a hair's breadth of killing herself. Having been signed off from her teaching job with anxiety, which she had not then connected with going through the menopause, the 51-year-old had booked a few days away from home to try to clear her head. A long walk in the country brought her to a spot notorious for suicide attempts.

At that stage, she says, she had not considered how she might kill herself, but she had put her affairs in order for her two daughters, who were away at university. "I did think it would be easier if I wasn't here. The kids would get the house, the mortgage paid off."

This moment, she says, was her turning point. "I remember thinking how desperate you have to be … And thinking very lucidly: 'I don't want to die, I don't want to kill myself, that's too real for me.'" Instead, she walked to the nearest pub, ordered chips and a hot chocolate with rum. Then "I took my journal out and decided that I wanted to live. I started to write about the things I wanted to do. That was the lowest point but also the highest point – it brought me back from the brink."

Arthur quit teaching, started therapy, embarked on a new career in fashion design, and six years later – in the emotionally charged aftermath of George Floyd's murder, amid the rise of the Black Lives Matter movement – created the positive ageing podcast Menopause Whilst Black, after finding woefully few resources catering specifically for black women. Research suggests they enter menopause earlier on average than white women, and are more likely to experience some symptoms, including depression. When she first saw her GP about her anxiety, she mentioned she was having hot flushes, but, she says, she wasn't offered hormone replacement therapy (HRT) and, at the time, thought being menopausal was the least of her worries. "I didn't know that anxiety and depression could be linked to menopause. Everything I know about my journey, I know in retrospect."

Midlife mood swings, rage and forgetfulness may be the stuff of jokey Instagram memes. But, as Arthur found out, for many women in perimenopause (the transition stage leading up to periods stopping) and menopause (defined as having gone a year without a period), they are anything but funny. A survey of 2,000 women commissioned by the House of Commons women and equalities select committee inquiry into menopause at work last year found 75% reported problems with memory or concentration and 69% reported feeling anxious or depressed – not necessarily to clinical levels, but often enough to reduce concentration and confidence at work. And in rarer cases, those mood swings can be extreme.

Last month, the actor Kathy Burke told the Observer that she had experienced "pretty dark, suicidal thoughts" in her early 50s, which she linked to menopause. Unable to take HRT because of other medication she was on, Burke said she had struggled for years. Meg Mathews, the menopause campaigner and former wife of Oasis star Noel Gallagher, has similarly described such anxiety in her late 40s: "I couldn't leave the house for three months."

Yet mental health in menopause remains surprisingly ill-explored, the waters muddied by the way it coincides with what is often a time of wider upheaval in women's lives. These are the emotionally turbulent years of children leaving home, elderly parents getting sick, midlife divorces and transitions at work that can make it harder to disentangle cause from effect. Do you feel mentally unwell because your life is in flux? Or is your life in flux, at least partly, because your hormones are?

Dr Louise Newson, a GP and menopause specialist, has recently worked with the Royal College of Psychiatrists to train its members on the mental health implications of menopause. Most of the patients she sees at her private clinic in Stratford-upon-Avon cite mental as well as physical menopause symptoms and many, she says, are desperate; some have tried everything from electric shock therapy to spending thousands of pounds on experimental treatments. "We've seen people who have been on ketamine, clinics that have been giving ketamine – that really scares me," she says. (Ketamine is a licensed anaesthetic, sometimes used illegally as a party drug and sometimes prescribed "off-label" to treat depression.) "We see a lot of women who are suicidal."

Research into mental health during menopause is still "not as good as you would want," Newson says, but it is now well established that the hormones oestrogen and testosterone, which decline in midlife, play important roles in brain function. "We know that anxiety and memory problems, low mood and reduced motivation are very common in menopause. Whether it's the actual level of hormones or fluctuations of hormones – anything that's changing in the brain has a knock-on effect." She says women who have previously had episodes of depression – as Burke had – or postnatal depression may be at particular risk of deteriorating mental health in menopause; so might women who suffered severe premenstrual syndrome or its more intense cousin premenstrual dysphoric disorder (PMDD) around the time of their periods.

Not all mental health problems in middle-aged women are hormone-related, Newson stresses, and HRT isn't a magic cure for everyone. "Often I will optimise hormones and then see what the patient's mental health is doing. Some women do need antidepressants." But the link between menopause and depression is now sufficiently recognised that the NHS prescribing watchdog, the National Institute for Health and Care Excellence, recommends HRT as a first line of treatment for low mood or anxiety in menopausal women. Yet still, Newson says, she sees women who have been sent away by GPs with nothing but antidepressants. One reason she created Balance, her free app which helps women recognise and log menopause symptoms, is to help doctors and patients to join the dots. "For so long we have been told that menopause is about hot flushes and vaginal dryness. We haven't been told it can affect your mood or energy or concentration," she says. "Women get told to put up and shut up the whole time."

That resonates with Kate Duffy, who was a 44-year-old single mother of children aged four and two when she went to her GP complaining of anxiety, insomnia and severe mood swings along with more puzzling physical symptoms, including hair loss. Her doctor diagnosed depression, but Duffy was convinced it was more complicated. "I was thinking, 'I'm not saying I'm not depressed, but I think it's related to menopause'," she says. "I kept going back and saying that, but they wouldn't listen. I was banging my head on a brick wall for a year, it was so frustrating. I'd be Googling and there would be lots of women like me, up in the middle of the night trying to find out what was wrong with them, saying: 'My marriage is over, I can't do the job I've done for 30 years, I can't think straight, I feel suicidal …'"

It was only after her first hot flush, she says, that the GP – who had thought her too young to be perimenopausal – ordered the blood tests that confirmed her hunch. Even then, says Duffy, she had to fight for HRT; and only when another woman tipped her off about a specialist menopause clinic in her home city of Oxford was she diagnosed retrospectively with PMDD, explaining a long previous history of severe mood swings around her periods. "It made sense of the past 30 years of my life, where I was up and down like a yo-yo, going in and out of the GPs, saying, 'I feel like killing myself … oh no I don't, I'm fine now.' It was completely cyclical." Duffy now serves as a "patient tutor", sharing her experiences with trainee doctors to help counter what she sees as "the lack of awareness, the lack of training in women's healthcare – it's an absolute disgrace. It's like we're not worth the research."

At 55, her moods are now far more stable, but the experience has left its mark. Having felt unable to return to her old office job, she now makes a more flexible living painting and upcycling furniture. Shockingly, a survey of 4,000 women commissioned for the recent Channel 4 documentary Davina McCall: Sex, Mind and the Menopause found one in 10 had quit their jobs because of menopause symptoms – either mental or physical – while 14% had reduced their working hours. "I know of women signing non-disclosure agreements and being performance managed out of jobs at quite a high level [because of menopause symptoms]," says Kate Muir, the author of Everything You Need to Know About the Menopause, who produced the Channel 4 documentary.

Muir, who herself had such chronic "brain fog" in her late 40s that she feared she was getting Alzheimer's, says her memory improved dramatically within a week of starting the right HRT. But she remains intrigued by the relationship between mental health and the chronic insomnia middle-aged women often experience, sometimes without realising that it can be a menopause symptom. "One of the markers for future dementia is lack of sleep. It really matters, and it's a marker for depression, too," she points out. For many working mothers, there is a particularly cruel irony to battling through the sleepless fog of early motherhood, only to be sideswiped professionally by broken nights again just as their children are finally grown up.

Lauren Chiren, 54, was in her early 40s and working as a senior executive in financial services when she found herself struggling to remember things. It wasn't just forgetting the odd name, she says: one night she came home from work, greeted her son and his nanny, and then picked up her bags again to go out to work. "I'd forgotten I'd left for the day. I was losing the plot." Her confidence plummeted, and she began to avoid speaking up in meetings for fear of revealing the gaps in her memory. Convinced she must have early onset dementia, and terrified about how she would cope as the single parent of a child with lifelong medical needs, Chiren negotiated an exit deal and resigned. "I left work because I genuinely felt I was running out of time, and I would have to find someone else to look after my son," she says. When blood tests carried out by her doctor confirmed she had been through early menopause, she was flabbergasted: "I thought that was something that happened to older women, and it would be the occasional hot flush."

Chiren now runs a coaching business, Women of a Certain Stage, providing awareness training for employers to support staff through menopause, plus personal coaching for women to keep their careers on track. She helps her clients to recognise and track their symptoms, seek out what she calls "small adjustments" at work that can help them cope, and consider lifestyle changes such as taking up exercise and improving their diet. (Not everyone can take HRT, she points out, and some actively don't want to.) Her first event in the City of London was so packed that it was standing room only, but she realised several of those attending had blacked out their diaries for the day "so that people didn't know they were there".

It is still hard, says Chiren, for some women in competitive environments to talk about menopause at work. "Often they've worked hard to get where they are. They don't want anything to single them out as weak or vulnerable." Women who coast through this period relatively easily, meanwhile, may be reluctant to advertise the existence of midlife anxiety and forgetfulness, worried that it will become just another excuse for writing off older women.

Yet as Arthur points out, the embarrassed silence that can shroud mental health problems in menopause leaves many women woefully ill-prepared to recognise the symptoms. When it happened to her, she says, she felt utterly alone. "My thinking now is that the more of us who speak, the less we will feel alone."

In the UK and Ireland, Samaritans can be contacted on 116 123, or email jo@samaritans.org or jo@samaritans.ie. In the US, the National Suicide Prevention Lifeline is 1-800-273-8255. In Australia, the crisis support service Lifeline is 13 11 14. Other international helplines can be found at befrienders.org.

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