Perimenopause and Mood
If you’re entering the perimenopause years, it’s easy to feel like you’re on an emotional rollercoaster. It seems like everyone around you appears to be taking life in stride while you’re just barely getting through the day. You may be feeling uninspired and flat. The things you normally love to do aren’t lighting you up quite like they used to. Maybe it’s anger. Even the slightest irritation can have you feeling like you might fly off the handle. Or perhaps you’re anxious. You’ve noticed an increasing tendency to marinate in a conversation that happened days ago. Was that comment sarcastic or sincere? Whether subtle or severe, changes in your emotional landscape during perimenopause are incredibly common and real. In this article we’ll dive into biological and social drivers behind perimenopause mood-related symptoms and discuss things you can put in place to feel grounded, even-keeled and empowered during this transition.
As your body enters perimenopause, there is seismic activity happening in your endocrine system. It’s gearing up to stop releasing eggs and put the kibosh on menstruation so it can enjoy the post-reproductive phase of life. During the time leading up to menopause, hormone levels fluctuate like crazy (particularly estrogen) and regular periods be damned. These new hormonal shifts are responsible for a slew of physical symptoms that may arise during perimenopause– insomnia, hot flashes, palpitations, vaginal dryness, brain fog, reflux, weight changes, etc. – but they certainly don’t just impact the physical body. They often profoundly affect mind and mood. Research¹ shows women are increasingly vulnerable to both depression and anxiety during perimenopause. But despite how common it is to feel emotionally off kilter during this time, for many females, the mood-related symptoms come as surprise. And they are so often the most challenging and lonely part of this transition.
“We prepare our daughters for their periods, but no-one prepares us for menopause”
Someone once told me this and it was striking. Perimenopause is essentially reverse puberty, but without anyone telling you how to prepare for it. You’re left to your own devices to navigate the wild fluctuation of hormones that is about to ripple through your body for the next four-ish years. What if someone sat you down and told you not only what is about to happen in your body is real and normal, but there are things that can make it easier? Before we jump into what can serve as a lifeline during this time, let’s talk about why what you’re feeling is not just in your head.
What the research says
The connection between perimenopause and mood-related symptoms is clear. According to research² published by the Obstetrics and Gynecology Clinics of North America, a female’s risk for depression rises sharply during perimenopause. They found risk for Major Depression increases two to five-fold during menopause³-⁶, with the highest rates of depression occurring during perimenopause or the early phase of post menopause. Depression is complex and can so often be the result of many factors. Stress, interpersonal challenges, major life events happening to significant others, financial difficulties and lack of environmental resources have all been shown to be correlated with developing depression during midlife.⁷ But when adjusting for all these factors, the research still shows a persistent elevated risk for development of depression during perimenopause alone. For many females, entering perimenopause during an acutely stressful time can be the straw that breaks the camel’s back. Why is this?
Our hormones play a huge role in our mood state. During perimenopause, estrogen levels become erratic as they begin a general trend down. Our brains are packed with estrogen receptors, making them highly sensitive to declining levels of estrogen. Estrogen receptors exist across many regions of the brain including the hippocampus, hypothalamus, amygdala, cerebellum and cortex.⁸ These regions govern our cognition, memory, coordination and emotions, and subsequently turbulent estrogen levels can result in potent changes in brain neurochemistry, structure and function across these regions.⁹ Unsurprisingly, this can cause big changes in everything from executive functioning to mood.
When looking specifically at the relationship between perimenopause hormones and mood, estrogen’s effects on the feel-good neurotransmitter serotonin is a hot topic. Serotonin is what makes us feel happy and calm, and contributes to emotional stability. Healthy estrogen levels promote serotonin synthesis and slows down its degradation so it can have more enduring effects .¹⁰ Estrogen also increases the number of serotonin receptors available and helps facilitate its binding to its respective 5-HTP receptor.¹⁰ This results in us feeling more settled, happier, better. Knowing this, we can begin to understand why a sudden downturn in estrogen and, consequently serotonin, would put a female at risk for feeling flat, or more seriously, depressed.
Depression isn’t the only mental health concern for perimenopausal females. A report⁷ from the Study of Women’s Health Across the Nation (SWAN) found females are more likely to feel anxious during perimenopause than in their reproductive years. Recent findings¹¹ published by the Journal of Australasian Psychiatry corroborated, noting menopause increases vulnerability to both depression and anxiety. In addition to reduced levels of serotonin during perimenopause, research¹² suggests anxiety during this time could also be connected with declining levels of the neurotransmitter GABA.
You can think of GABA as the body’s natural dimmer switch. It helps us feel relaxed, grounded and promotes good sleep. Low levels of GABA are linked with anxiety, depression, restlessness and insomnia, and are also thought to contribute to heightened feelings of anxiety. GABA depletion is also thought to be linked to inexplicable feelings of unease and anxiousness occurring during perimenopause. But are low GABA levels entirely to blame? Most likely not. Perimenopause hormonal changes impact many other biological chemicals and systems, many of which are connected to our mood state. And as we’ll discuss shortly, social and interpersonal factors can weigh heavily in the balance. The research surrounding hormones and mood is theoretically inexhaustible – there is a lot that has been uncovered but so much we have yet to, or will likely ever, understand.
Beyond biology — social and interpersonal aspects of aging and menopause
The connection between hormones and mood is evident. But is that it? While our biology certainty impacts our emotional landscape, there are social and interpersonal factors that can deeply influence these years. Maybe you are caring for an elderly parent or the kids are flying the coop. Perhaps you are coming up for air after the news of a life-altering diagnosis or figuring out how to move forward in the wake of loss. These kinds of experiences shake something fundamental in our being. Midlife can bring life changes that leave deep imprints on our physiology and emotional being.
Additionally, the idea of menopause itself can be a very emotionally charged concept. It marks an entirely new phase of life and there may be contemplation about aging and what lies on the road ahead. Going through menopause in a society that so often touts aspects of youth often brings up complex emotions. How could it not? As females, we’re the overt targets of a million different anti-aging products and potions. As one journalist put it poignantly, “In this culture, to age is to be erased — to be deemed irrelevant, disappear from magazine covers and popular films and get tucked away into facilities, managed and cared for. For women, it also means being turned from a coveted object into a disposable one. We spend our lives fighting our own disappearance.”¹³ It is one thing to navigate biological impacts of menopause. It is an entirely different challenge to go through menopause in a society where mainstream messaging tells us our very nature is something to oppose, hide and reverse. Societally and interpersonally, we have a long way to go in order to make ourselves and others feel valued at all stages of life.
For many generations, females have quietly gritted their teeth. Fortunately, it seems, the paradigm is shifting. There is more conversation and awareness around how we can support each other through what can be a wonderful season of life. There is an increasing recognition that aging is an innate aspect of the human experience, one that can not only merely be accepted but embraced. In fact, Traditional Chinese Medicine has long honored perimenopause as a powerfully transformative time. It provides a lens in which to view this transition as an opportunity and encourages us to lean into what these years have to offer.
Perimenopause – A Second Spring
Chinese Medicine views perimenopause as a renaissance of sorts, so much so it has dubbed it the Second Spring. According to the traditional text The Yellow Emperor’s Classic of Medicine, the menopause transition is described as such: “At seven times seven (perimenopause years) a woman’s heavenly dew (menstruation) wanes; the pulse of her Conception channel (hormones) decreases. The Qi that dwelt in the baby’s palace (the uterus) moves upward into her heart and her wisdom is deepened.” According to Chinese Medicine, perimenopause is a physical and energetic shift. When we age, magic happens. A body that was busy expending reproductive energy every month now has the opportunity to go do other awesome things. We can consider this time fertile ground for reflection, leaadership and heart-centered growth.
Let’s honor the transition to menopause by reclaiming this time and celebrate what is gained with aging. If you’ve made it to menopause, chances are you’ve lived through a lot. And with lived experience comes irreplicable perspective, that when shared, has the capacity to make others feel understood and less alone. Perspective that has the potential to unify, teach, inspire and heal. What if we saw our Second Spring as a gateway for creativity, intuition, empathy, expression and leadership? The knowing of ourselves, our gifts and the human experience only deepens from here.
Supporting Your Mental Health During Perimenopause
The perimenopause years can hold a lot. Here are ways you can support mental health during this time so you can enjoy what this season has to offer.
Traditional Chinese Medicine
Acupuncture offers a gentle and sweet avenue of care during perimenopause. Beyond serving as a blissful container for relaxation, clinical trials show acupuncture reduces the severity of both depression and anxiety, as well as depression specific to perimenopause. ¹⁴,¹⁵,¹⁶(Acupuncture is can also be a highly effective treatment for physical symptoms associated with perimenopause. This topic is juicy and deserves a separate article). It may seem mind-boggling that placing tiny needles along the body can improve one’s emotional landscape, but there is a method to the madness.
Acupuncture improves mood by regulating the flow of the body’s Qi and blood, as well as calming the Shen or mind. Physiologically speaking, during acupuncture the body can release a mix of mood stabilizing neurotransmitters like serotonin, GABA, dopamine and endorphins. In addition to this cocktail of feel-good substances, acupuncture can also facilitate the release of many other healing neurochemicals, including ones that lower inflammation, enhance circulation and ameliorate pain. By stimulating the release of the body’s innate healing resources, acupuncture can profoundly impact mind, body and mood.
Acupuncture treatment for perimenopause is focused on balancing the Yin and Yang energies of the entire body. During perimenopause the body’s Yin energy (estrogen) is naturally declining and the Yang energy (follicle stimulating and luteinizing hormones) can become relatively out of balance. Acupuncture cues the body appropriately to bring Yin and Yang energies into balance via activation of the nervous system and meridians. Research¹⁶ shows a consistent trend between successful acupuncture treatments and a subsequent increase in circulating estrogen levels (Yin) and decrease in follicle stimulating hormone / luteinizing hormone levels (Yang). Because of its hormone regulating abilities, acupuncture can also help ameliorate physical symptoms of perimenopause.
In addition to acupuncture, herbal medicine works synergistically to regulate the perimenopause hormonal transition and address related symptoms from the inside out. An herbal formula is not an everyday tea you grab off of the shelf at your local grocery store, nor is it a one-size-fits-all approach. Herbs are carefully selected based on your symptoms, constitution (tongue, pulse, complexion), physiology, medical conditions and any supplements or medications you are taking.
We often get asked how Chinese herbs differ from medications or single supplements. A big difference is that medications and single supplements have potent effects on a single pharmacological target. Herbal formulas offers more wide-spread biochemical effects. Many herbs and formulas have been shown to exhibit a wide-variety of anxiolytic and anti-depressant effects.¹⁷,¹⁸Additionally, medicinal plants that make up herbal formulas contain rich arrays of vitamins, minerals and antioxidants. Like acupuncture, herbal medicine can help simultaneously address both the psycho-emotional and physical symptoms related to perimenopause.
Acupuncture and herbal medicine are just two therapies under the broader scope of Traditional Chinese Medicine. They serve as part of a holistic approach to addressing perimenopause symptoms. Acupressure, cupping, gua sha, tui na (traditional Chinese bodywork), dietary and lifestyle recommendations are all wonderful, additional modalities you can receive during your session.
Attitude as Medicine
The Study of Women’s Health Across the Nation looked at the relationship between attitude and perimenopausal depression. What they found is fascinating. Being a highly action-oriented middle-aged female is protective against depression symptoms. On the contrary, anxiety, pessimism, rumination, self-consciousness and a tendency to experience chronic, negative emotions were all significantly associated with an increase in reported depressive symptoms. While this information may seem intuitive, it offers an important insight. Our attitude and actions are where we have skin in the game for helping ourselves emotionally.
Anxiety and depression are characterized by stickiness (in Chinese Medicine we see anxiety and depression as having components of both physical and metaphorical phlegm – this concept of phlegm also deserves an article of its own). It’s hard to get out of bed and our thought patterns. In general, we feel stuck and have trouble getting moving and doing. When life gets stressful (e.g., hitting perimenopause), it can be far easier to feel stuck. One very powerful tool to help us dislodge ourselves is learning the difference between feeling and ruminating. Feeling our emotions is healthy and helpful. Ruminating is not. Here’s how to tell the difference.
Feelings are strong waves of emotion that often accompany bodily sensations like chest tightness, closing of the throat, tears, sensation of heat, shakiness, an upset stomach, you name it. They can be incredibly intense and unpleasant, but are quick-lived. On average, peak intensity of an emotions lasts just 90 seconds. But if we can allow ourselves to fully sit with the discomfort of a strong emotion, we enable it to eventually move through us.
Rumination is the act of allowing the mind to ceaselessly wander down the path of ‘what-ifs’ or dwell in a past situation. We are quite literally stuck in a thought loop. Rumination is a wolf in sheep’s clothing because we can trick ourselves into believing we are doing emotional due diligence. But at its core, rumination is fundamentally draining and unhelpful because we are either 1) churning over something in the past we can’t change or 2) refusing to accept the reality of future uncertainties. Cutting off rumination is uncomfortable at first, but we can spare ourselves grief in the long run by learning how to do so.
Pumping the brakes on rumination begins with recognizing the moment the mind starts looping through the ‘what ifs’ or what is past. When this happens, it’s time to reorient to the present. And one amazing way to do this is by taking action. Even though I’m feeling glued to my mattress and lost in my thoughts, I’m going to choose to get up and walk around the block, cut the scrolling, pick up the paint brush or pen, scrub the bathroom floor, etc. So often the hardest part is getting started. And once we do, it can be tempting to believe the myth we should feel better immediately. And when we don’t, it’s easy to throw in the towel. Action-oriented folks recognize the psychic rewards of engagement may not be instantaneous, but they do it anyways. When we elect to put anxious thoughts on the shelf and step out into the world, magic happens. Things like enhanced creativity, new friendships, more time for uninterrupted rest, greater resiliency and a quieter headspace become more abundant. We can choose intimacy with our negative thoughts or our lives. The choice is ours.
Yin Nourishing and Mood Boosting Activities
Read a book. Good literature gets us out of our own head and fosters new perspective and empathy. If you’re searching for inspiration to go after your purpose, look no further than Moonrise, The Power of Women Leading From the Heart. Editors Nina Williams and Anneke Campbell have woven together excerpts from the lives of females who are changing the world by following the thread of their purpose and expanding the definition of leadership to encompass tolerance, intuition, relational intelligence and respect. For those of us who want some cut and dry advice on ways to banish self-limiting ways of being, The Four Agreements by Don Miguel Ruiz is a quick read that empowers and inspires accountability. If you’re seeking a page of perspective a day, few writers are as adept at touching on aspects of our humanity as poets Mary Oliver and Mark Nepo. Devotions and The Book of Awakening can remind us of the resiliency of the human spirit and our capacity for love.
Garden. Few things are as grounding as spending some time in the dirt. Don’t have a garden of your own? Sign up for a Farm & Garden volunteer shift at world-famous Esalen Institute and enjoy a free pass to their facilities, including dreamy hot springs overlooking the coast.
Take a bath. A bath is an easy way to reset the nervous system and sink a good night’s sleep. Take it to the next level by carving out time to visit one of California’s numerous natural hot springs for a mineralizing and deeply restorative soak.
Build five communities. Few things support mental wellness like human connection. Five communities can be friends, family members, an exercise group, clubs, colleagues, meetups, classmates, neighbors, online circles, etc. Join the group, strike up the coffee shop conversation, show up for the class. It may take a few swings and misses, but making a consistent effort can be the difference in welcoming incredibly special people into your life.
Questions about how Traditional Chinese Medicine can support you during perimenopause? Contact us at hello@alamereacupuncture.com.
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