The menopause is a natural event that is heralded by many changes, both physical and psycho-emotional. These changes often begin several years before the complete cessation of menstrual periods. Women may experience mood changes ranging from mild feelings of sadness to severe depression and/or varying degrees of anxiety. A major depressive episode as defined by the DSM-IV (Diagnostic and Statistical Manual) requires that "five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure." The additional symptoms include (3) weight loss or gain, (4) insomnia or hypersomnia (excessive sleep), (5) psychomotor agitation or retardation, (6) fatigue or low energy, (7) feelings of worthlessness or excessive guilt, (8) diminished ability to think or concentrate, and (9) recurrent thoughts of death, contemplating suicide or suicide attempt.

It is not surprising that depression and anxiety can surface for the first time in a woman entering the menopause. Hormonal fluctuations and changes in brain chemistry can cause drastic mood swings. Sleep deprivation is common during this time and can lead to fatigue and irritability. However, for many women, non-hormonal stresses may contribute significantly to the development of depression and anxiety. Women in the mid-life are often "sandwiched" between caring for their aging parents and caring for their younger children or adolescents. Getting older in a society that heavily values youth and beauty can be extremely difficult, and is often accompanied by changes in self-esteem and body image. Altered marital relationships or divorce, career issues, and the struggle to create a balance between family, work and caring for oneself are all common stressors for women in the midlife.

If you are experiencing depression or anxiety, a consultation with your physician is advised. Certain medical conditions, such as thyroid and adrenal disease, as well as medications (e.g. antihypertensives, steroids, birth control pills) may lead to mood disorders. Your physician can help you sort out which symptoms may be hormonal, biological or situational or stress-related.

What steps can YOU take to reduce mood changes? First, establishing the nature of the stresses in your life will empower you to begin making positive changes. Creating a balance between work and family obligations is difficult, but devoting even a small period of time on a regular basis for self-nurturing activities may be enough to make a difference. This might include reading, writing letters to friends, a warm bath by candlelight, gardening or meditation. Exercise is a natural mood enhancer and effectively reduces stress. This may include aerobic exercise four times a week or yoga. Nutritional therapy or natural supplements may help to reduce menopausal symptoms. If you are overweight, weight loss can improve mood and self-esteem. Of course, some stressors will not go away, such as caring for ill or elderly parents. However, small changes in other areas of your life can make a big difference. Open and honest communication with loved ones and friends might lighten the burden of responsibility.

Despite all their best efforts, some women may feel overwhelmed and need additional help. For some women, psychotherapy can offer healthy perspectives and effective coping skills. Others may additionally benefit from anti-depressants or anti-anxiety medication. There is some evidence that estrogen replacement may enhance mood in women who have mild feelings of sadness or "the blues." Estrogen receptors are present in the brain and have been found to exert an influence on brain chemicals, known as neurotransmitters. Hormone replacement therapy may also improve psycho-emotional well being by relieving menopausal symptoms such as hot flashes and night sweats, which often lead to sleep dysfunction, heightened anxiety and irritability.

However, depression that is severe may not be as responsive to hormone replacement. In this situation, medical treatment may be necessary in order to restore normal mood. Severe depression is marked by feelings of hopelessness and worthlessness, loss of interest or pleasure, weight loss or gain, insomnia or excessive sleep, fatigue, poor concentration and recurrent suicidal thoughts. Your primary care physician or psychotherapist can help you determine if medical treatment is appropriate. Multiple medications are available and treatment must be tailored for each individual, as there are variable side effects and drug interactions.

If you are living with depression and/or anxiety, recognize that you are not alone. Spend some time reflecting on possible causes of your mood changes. There are many options for treating depression and anxiety during the perimenopause and menopause. Natural therapies such as exercise or nutritional therapy along with carving out time for self-nurturing might be enough to make a difference. Other women may benefit from medication, psychotherapy or anti-depressant medication. Consider a consultation with your physician to discuss the options available to you.

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