It was always a delicate dance with my mental health - depression and anxiety were never far away - but in my early 40s, I started to feel next-level madness.
At first, I thought I felt dreadful because I’d finally stopped drinking alcohol. It was a victory after years of stopping and starting but I knew it had taken a toll on me physically. Maybe a few months of rest and healthy living would see me right? No, I was still bonkers. I could go from zero to 100 in two seconds, screaming at my kids, crying when the smallest thing went wrong. I began to hate people I previously loved, and had no energy. My hips and back hurt, I had major digestive issues and I was constantly itchy down there, though I didn’t have thrush. My sleeping was rubbish, I felt miserable and misunderstood and had a face full of zits to add to the wrinkles that were popping up. Worst of all, my hair started falling out. It was like some sort of puberty hell, but in reverse.
In fact, that’s what it was - perimenopause. My hormones were driving me mad.
I cottoned on to this reasonably quickly, but my doctor didn’t agree with my diagnosis. Because I was still menstruating, I had heaps of oestrogen and my ill health couldn’t possibly be to do with hormones. She tested everything else, told me everything was fine and trotted me out of her office. This happened a few times but I kept trotting back in, determined to get to the bottom of what was going on. The physical symptoms were almost bearable but my mood swings were definitely in full-on depression and anxiety territory and undoubtedly ruining my life. I knew HRT was something I needed to try.
The doctor finally agreed after I bawled my eyes out in her clinic, begging her to let me prescribe it to me. I raced to the chemist to pick up what I now call my Precious Patch of Sanity.
Most of my symptoms went away almost overnight and my mental health improved to safe levels for both me and everyone around me. I was nice again. I liked people. Once again, I liked my life.
Menopause is not an illness but hormones can control your mental health
That was 10 years ago. After a decade of outraged Gen X women yelling long and loud on social media about being denied HRT, perimenopause is well and truly on the table of women’s health. But although progress has been made, we still have a long way to go when it comes to hormones and mental health, says Deborah Brunt, a GP in Dunedin who specialises in integrative medicines and women’s health.
Generally speaking, depression has the highest rate among perimenopausal women, she says. It’s probably not a coincidence that poor mental health arises with massive hormonal shifts.
“I think women's mental health in general needs a bit of an overhaul because women experience different hormonal shifts that just aren't experienced by men,” Dr Brunt says.
She thinks that if women have mood changes, doctors need to consider the hormone factor.
Treating symptoms like pain with pain killers, depression with antidepressants and insomnia with sleeping tablets, without considering the possibility of hormone disruptions, seems counterintuitive.
“If somebody has low thyroid hormones and they are depressed, we don't try and treat their depression outside of treating their hormone [thyroid] issue. This is a really odd area of medicine where just treating all the different symptoms women are experiencing in perimenopause.”
What a lot of women experience in menopause is not illness, she says.
“Shouldn’t we just try and sort the hormones?”
Hormone therapy for women prior to perimenopause
International guidelines in medicine recommend the frontline treatment for women with premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) - prior to perimenopause or not - are SSRI antidepressants, Dr Brunt says. But because these conditions are hormonally mediated there are a number of hormonal treatments that can be helpful.
Some women are put on the contraceptive pill for PMDD, which changes hormones in a “roundabout” way, Dr Brunt says. However, hormone therapy also has a place in treating PMD - giving oestrogen patches and progesterone treatment at different points of the menstrual cycle and is one of the recommended treatments for PMDD in the international guidelines.
She’s treated women with hormone therapy from puberty until late 30s.
“We’ve had amazing results using estradiol patches and progesterone to treat PMDD in some women and it hasn’t shut down their ovary function. I've had people literally that have tried every hormonal contraceptive, which has had really negative impacts on their mood. After trying this approach they say, ‘This has changed my life’.”
Hormone therapy could also be used in women in their 40s as soon as they start experiencing hormonal changes to preserve their vaginal, urethral and bladder health.
“Some of the most important roles that oestrogen plays outside of the brain is in genitourinary symptoms.”
The microbiome of the vagina changes which can lead to deterioration of the vaginal vulval skin, otherwise known rather terrifyingly as vaginal atrophy.
But using vaginal oestrogen can prevent this deterioration and would be ideal for most women in their 40s. “It’s super important,” she says.
The whispers among women - “Oh-my-god I tried it and I went from ‘not tonight honey’ to wanting to hump a lamp post” - are getting louder and interest in this important hormone is growing.
All eyes on testosterone
The next hormone having a moment is testosterone. The whispers among women - “Oh-my-god I tried it and I went from ‘not tonight honey’ to wanting to hump a lamp post” - are getting louder and interest in this important hormone is growing.
Testosterone is important for wellbeing, mood, motivation and pleasure, Dr Brunt explains. It also works in many areas of the brain and body that oestrogen does - executive functioning, mood, temperature and metabolism and the brain.
By the time a woman reaches 40 she has half the testosterone levels she had at 20, and by the time her ovaries aren’t working, “There’s very little testosterone working at all.”
But in medicine, testosterone in HRT is a bit of an afterthought. There’s not a lot of research on how it affects women, other than women who have low libido in menopause improve by taking it.
“I think testosterone got labelled as a male sex hormone and oestrogen and progesterone got labelled as female sex steroids, which is also like a misnomer because men also make oestrogen and progesterone - it's just the ratios and the cyclical nature of the release that is different.”
Research on testosterone in menopausal women is scant but some studies have shown that some women with low libidos can benefit from taking the hormone. Testosterone has also been found to be useful for treating bone pain in women who’ve had breast cancer.
Dr Brunt hopes there’s more evidence to support using testosterone and other hormones in mainstream women’s HRT, ideally sooner than the 20 years it classically takes to filter down into clinical practice.
In the meantime, Pharmac has funded a testosterone gel which can be prescribed for women in menopause with low libido who might benefit from treatment. The funded version only comes in a male-strength dose, which needs to split into smaller doses. It’s a messy business but cheaper than the unfunded testosterone cream, that is formulated for use in women, which costs about $150 per tube.
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