Introduction

Menopause happens to all women as they grow older. Many women dread its onset because they associate it with myths that have circulated for generations. These myths center on the belief that all women "going through the change" must endure harrowing physical symptoms and mood swings that take them from irritability and rage to sadness and depression.

Menopause, in and of itself, does not cause depression. In 1996, researchers reviewed almost a hundred articles written about menopause and concluded that depression and menopause are unrelated¹. Menopause and mood were also a topic of discussion at the recent First World Congress on Women's Mental Health in Berlin, Germany. Researchers there again emphasized the psychological rather than biological causes of depression during menopause. They asserted that if a woman experienced changes in her mood during menopause, it was more likely due to her attitude toward menopause than to hormonal changes. In other words, if she thought that menopause was going to be a difficult experience, she was more likely to have a difficult time².

Therefore, it is safe to say that psychological changes at menopause often have more to do with the status of a woman's self-confidence, and her overall outlook, than with her hormones. It is these factors that make her susceptible to depression.

Basic Facts About Menopause

Except in the case of ovarian disease or surgical removal of the ovaries, menopause is the natural cessation of menses and the end of a woman's reproductive years. There is no discrete biological event marking menopause. Rather, a woman knows she has undergone menopause in retrospect - usually about six months after her final menstrual period. The process can take a year or so. For more information on the biological aspects of menopause, and what goes on in your body, please see the link at the end of this article.

Psychological Stress

A woman at midlife is apt to be undergoing changing family roles, shifts in her social networks, and personal losses, which can contribute to depression. For example, a woman in her 50s may see her children leave home to go to college, or move to a distant job, or perhaps get married. Commonly referred to as the "empty nest syndrome", this circumstance sometimes causes a woman to feel emotionally lost as a result of her children growing up, becoming more independent, and needing less direct care from her.

Also, this may be a time of marital separation or divorce if a couple has been unhappily married but stayed together for the sake of the children (who by this time are presumably old enough to cope with a parental break up). Divorce almost always means the loss of family and friends and, along with that, loss of a stable social network. It may also result in the need to find employment outside the house, increase work hours, or attend school or a training program in order to develop marketable skills. If these cannot be accomplished, a woman in her 50s may face a lower standard of living and have to cope with financial pressures, which can also affect her psychological wellbeing.

Finally, as a woman ages, so do her parents. Menopause may occur when her parents' physical or mental health is beginning to decline. She may have to contend with taking on their care - in their home, her home or in a community facility. Besides these new and often agonizing responsibilities she may start to contemplate the eventual death of her parents, or perhaps confront their death at this time. These painful events come at a point when she is probably focusing on her own aging and mortality.

Sexuality

Besides changes in marital and care-taking roles, some women may experience an adjustment in the way they think about themselves as sexual beings. This may in part be due to the physiological changes that occur during menopause including vaginal dryness caused by the thinning of the cells that line the vagina. Such changes sometimes result in pain during intercourse.

These biological changes, together with intense and unrealistic societal pressures to retain a youthful appearance, can diminish a woman's sense of herself as attractive and sexually desirable. She may begin to experience a decrease in self-esteem as a result of this.

Depression

During the course of their lives, almost everybody has some rough times that are accompanied by bad days during which they feel down, tearful, frustrated or easily irritated. Though people may say they're "depressed" during those times, they are usually experiencing a normal reaction to a difficult period. Menopausal women may have many blue days as a reaction to stress factors (such as those described above) that can occur at the same time as menopause.

But when a bad day extends into many days, weeks and months, it's possible that a true depression has developed. True depression is more than fleeting sadness. A person is considered to have true depression when he or she has many symptoms that last continuously for more than two weeks. These symptoms include a depressed mood, diminished interest in daily activities, difficulty sleeping, agitation or lethargy, trouble concentrating, and thoughts of suicide³

Degrees of Depression

There are varying degrees of depression, with Major Depression being the most severe form. But depression can also occur in a lesser form known as Dysthymia, characterized by fewer symptoms. Many people with this diagnosis continue to function well despite their emotional discomfort, but could nevertheless benefit from treatment.

Insufficient Sleep

The biological, social and psychological issues that menopausal women may come up against can put them at risk for sleep deprivation. In some cases, lack of sufficient sleep can mimic some of the signs of depression. For instance, decreased hours of sleep, or disturbed sleep, could lead to a "domino effect" in which lack of restful sleep results in fatigue, impaired concentration, and loss of interest in activities that are normally pleasurable. In other instances, these symptoms can make existing feelings of loss and sadness worse, thereby fueling the onset of depression.

Managing Depression During Menopause

Regardless of the degree of depressive symptoms a woman may experience, there is no reason for her to put up with them. There are many effective treatments for depression and its variations. Psychotherapy is one such treatment, though for Major Depression, it is often only one part of a two-part program, which generally calls for a combination of anti-depressant medication along with psychotherapy. Primary care physicians often prescribe anti-depressant medications, as do psychiatrists. Generally, anti-depressants have few or no side effects, but can take up to several weeks to work.

Psychotherapy most often involves meeting weekly with a trained mental health professional. This can be a psychologist, social worker, or psychiatrist. Psychotherapy is based on the idea that, with the guidance and support of an objective listener, people can devise new and better strategies to cope with life's problems.

Common forms of therapy that women may find useful include the following, used either alone or in combination with one another:

• Cognitive-Behavior Therapy: This form of therapy looks at a person's behaviors, thoughts and feelings and how they are inter-related. Through this, individuals learn coping skills that allow them to manage strong feelings such as sadness and hopelessness. When people become depressed, they tend to see most situations in a persistently negative light. Through Cognitive-Behavior Therapy, people learn to clarify their perceptions and see things in a more realistic light. (For more information on how these strategies can better help you deal with being upset, please see the link at the end of this article).
• Relaxation Training: The goal of relaxation training is to teach people how to reduce the intensity of their emotional reactions in stressful or upsetting situations. Through the consistent use of various relaxation methods, including meditation, yoga or self-hypnosis, people increase their capacity to cope with difficult situations. (For more information on meditation and deep breathing please see links at end of article.)
• Group Therapy: This treatment consists of a small group, led by a trained therapist. The group typically meets once a week, and members can share experiences and derive comfort from one another. In addition to being a good source of support during menopause, it also reassures people by making them aware they are not the only ones facing the problems they are dealing with.

Midlife: a Time for Self-Care

Midlife is an ideal time for women to focus on taking care of themselves and improving the quality of their lives. After all, it stands to reason that a woman who feels healthy and happy is going to be better able to meet the challenges of the aging process, including menopause.

However, as daughters, wives and mothers, women spend so much of their time attending to other people's needs that they may forget, or may not have the opportunity to notice their own needs and attend to them. In addition, some women may be socialized to think that paying attention to one's own needs is "selfish".

It is important to bear in mind that "self-care" is not the same as selfishness. Taking care of yourself is not a luxury but a necessity, since your long term well-being and happiness depend upon it. There are many ways to take care of yourself during menopause. Here are some suggestions:

• Keep in connection with others: Make the time to talk with friends and family. These relationships are valuable sources of comfort and support during times of stress and sadness. If you cannot get adequate support from your family or friends, then explore support groups, either in your community or on the Internet. Whatever you do, make sure you are not isolated.
• Exercise: In addition to benefiting your mood and sense of self, it helps your heart and bones. Regular exercise also helps regulate weight, and can help improve sleep.
• Take time to engage in enjoyable activities: Try to find time each day to do something enjoyable such as reading, quietly drinking a cup of tea, or taking a relaxing bath. Pursue your hobbies. All of these help to increase your good feelings and lower the chances that you will feel down.
• Ensure Proper Nutrition: Make sure you are getting the proper nutrition in the right amounts and don't cut down on healthy foods because you find yourself busy. For more information on proper nutrition, please see links at the end of the article.
• Healthy Habits: Consume only moderate amounts of alcohol and caffeine. In excess, they can have negative health consequences including disturbed sleep and disturbed mood. If you smoke, consider stopping. (For more information on stopping smoking, please see link at the end.)

Summary

It is reassuring to remember that menopause won't last forever. Most women go through it with minimal discomfort. For those who encounter mood disturbances or depression, there are a variety of effective treatments.

More important, after menopause many women feel a sense of liberation. They no longer have to contend with premenstrual pain or unintended pregnancies. Some report actually experiencing "postmenopausal zest"- that is - renewed energy and interest in making the last third of their lives a time of pleasure and personal fulfillment.

If you are going through menopause and find yourself feeling blue, remember to seek advice from health care professionals in your community. With self-help programs, psychotherapy, medication, or a combination of these, you can get through a tough period and look forward to better times ahead.