Why do I feel so anxious all the time, and what can I do about it?
This prevalent complaint is one that I often hear from my patients who are 40-55 years old. This age group is going through the menopausal transition—the years leading up to menopause, also called perimenopause. Perimenopause is often a time of significant life changes in addition to physical ones. Stress is a natural outcome when you're juggling childcare issues, household chores, aging parents, financial challenges and other responsibilities. Many women complain of memory lapses, or feeling like they’re “going crazy.”
During perimenopause, ovarian function slows and levels of estrogen and progesterone begin to decrease. Mood changes, including depression, anxiety, anger and irritability can occur. There are a variety of causes and treatment options for women experiencing these symptoms. In this post, I will discuss some general strategies for handling these life changes. Things to try:
Get enough sleep. It is critical.
Perform daily exercise; enough to make you sweat. It really helps!
Practice meditation/relaxation/stress reduction. There are wonderful meditation courses, apps on your phone, yoga classes, religion, walks in nature, etc. available to you. Clia Tierney's post on mindfulness has some useful resources.
Get help. Communicate with your family and your work colleagues that you need to offload some work for a time. What tasks can you delegate to someone else? Would talking about issues with a friend or a counselor help you cope, or facilitate making those hard decisions?
You can’t be everything to everyone, all at the same time. You must put the oxygen mask on yourself first before you can help anyone else.
Sleep issues Perimenopausal women often have sleep problems. They may have insomnia, difficulty falling asleep, early awakening or sleep disruptions in the middle of the night. Night sweats are a common complaint. When we dream, rapid eye movement (REM) occurs; if REM and dreaming are inadequate, a person’s mood, concentration and ability to cope with challenges are impaired. Anger, depression, anxiety and other mood changes commonly result. More than 75% of women with insomnia can identify a specific cause; often it is stress related to work and/or family issues. Also, depression/anxiety symptoms themselves contribute to sleep disturbances. New-onset sleep apnea, chronic pain, acid reflux, a new need for over-the-counter medications (decongestants, cold medications), a snoring bed partner and restless legs syndrome are also common in this age group. Things to try:
Do your best to address identifiable causes of stress—sometimes a counselor who is distinct from your immediate friends and family can be especially valuable.
Don’t get frustrated if you wake up. It is entirely normal to wake in the middle of the night, and it's very common. If you can’t get back to sleep in a few minutes (don’t watch the clock), get up, read a relaxing, happy book in low light (avoid screens), and return to bed within 30 minutes or so.
If hot flashes are extreme, consider hormonal therapy for a short period.
For further suggestions on general sleep hygiene, look at these two Soulful Insight posts: Understanding Inflammation and The Power of Sleep.
Depression/anxiety New-onset depression or anxiety is twice as likely in perimenopausal women. Preexisting premenstrual syndrome (PMS), or mood changes the week before menses, may worsen. Anger and crying episodes may occur. Things to try:
If episodes are short (hours to a day) and manageable, extra kindness to yourself can sometimes be enough. Schedule more downtime during these periods, have dinner delivered, put off that big decision, watch something funny and laugh out loud.
If episodes last closer to a week, or repeatedly recur throughout the month and are significantly affecting your quality of life, it’s time to visit your healthcare provider. Screening for depression/anxiety, substance abuse and evaluation for thyroid disorders is helpful to determine the next step.
Often, a small amount of daily estrogen, or a low dose of an antidepressant taken just the week before your period (if that’s the only time mood is an issue) or continuously for six months to a year, may be all that is needed.
Taking a low-dose birth control pill continuously, which removes the cyclic swings of hormones, can help mood and control irregular bleeding, which is common during the menopausal transition.
If none of this is enough, a visit to a psychiatrist and consideration of anti-anxiety medications is an option.
Sometimes, just knowing the diagnosis and understanding that symptoms frequently resolve after menopause is enough to help you cope. Try to remember to have a sense of humor and laugh at yourself. It can be very freeing to perimenopausal women to bring your symptoms out from the shadows and openly discuss them with family and friends—and to do so with humor. A good, loud belly-laugh on a daily basis is my strong recommendation. It won’t fix everything, but you’ll definitely feel better. To that end, enjoy this funny video featuring Tom Hanks and James Corden. Be ready to laugh out loud!
Resources
Bromberger JT, Schott LL, Kravitz HM, et al. "Longitudinal change in reproductive hormones and depressive symptoms across the menopausal transition: results from the Study of Women's Health Across the Nation (SWAN)." Arch Gen Psychiatry. June 2010; 67:598. www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-menopause/abstract/7
Grady Deborah. "Clinical practice. Management of menopausal symptoms." N Engl J Med 2006; 355:2338–47. www.nejm.org/doi/full/10.1056/NEJMcp054015
Greendale GA, Derby CA, Maki PM. "Perimenopause and cognition." Obstet Gynecol Clin North Am. 2011; 38:519. www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-menopause/abstract/25
Maki PM, Freeman EW, Greendale GA, et al. "Summary of the National Institute on Aging-sponsored conference on depressive symptoms and cognitive complaints in the menopausal transition." Menopause. July 2010; 17:815. www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-menopause/abstract/11
Juang KD, Wang SJ, Lu SR, et al. "Hot flashes are associated with psychological symptoms of anxiety and depression in peri- and post- but not premenopausal women." Maturitas. 2005; 52:119. www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-menopause/abstract/48
Stanford Medicine Sleep Health and Insomnia Program: med.stanford.edu/insomnia.html
Andie Hutchinson, MD
Andie Hutchinson completed her undergraduate major and master's degree at UCLA in kinesiology, specifically cardio-respiratory exercise physiology. She obtained her MD at the University of South Carolina and her residency in OB/GYN at Kaiser Santa Clara. Andie was a clinical assistant professor at Stanford, where she also operated and delivered babies. After having her third child with her physician husband, she moved her practice to Kaiser Santa Clara where she sees both obstetric and gynecologic patients. Her interest in exercise physiology continues into her clinical practice, where she helps manage pregnant athletes. She also has a special interest in teens and in menopausal patients. Andie uses a holistic approach to patient wellness, discussing diet, exercise, emotional well-being and goals at patient visits. She encourages patients to seek help where needed, and become better advocates for themselves and their families. ahutchinson13@gmail.com
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