There are many myths associated with menopause. One is the myth that mental health problems, such as depression and anxiety, are inevitable as hormone production decreases. In reality, there are no scientific studies to support the belief that natural menopause contributes to true clinical depression, anxiety, severe memory lapses, or erratic behavior.
However, many midlife women do suffer from feeling blue or discouraged. Others suffer from sleep deprivation and overwork, leading to fatigue and sometimes irritability. Support and encouragement can help women find their way through any difficult time to thrive once again during what can be the best years of their lives.
During reproductive years, most women become accustomed to their own hormonal rhythm, but during perimenopause, this rhythm changes. These hormonal fluctuations, although normal, can contribute to mood swings. The unexpected timing of menopause can also be upsetting. For some, the hormone-related changes coincide with other stressors and losses in life. Women in midlife are not unaccustomed to stress, but some women can be especially vulnerable to stressors that may arise.

In addition, in today's youth-valued society, getting older can be difficult. Midlife women often experience changes in self-concept, self-esteem, and body image. They may start to think about their own mortality and become introspective about the meaning or purpose of their lives.
Although these changes can be opportunities for positive transformation and growth, some women react by feeling overwhelmed, out of control, angry, and/or numb. They may look for refuge in alcohol or drugs and, thus, compound their problems.
In fact, women are more likely than men to drink more in response to feeling blue, experiencing loss or divorce, or children leaving home. Thus, although not caused by menopause, psychological problems can arise during midlife.

Emotional health during perimenopause requires a balance between self-nurturing and the obligations of work and caring for others. Many women are able to identify and describe sources of tension and symptoms of stress, but they often find it difficult to take care of themselves during these times. Recognizing a problem can lead to understanding its causes and developing new coping mechanisms. Although many stressors cannot be altered, coping skills can be learned to make a woman feel empowered to meet life's challenges. A renewed sense of self-confidence can restore balance and harmony.

Sometimes, coping skills are not sufficient to relieve the symptoms of stress. These feelings may be a side effect of medication, a symptom of a medical condition, or the result of depression. A healthcare provider can help determine the cause of mental health stressors, assess options, and prescribe appropriate treatment.

The psychological disturbances reported most often by perimenopausal women are irritability and blue moods. These can often be relieved through lifestyle changes. Relaxation and stress reduction techniques help many women cope with life stress factors during this time of hormonal fluctuation. Mood disturbances brought on by sleep deprivation resulting from hot flashes usually improve when hot flashes are treated.
Clinical depression is not related to menopause, but it is associated with a chemical imbalance in the brain. If medication is needed for mild to moderate depression, herbal remedies such as St. John's wort may help. If the depression is more severe, one of a variety of effective prescription antidepressant medications can be prescribed to correct the chemical imbalance. Although several weeks are usually needed for the drug's full effect, most women show a marked improvement with these medications with relatively few side effects. Antidepressant medication is best used in combination with counseling or psychotherapy.

• Eat three nutritious meals a day, don't skip meals
• Snack on healthful, crunchy foods, such as apples and raw carrots
• Find or renew a creative outlet or activity that fulfills mental and spiritual needs.
• Try stress reduction and relaxation techniques, such as deep breathing and meditation
• Get adequate sleep each night
• Laugh as much as possible

Hormone therapy, as part of a comprehensive treatment plan, is reported to help some women with depression. Many women respond well to estrogen therapy, but it may actually worsen mood in some women who are clinically depressed.
The prescription hormone progestin, a synthetic progestogen, may also worsen mood, particularly in a woman with a history of mood changes prior to each menstrual period during younger years. Women who must take progestin to protect the uterus from cancer and who have mood problems while taking one drug regimen may find relief by trying different forms, doses, or regimens of progestogens. No hormone is FDA-approved for relief of psychological symptoms.

Anxiety - an agitated sense of anticipation, dread, or fear - is experienced by everyone at one time or another. Perimenopausal women may have more anxiety due to physical and psychological changes as well as a variety of stressors. Although this anxiety usually resolves on its own without treatment, it may accompany or be a warning sign of another medical illness, such as panic disorder. Panic disorder can result in shortness of breath, chest pain, dizziness, heart palpitations, and/or feelings of "going crazy" or being out of control. Sometimes the unsettling feelings that precede a hot flash can trigger feelings of panic or an attack of anxiety. Sometimes anxiety symptoms can be related to depression.
Women with severe symptoms of anxiety can usually find relief through therapeutic approaches, including prescription drug treatment, relaxation techniques, stress reduction techniques, counseling, and psychotherapy.

Perimenopausal women frequently report difficulty concentrating and minor memory problems (especially remembering something that was very recent). These difficulties often frighten women, who may think they are beginning to have early symptoms of Alzheimer's disease. This is rarely the case. More research is needed to determine the cause of these complaints. They may be more related to stress and aging than to the menopause transition. Some women report that estrogen therapy provides relief, but estrogen is not FDA-approved for this use. Also, lowered estrogen levels may be associated with memory problems and Alzheimer's disease later in life, although research in this area is contradictory.

Although some individuals may feel embarrassed or even ashamed about revealing their mental health problems, no one should suffer in silence. Women should seek help from their healthcare provider, who will be better able to help when given as many facts as possible about family and personal history. Most healthcare providers are not specifically trained in the management of mental health disorders. A consultation with a mental health professional is sometimes appropriate. For a specific problem, such as marital trouble or an eating disorder, a counselor with expertise in that area is best. Consultation with a mental health professional is not a commitment to long-term treatment, and getting an expert opinion can be reassuring.

Perimenopausal women often report other health changes that may or may not be attributed to approaching menopause. Among these changes are weight gain, heart palpitations, joint pain, headache, and changes in the skin, eyes, hair, and teeth.

In their 40s and 50s, women often gain weight and sometimes attribute this gain to menopause or hormone therapy for menopause-related conditions. However, the notion that menopause or hormone therapy is responsible for weight gain is not supported by scientific evidence. Midlife weight gain appears to be mostly related to aging and lifestyle. Studies reveal the following:

• Behavioral factors, particularly decreased exercise and increased alcohol consumption, are more closely linked to weight gain than either menopause or hormone therapy.
• Body shape typically changes with aging - from a "pear" (wide hips and thighs) to an "apple" (wide waist).

Muscle mass often decreases, while fat often increases. Although this shift may not increase weight (muscle weighs more than fat), body size will go up. The loss of muscle mass also decreases metabolic rate and lowers a woman's caloric need, which can lead to weight gain. Exercise seems to have the most beneficial effect on minimizing fat increases and maintaining muscle (thereby minimizing body size and increasing caloric need). Women, both perimenopausal and postmenopausal, who are looking for a lower fat-to-muscle ratio will find more reward in resistance type exercises, such as weight lifting.
In general, fewer calories are needed after menopause, when less energy is expended. Thus, a woman can eat the same amount and gain weight.

There is no scientific evidence linking heart rhythm abnormalities (palpitations) with the diminished hormone levels of menopause. However, an increase of 8 to 16 beats in heart rate can occur during a hot flash, which some women may interpret as a heart problem. Palpitations may also be the result of thyroid disease or anxiety experienced with mood changes or from more serious psychological upset. It is unlikely that palpitations experienced at this time are related to heart disease. Nevertheless, women experiencing heart palpitations should report these feelings to their healthcare provider to rule out serious illness.

There are no studies linking menopause and joint pain. However, the risk of osteoarthritis - the most common form of joint disease - increases with aging. Suffering from joint pain is not inevitable. A woman's healthcare provider can recommend the best type of exercises to help alleviate pain and, if needed, over-the-counter and prescription therapies.

Studies suggest that perimenopausal hormonal fluctuations may play a role in headaches. Women at special risk for hormonal headaches during perimenopause are those sensitive to hormone fluctuations, which is usually indicated by a history of headaches at the same time each month during their menstruating years. Some nonhormonal causes of headaches are infection, dental problems, or sinus problems, and some can be a sign of more serious conditions, such as hypertension.

Most headaches are minor, but some can be more severe and interfere with daily life. These include the following:

• Tension headaches - Squeezing or pressing pain across the forehead or around the head that often occurs upon waking; the headache can last from 30 minutes to several days.
• Migraine headaches - Severe, throbbing pain, typically located one-sided at the temple, that occurs periodically; the headache may be accompanied by nausea, vomiting, and sensitivity to light and noise.
• Cluster headaches - Multiple episodes of short-lived but severe one-sided pain.

Most headaches either do not require treatment or can be treated with nonprescription pain medications. Hormonal headaches that are related to hormone fluctuations of perimenopause can sometimes be relieved through hormone therapy that attempts to level the fluctuations. With migraine headaches, estrogen may either make them better or worse. Estrogen is not FDA-approved for treatment of headaches, but there are several other prescription drugs approved for this use.

The skin undergoes normal changes with aging, including loss of collagen and elasticity, creating slight sags and wrinkles. Skin becomes more dry and flaky. Drinking plenty of water and using skin creams will help keep skin moisturized. Long-time smokers have even greater skin damage, particularly wrinkles around the lips and dark circles under the eyes. Maintaining skin health is yet another reason not to smoke. Aging skin becomes more prone to sun damage, so protecting the skin from harmful UV rays through use of a good sunscreen is more important than ever. Any dark or changing moles should be evaluated by a clinician.
A small percentage of perimenopausal women report irritating sensations to the skin, ranging from severe itching to phantom symptoms of "ants crawling under their skin." This condition, called formication (from the Greek word for ant), is difficult to diagnose and even more difficult to treat. There are no scientific studies to guide clinicians. Sometimes hormone therapy or antihistamines will help.

Getting older increases the likelihood for hair to become gray and more brittle. In addition, excessive hair growth can occur in areas of the body where hair follicles are most androgen-sensitive, such as the chin, upper lip, and cheeks. Women often report a large "rogue hair" on their chin that seems to grow to a great length almost overnight. Hair thinning may also occur, a condition that is typically genetic and in response to a shift in the internal balance between estrogen and androgen. After menopause, the increase in the androgen-to-estrogen ratio may cause hair thinning to worsen. However, the tendency for hair thinning may decrease for women experiencing surgical menopause because the internal androgen levels plummet after the ovaries are removed. Androgen therapy may result in hair loss; some women also have hair loss with estrogen therapy. Eating a healthy diet, adding a daily multivitamin, and avoiding harsh chemicals and sunlight that dry the hair will help keep hair healthy. Treating severe hair loss is more of a challenge because finding the cause is often difficult. Women suffering from this condition should consult a dermatologist.

Aging often results in the need to wear corrective lenses. There is also an increased risk of eye diseases such as cataracts and macular degeneration. Some women report dryness, scratchiness, and burning of the eyes, as well as light and cold intolerance. Use of eye moisturizers can help for this dry eye syndrome. If symptoms persist, an ophthalmologist should be consulted.

After menopause, there is an increase in tooth loss, the need for dentures, and gingival bleeding and inflammation. Thus, good dental hygiene and regular checkups are as important as ever. Some dental changes may be related to diminished levels of internal estrogen. Often, tooth loss is a sign of underlying bone disease, such as osteoporosis. A woman's primary healthcare provider needs to be kept current on any changes observed by her dentist.

For more information, go to the North American Menopause Society at www.menopause.org

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