Mood Changes in Menopausal Women: A Focus on Anxiety

Menopausal status should be considered when assessing women with anxiety.

Menopause, defined as the complete cessation of menstrual periods for 12 months,1 is often associated with new or recurrent mood disorders.2 With the aging of the population, it is estimated that 1.2 million women worldwide will be going through perimenopause or will be postmenopausal by the year 2030.3 Estimates of the prevalence of mood disorders are inconsistent and vary greatly4 but range from 12% to as many as 50% of women who will experience mood symptoms or disorders during this transitional time in their lives.5

Although many studies have assessed risk of depression during the perimenopausal transition, few have systematically investigated the relationship between menopause and anxiety, although prevalence of anxiety in midlife women is substantial.2 As many as 51% of women aged 40 to 55 years report occasional tension, nervousness or irritability and 25% report frequent irritability or nervousness.6

“One of the reasons that less attention has been paid to anxiety than to depression during menopause may be that we are generally focused on morbidity and mortality related to depression, since it affects other medical conditions in older populations,” Sarah Mathews, MD, NCMP, assistant professor of psychiatry at the University of Pennsylvania, told Psychiatry Advisor. But “the morbidity of anxiety disorders is very significant.”

Additionally, “historically, menopause was considered a time of vulnerability to a special kind of depression, with the concept of a woman being ‘dysfunctional’ and ‘melancholic’ during this time,” noted Joyce Bromberger, PhD, professor of epidemiology and psychiatry at the University of Pittsburgh.

Arguably, anxiety disorders may be even more common than depressive disorders among seniors, so “we should start to shift more of our focus to look at them,” said Dr Mathews.

Biochemistry of Perimenopausal and Postmenopausal Anxiety

Anxiety and depression are both associated with dysregulation of the monoaminergic pathways in the central nervous system, according to Dr Mathews. Fluctuations in estrogen levels during perimenopause can alter the serotonergic and noradrenergic systems. Some studies suggest that changes in mood and serotonin transmission are associated with hormonal status.7,8 The variability in estrogen levels rather than the diminished levels, per se, may be associated with mood symptoms.9 It is known that fluctuating levels of estradiol increase the risk of vasomotor symptoms, which positively correlate with anxiety during perimenopause.2 It is also possible that impaired gamma-aminobutyric acid (GABA) receptor modulation of the hypothalamus-pituitary-adrenal axis during the menopausal transition may prolong the stress response, thereby increasing anxiety.2 

Anxiety-Provoking Perimenopausal Symptoms

Women experience physical changes and somatic symptoms that are not only uncomfortable but also anxiety provoking. Although cognitive changes that frequently occur during perimenopause are not typically associated with neurodegeneration, they may lead to undue worry about early-onset dementia. Since there are parallels and overlapping symptoms between hot flashes and panic attacks, women prone to panic attacks cannot always differentiate between the two.2,10