menopause

Menopause Management

Female Mental Health
Psych Team

Menopause is not a disease or disorder. This time in a woman’s life is often full of other transitions in addition to physical ones: Women may be caring for aging parents or relatives, supporting their children as they move into adulthood, or taking on new responsibilities at work. -NIH

The Dilemma

It’s getting warm again so it’s time to help women who are dealing with hot flashes or menopause. Menopause is as natural as getting wrinkles, which also isn’t a condition or something requiring interventions. However, a person doesn’t feel the effects of wrinkles but imbalanced hormones are like wrestling with alligators so yes it can definitely worsen the mood and behaviors. 

Also, people seek treatment for wrinkles or the effects of aging all the time, so psych providers shouldn’t get too irked if someone asks about treating menopause symptoms. OB or primary doesn’t treat moods and prescribing (hormonal replacement therapy) HRT is a hit or miss. Some people say try dietary soy and others believe it’s a risk for CA (cancer) or can affect the thyroid. I don’t see the harm in using soy products at least temporarily but there are a lot of myths and frustration…  Overall, try to focus on the mood and the behaviors…things that psych providers can improve. 

Why Does This Matter?

If a woman is going through the beginning of the menopause process (perimenopause), be mindful that it’ll be a new experience for the patient, thus for the provider as well. The patient and the provider are both trying to figure out what’s normal vs a problem. For example, a patient may say, well I’ve always been crazy and had bleeding problems, but if a person is starting to bleed clots, have bizarre behaviors, or mental changes -the person may not know that this is something unusual…The main point here is how there’s nothing written in stone for dealing with the aging body. It could truly be something serious or simply just a phase. In truth, most things in healthcare are like a retrograde study so when things are getting blurry, try to stick to what’s practical and safe. 

When To Get Concerned?

With menopause symptoms, some online forums and other peers suggested the patient can be referred back to PCP, f/u with OB, home remedies, etc. but if that was the case, it would’ve been resolved or improved. Here are a few reasons a psych provider will have to take it into serious consideration:

  • Because our medications can help: psych meds can at least improve the mood, difficult thoughts, and restlessness. Remember, the home remedies, ice cream, meditation, healing lights, and nature walks are not helping, so this IS the last resort.  
  • SEVERE mood symptoms: frequent, uncontrolled crying/rage episodes, lack of sleep, it’s putting a person at risk for relapsing, or the mood is getting so difficult it’s affecting ADLS.
  • The Psych Provider is the PCP: sometimes I do things because clearly, NO other options are available; people can’t do 3 appointments in a week or wait months to see a doctor, go to work, feed the kids, etc. if it’s in my power to act on something, it’s best NOT to keep hesitating and try to avoid bigger problems. 

Those Most At Risk

  • S/P Hysterectomies: removal of ovaries or certain body structures and the patient was not aware or prepared for these sudden hormone changes. Again, educating is really important because if a female doesn’t understand how this will affect her mood, it can cause PANIC.  
  • Smoking/ETOH/Overweight: certain habits and lifestyles speed up the aging process or increase the risk of illness/infections and will make a person more prone to having mood problems. However, premature menopause is overall rare but >90% of the cases are unknown –NHS (UK). 
  • Family Hx: not just for perimenopause but I also try to prepare young girls for their menstrual phase especially if the parent or the family has a history of reproductive/behavioral issues. 
  • HIGH STRESS: most of my females who have the most difficult symptoms in menopause work stressful jobs, going through a divorce, substance abuse hx, certain medical conditions, etc. I usually try to discuss stress management ALL the time, mainly that it’s not them but the HORMONES.  

Even if a provider doesn’t want to focus on treating the menopause issues, with the above situations, it’ll eventually become more difficult to stabilize the patient. However, I also don’t make it an initial priority because many females DO tolerate or manage the symptoms without treatment.

My mom acted completely shocked that this occurs but I vividly remembered when she will get hot flashes and just stand outside during snowstorms. Again some women think these are normal behaviors and not a big deal when the family (or us normal people) was getting mad at her for trying to get everyone sick.

It wasn’t her intention but if a woman is randomly smiling outside, taking off clothes in the middle of winter, people will get worried. I would’ve rather for her to be on medications than risk getting pneumonia or falling. Therefore, you truly have to consider how this is affecting the ADLS, the family, and other factors.  

menopause symptoms

About Treatment

As usual, with medications, the ideal is to STILL start low and go up slowly. Not only are we treating the symptoms but also trying to avoid the adverse reactions. Here are some considerations for medications: 

  • Anxiety: antidepressants should address some of the anxiety if not all. For breakout anxiety/restlessness, I would consider bupropion, clonidine, hydroxyzine, or a small dose of antipsychotic PRN. I would avoid BZD in this category but if not, rule out ETOH and substance abuse, which can be masked as “anxiety” or mood problems.
  • Hot Flashes:  clonidine is usually my go-to because it also helps with focusing and anxiety. People have also mentioned magnesium supplements, black cohosh, or a cup of soy milk/day that has significantly helped but isn’t proven –NIH
  • Insomnia: again clonidine and hydroxyzine are great options and you can increase the dosages as needed. Some people recommended mirtazapine but as with all women –we worry about weight gain so it’s not my go-to…you can also put quetiapine and SGAs, mood stabilizers in this category, or consider small doses/PRNs. Make sure you don’t have too many NE activating meds like bupropion, some newer generation antidepressants, or high dosed-medications that will keep a person wired. Usually, patients already have sleep issues so be mindful of the long-term solutions (like not using a BZD), and promote good sleep habits/non-pharmacological help like magnesium or OTC supplements.
  • Night Sweats: consider antihistamines for the anticholinergic effects. Some of my patients use Benadryl or you can trial hydroxyzine or Trazodone. FYI, a decrease in estrogen also leads to vaginal dryness and risk of UTIs/urinary incontinence (–Very Well Mind) so some of these meds shouldn’t be used EVERY night. I also don’t prescribe TCAs for this group.  
  • Depression: I start with SSRIs either sertraline, fluvoxamine, escitalopram, or fluoxetine. I usually go with what has helped before or start with sertraline (quick side-note: sertraline is the best choice especially if the person has major co-morbidities i.e. dialysis). Some providers start with venlafaxine, which is a good option if the patient doesn’t have other major issues but if they do, caution because of the horrible withdrawals. Paroxetine is not my first line, though people said it has been useful and FDA approved a small dose (for hot flashes). Keep in mind, that low-dose paroxetine may undertreat the depression so we are back at square one…If SSRIs did not improve the mood or weren’t tolerated, I normally go to desvenlafaxine or duloxetine. I would ask my patient, do you want a response that’s more settled or robust? or switch things around if needed. In conclusion with depression, I stay on the safe side and start with SSRI -> SNRI -> then possibly antipsychotic adjuncts (small doses) if it’s getting worse. These hormone issues can truly be that much of a nightmare so I do remind the patient, that extra medications don’t have to be forever but at least until the moods can be better controlled.

Other Considerations

  • ADHD/Brain Fog Issues: I don’t use stimulants r/t menopause though there’s literature suggesting Vyvanse (lisdexamfetamine) may be useful. However, as I previously mentioned these women are usually dealing with significant stress not a decline in executive functioning. Caution with Ginkgo Biloba and garlic supplements because they can thin the blood. If the patient has a past history of ADHD, I’ll rather restart a stimulant regimen at the lowest dose. If there’s no prior ADHD history, consider atomoxetine, bupropion, clonidine, or guanfacine. 
  • Calcium/Multivitamins: educate about increasing CALCIUM intake. Older women and past smokers are at an increased risk for osteoporosis and nutritional deficiencies =’s more psych problems. I discussed the importance of supplementing. 
  • HRT: they need to f/u with a specialist, menopause can be >10 years so the treatment is long-term and possibly costly -unsure if insurance covers…  HRT risks include CVA, CA, clots, etc. so some people truly don’t qualify for it like smokers and those with a CA history. -(HRT for Menopause, WebMD)
  • OTC: other online forums have mentioned some products that helped with good reviews- Remifemin (uses black cohosh) & Femmenessence (uses maca). Other OTC includes soy tablets and magnesium supplements for hot flashes.

In Conclusion

Educate. Menopause is not new to mankind and usually, women are written off as crazy but these symptoms are serious. Overall, there are very few studies or any literature about a “plan of care” and a person would start to feel hopeless. I only know about it from working post-op hysterectomies that even removing a set of ovaries, is enough to trigger a completely different personality. I just figured the person got a bad batch of anesthesia, the difference can be that extreme.

I had a patient who went into early menopause after getting her kidney removed so it’s not always lady parts. Document this under mood/behaviors and not as “menopause” treatment -or you risk not getting paid. Educate females about how these symptoms may be long-term despite it being a “temporary phase”. The person will not be a green monster forever and yes they NEED that reassurance.

Additional Resources 

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