Menopause is the final menstrual period, representing the loss of ovarian follicular function. The menopause starts after 12 months without a menstrual period. Most women have their natural menopause in their 40s or 50s. (1)
Symptoms of menopause vary from one woman to another. As physical symptoms arising, mental health is also affected during menopause. Phycological symptoms include depression, anxiety, and a decreased sense of well-being (1).
There is little attention regarding anxiety symptoms experienced by menopausal women though such symptoms have a considerable impact on life. Siegel et al. revealed that a rather poor amount of literature addresses this issue (2).
Anxiety disorders manifest excessive fear or anxiety, which is different from ordinary nervousness or anxiousness. There are six types of anxiety disorders in general, including generalized anxiety disorder, panic disorder, phobias, agoraphobia, social anxiety disorder, and separation anxiety disorder (3). For general diagnosis, it starts with a physical examination to exclude symptoms caused by the physical problem (3). After that, mental health professionals need a psychological evaluation to validate a diagnosis and potential complications. At last, mental health professionals need to complete matching patients’ symptoms with diagnostic criteria. Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) criteria is widely used across the world (4).
Many tools are used to screen anxiety disorders in menopausal women, such as Greene Climacteric Scale (GCS), Women’s Health Questionnaire (WHQ), Menopause-Specific Quality of Life, The Menopause Rating Scale (MRS), The Midlife Women’s Symptom Index (MSI), and Everyday Complaint Checklist. GCS is extensively used both clinically and academically for its coverage of psychological, somatic, and vasomotor symptoms with 21 items (5).
Women in menopause have more intensive anxiety symptoms regarding similar issue than they are not in menopause. As Bremer et al. reported, although the severity of anxiety is individualized, most women tend to share similar symptoms including “short of breath”, “weakness”, “feeling a sense of loss of control”, “waking up between 2 and 3 am with heart racing” . The anxiety experience of women in menopause is unique. Bremer et al. further pointed out DSM-5 criteria may not be suitable for the unique diagnosis. (6)
World Health Organization reported an estimation of 1.2 billion women worldwide to be menopausal by the year 2030. 1.5 million women in Australia experienced distinct menopause symptoms each year (7). A population-based assessment found that 86% of Australian women in their mid-life did consultations with doctors for solutions of menopausal symptoms (8). An early study in 2001 also showed that 51% of women aged between 40 and 55 years old reporting anxiety symptoms in last fortnight or at the moment (9) while another study in 2004 showed that 25% of mid-life women suffering from frequently occurred anxiety symptoms (10).
One of the major triggers of mental disorder is the change of steroid hormones level. Stressful life events in menopausal transitions also contribute to phycological symptoms (11). The risk of relapse during menopause exists for women with mental disorder history (12). However, those who have no history of anxiety can suffer the increased risk of having high levels of anxiety during and even after menopausal transition (13). Ethnics remain with the result conducted in 2018 that European and Latin American women are at a higher prevalence of mood changes comparing with women of other ethnicities (14). Although education background has low relevance with menopausal anxiety, the ability to pay for psychotropic medications is significantly relate to a high level of menopausal anxiety (13).
It was estimated in 2017 that the mean annual per-patient direct cost for treatment of symptoms associated with menopause is $248 in the US apart from prescription medication cost. For anxiety disorder, the annual per-patient cost was $46. (15)
A reduction of mental and physical quality-of-life scores appeared among the menopausal population. Menopausal symptoms in certain degree deteriorate relationships, decrease working productivity, and affect economic outcomes (16). Up to 40% of women described a reduction of performance in work due to menopausal symptoms. They are also likely to share emotion burden of embarrassment for their symptoms (17).
The neglection or mismanagement of anxiety disorders in menopausal women can cause serious consequences. It was indicated that mental disorders in menopausal transition could develop dementia afterward (18). Anxiety-related symptoms as sleep disturbances can increase the risk of cardiovascular disease and carotid atherosclerosis among mid-life women (19).
Management and Treatment
Psychotherapy is recommended by specialists for treating mild phycological symptoms while pharmacologic treatment is often required for moderate to severe symptoms. For handling stress commonly occur at midlife, nonpharmacologic methods should be considered. The importance of education is highlighted in official guidelines (1) for health providers.
Hormone-based therapies appeared to be more effective than other treatments that target to single symptom each time. Nevertheless, hormone-base therapies cannot be adopted to certain groups of women.
Complementary and alternative medicine usage can be adopted as well for women who are interested. The study showed that the diet of increased phytoestrogens could help reduce symptoms. The herbal product can be advised for the efficacy of menopausal depression (1). It was demonstrated that kava, a kind of herb might reduce anxiety. Acupuncture can be quite helpful to improve sleep quality.
Women play vital roles in families and societies. Accordingly, menopause is a life stage inevitable for all women. Unique anxiety symptoms arise during menopausal transitions, which can have significant and long-lasting impacts on individual and society. Anxiety disorders in menopause need to be recognized and acknowledged. Also, women in menopause need to be characterized treated with care.
In the UK, government officials conducted prospective work regarding the support for women in menopausal transitions. The Equality Act 2010 urges employers to support their female employees. Business in the Community has produced a free toolkit aim to educate business owners to support women at menopause. The faculty of Occupational Medicine published guidelines in 2016 entitled “Guidance on menopause and the workplace” to help women tackle troublesome menopausal symptoms with clear instructions based on works by the European Menopause and Andropause Society. (20)
As it was suggested earlier, helping women overcome obstacles regarding menopause required attention and support from the interior and exterior environment. Women themselves need education and awareness of menopause and related anxiety disorders before the actual menopausal transition starts. On the other hand, policies should be made while family care should be attended during menopause. The menopause-friendly working environment needs to be established.
Based on the considerable rate of anxiety disorders among mid-life women in menopause, Strengths-based recovery model can be advocated for cost-effectiveness.
- Shifren JL, Gass ML. The North American Menopause Society recommendations for clinical care of midlife women. Menopause. 2014;21(10):1038-62.
- Siegel AM, Mathews SB. Diagnosis and Treatment of Anxiety in the Aging Woman. Current Psychiatry Reports. 2015;17(12).
- Parekh R. What Are Anxiety Disorders? Washington: American Psychiatric Association; 2017 [Available from: https://www.psychiatry.org/patients-families/anxiety-disorders/what-are-anxiety-disorders.
- Staff MC. Anxiety disorders diagnosis 2018 [Available from: https://www.mayoclinic.org/diseases-conditions/anxiety/diagnosis-treatment/drc-20350967.
- Hall E, Steiner M. Psychiatric Symptoms and Disorders Associated with Reproductive Cyclicity in Women: Advances in Screening Tools. Women’s Health. 2015;11(3):399-415.
- Bremer E, Jallo N, Rodgers B, Kinser P, Dautovich N. Anxiety in Menopause: A Distinctly Different Syndrome? Journal for Nurse Practitioners. 2019;15(5):374-8.
- Santoro N, Epperson CN, Mathews SB. Menopausal symptoms and their management. Endocrinology and Metabolism Clinics. 2015;44(3):497-515.
- Guthrie JR, Dennerstein L, Taffe JR, Donnelly V. Health care-seeking for menopausal problems. Climacteric. 2003;6(2):112-7.
- Avis NE, Stellato R, Crawford S, Bromberger J, Ganz P, Cain V, et al. Is there a menopausal syndrome? Menopausal status and symptoms across racial/ethnic groups. Social science & medicine. 2001;52(3):345-56.
- Anderson D, Yoshizawa T, Gollschewski S, Atogami F, Courtney M. Relationship between menopausal symptoms and menopausal status in Australian and Japanese women: preliminary analysis. Nursing & health sciences. 2004;6(3):173-80.
- Harlow SD, Gass M, Hall JE, Lobo R, Maki P, Rebar RW, et al. Executive summary of the Stages of Reproductive Aging Workshop+ 10: addressing the unfinished agenda of staging reproductive aging. The Journal of Clinical Endocrinology & Metabolism. 2012;97(4):1159-68.
- Bromberger J, Schott L, Kravitz H, Joffe H. Risk factors for major depression during midlife among a community sample of women with and without prior major depression: are they the same or different? Psychological medicine. 2015;45(8):1653-64.
- Bromberger JT, Kravitz HM, Chang Y, Randolph JF, Jr., Avis NE, Gold EB, et al. Does risk for anxiety increase during the menopausal transition? Study of women’s health across the nation. Menopause (New York, NY). 2013;20(5):488-95.
- Monteleone P, Mascagni G, Giannini A, Genazzani AR, Simoncini T. Symptoms of menopause—global prevalence, physiology and implications. Nature Reviews Endocrinology. 2018;14(4):199.
- Assaf AR, Bushmakin AG, Joyce N, Louie MJ, Flores M, Moffatt M. The Relative Burden of Menopausal and Postmenopausal Symptoms versus Other Major Conditions: A Retrospective Analysis of the Medical Expenditure Panel Survey Data. Am Health Drug Benefits. 2017;10(6):311-21.
- Whiteley J, DiBonaventura Md, Wagner J-S, Alvir J, Shah S. The impact of menopausal symptoms on quality of life, productivity, and economic outcomes. Journal of Women’s Health. 2013;22(11):983-90.
- Jack G, Riach K, Bariola E, Pitts M, Schapper J, Sarrel P. Menopause in the workplace: what employers should be doing. Maturitas. 2016;85:88-95.
- Ownby RL, Crocco E, Acevedo A, John V, Loewenstein D. Depression and risk for Alzheimer disease: systematic review, meta-analysis, and metaregression analysis. Archives of general psychiatry. 2006;63(5):530-8.
- Thurston RC, Chang Y, von Känel R, Barinas-Mitchell E, Jennings JR, Hall MH, et al. Sleep characteristics and carotid atherosclerosis among midlife women. Sleep. 2017;40(2):zsw052.
- Hawes C. The menopause & the Equality Act: why it pays to provide support 2018 [Available from: https://www.hrgrapevine.com/content/article/insight-2018-01-29-the-menopause-and-the-equality-act-why-it-pays-to-provide-support.