Bharti Kalra ( Department of Obstetrics, Bharti Hospital, Karnal, India. )
Sanjay Kalra ( Department of Endocrinology, Bharti Hospital, Karnal, India. )
Saptarshi Bhattacharya ( Department of Endocrinology, Max Hospital, Patparganj, New Delhi, India )
Atul Dhingra ( Department of Endocrinology, Gangaram Bansal Hospital,Sri Ganganagar )
We propose the use of the term ‘menopause distress,’ and share a conceptual definition. Menopause distress is defined as an emotional response characterised by significant, persistent apprehension, discomfort or dejection, due to a perceived inability to cope with the biomedical and psychosocial demands and challenges of living with menopause. This review discusses menopause distress, its definition, etiology, clinical features, and management. It calls for differentiation of menopause distress from other psychiatric conditions such as major depressive disorders and anxiety neurosis.
Keywords: Anxiety, depression, estrogen, estropenia, menopausal hormonal therapy, MHT, mood disorders, patient centred
Menopause is an endocrine transition which presents with myriad challenges as well as multiple opportunities. The perimenopausal and menopausal phases are characterized by various metabolic and endocrine alterations, which may lead to psychological, metabolic, cardiovascular and musculoskeletal dysfunction.1 Along with this, estropenia per se may cause complaints such as hot flashes and genito-urinary symptoms. Partly due to these, perhaps due to the direct impact of low estrogen on the brain, and because of a change in the psychosocial circumstances of the ageing female, menopause may be associated with mood disorders.2
Depression in menopause
The prevalence of depression and anxiety disorders has been described in various large scale cross-sectional and longitudinal studies. These data have been reviewed in detail by updated guidelines for the evaluation and treatment of perimenopausal depression.3 In these studies, as in clinical practice, depression is diagnosed4 using objective diagnostic criteria laid down in Diagnostic and Statistical Manual-5(DSM5) or International Classification of Diseases (ICD10).
Distress in menopause
Many women with menopause, however, complain of mood disturbances which do not necessarily meet the diagnostic criteria listed in DSM-5 or ICD-10. Earlier workers have used the descriptor ‘menopause distress,’ and described it in non-specific, qualitative terms. Feeling tense or nervous, feeling blue or depressed, and feeling irritable or grouchy, have been proposed as symptoms of ‘psychologic distress’ in menopause.5 Current guidelines use the term ‘depressive symptoms’ to differentiate this condition from depression or major depressive disorder. Subsyndromal depression, adjustment disorder, psychological distress, bereavement, bipolar causes of depression, and general medical causes of depression are some differentials of major depressive disorder during menopause.3 The use of the terminology ‘depressive symptoms’ suggests that they be given lesser importance than ‘major’ depressive disorder. This is unfortunate, as mood has a direct relationship with overall health. If not addressed properly, depressive symptoms may worsen physical health as well. As a corollary, alleviation of mood disorders will improve overall health in menopause as well. Distressful or depressive symptoms of menopause can precede, occur with and mimic depression.3 A careful history helps elicit the correct diagnosis and plan appropriate therapy.
To focus attention on this aspect of menopause medicine, we propose the use of the term ‘menopause distress,’ and share a conceptual definition. Menopause distress is defined as an emotional response characterized by significant, persistent apprehension, discomfort or dejection, due to a perceived inability to cope with the biomedical and psychosocial demands and challenges of living with menopause.
Critique of definition
This definition is a person-centred, ‘non-medical’ construct as it focuses on ‘living with menopause’. It approaches the emotions of apprehension, discomfort on dejection’ as normal variants and lists only ‘significant, persistent’ symptomatology in the definition of distress. The term ‘significant’ implies that the dysfunction should be important enough for the affected woman to seek help. Noteworthy is the inclusion of an etiologic factor, ‘the perceived inability to cope with’. This phrase suggests that menopause distress is a coping or adjustment disorder. The also implies that distress can be managed by improving coping skills, or by reducing ‘the biomedical or psychosocial demands and challenges’ associated with menopausal life. The precipitating factors, i.e., biomedical and psychosocial demands and challenges, offer an insight into the clinical features of menopause. It also directs attention to the relevance of the biopsychosocial model of health in menopause care, and underscores the need for a multidisciplinary approach in this field. The action-oriented definition that we propose offers a proactive solution to menopause distress. Distress does not need anti-depressant therapy, as it does not meet the diagnostic criteria for depression. Rather, it can be managed by improving coping skills, or by reducing the ‘biomedical burden’ of menopause and reducing the ‘psychosocial problems’ of menopause. This needs psychological support such as coping skills training, biomedical intervention, including alleviation of oestropenic symptoms, and social modulation e.g., family therapy and social marketing of menopausal medicine. It must be noted that though controversial,6 menopausal hormonal therapy (MHT) has been shown to prevent depression in perimenopausal women.7 The person-centred definition of menopause distress is successfully able to walk the tightrope of quaternary prevention.8 By terming distress as an ‘emotional response’, it provides a ‘humane’ or ‘normal’ angle to the syndrome. At the same time, it offers a label which helps explain the condition to the woman and her family. The definition, which includes etiology, precipitating factors and clinical symptoms, also facilitates planning of therapeutic interventions by the menopause care team.
Hormone related mood symptoms have been described as a ‘window of vulnerability’. However, these can also be viewed as a window of opportunity to address symptoms, prevents complications, and promote healthy living. Using the term menopause distress will help improve the quality of menopause care, and its acceptance, in women who need it the most.
1. The NAMS 2017 Hormone Therapy Position Statement Advisory Panel. The 2017 hormone therapy position statement of The North American Menopause Society. Menopause (New York, NY). 2017;24:728-53.
2. Nappi RE, Cucinella L. Long-Term Consequences of Menopause. Female Reproductive Dysfunction. 2020:1-13.
3. Maki PM, Kornstein SG, Joffe H, Bromberger JT, Freeman EW, Athappilly G, Board of Trustees for The North American Menopause Society (NAMS) and the Women and Mood Disorders Task Force of the National Network of Depression Centers, et al. Guidelines for the evaluation and treatment of perimenopausal depression: summary and recommendations. Menopause. 2018;25:1069–85.
4. Maurer DM, Raymond TJ, Davis BN. Depression: Screening and diagnosis. American family physician.2018;98:508-15.
5. Bromberger JT, Meyer PM, Kravitz HM, Sommer B, Cordal A, Powell L, et al. Psychologic distress and natural menopause: a multiethnic community study. Am. J. Public Health. 2001;91:1435-42.
6. Joffe H, Hickey M. Should hormone therapy be used to prevent depressive symptoms during the menopause transition? JAMA psychiatry. 2018;75:125-6.
7. Gordon JL, Rubinow DR, Eisenlohr-Moul TA, Xia K, Schmidt PJ, Girdler SS. Efficacy of transdermal estradiol and micronized progesterone in the prevention of depressive symptoms in the menopause transition: a randomized clinical trial. JAMA psychiatry. 2018;75:149-57.
8. Jamoulle M, Roland M, Bae JM, Heleno B, Visentin G, Gusso GD, et al. Ethical, pedagogical, socio-political and anthropological implications of quaternary prevention. Rev Bras Med Fam Comunidade. 2018;13:1-4.