‘It shut all the joy down.’ Menopause can take a serious toll on mental health but many women don’t see it coming

When Sandra Ingram found herself crying uncontrollably at the dinner table, she knew something was wrong, she just didn’t think it was menopause. “We would be eating and I would just burst into tears for no reason, and would have to run,” says Ingram. “I didn’t want my kids to see that.”
This was just one in a series of mood changes Ingram began noticing in her mid-forties, but brushed off. “I just kept saying, ‘What do I have to complain about? Snap out of it, there’s nothing wrong.’”
Things came to a head when she was 47, and an annual family summer camp was ruined. “That was one of the happiest places on earth, and I cried the entire time I was there.” She decided to go to her doctor, who prescribed counselling and an antidepressant. That seemed to work — she even went off the medication after a while — but Ingram wasn’t satisfied with the “why” of it all. Why was this happening out of nowhere?
While her family doctor was receptive and suggested it could be related to her hormones, “the only option he was able to put forward was that sometimes when women go back on the birth control pill, it can help smooth things out.”
Ingram went back on the pill, but developed a large superficial blood clot. As a result, her doctor said she shouldn’t take anything with hormones in it again, and put her back on the antidepressant. “That was OK for a bit, but then other symptoms started to show up really, really badly, like hot flashes, a real lack of confidence, low mood and no resilience to be able to work through small, small things.” She stopped seeing friends. 
Ingram was bewildered by her transformation from busy, high-functioning adult to someone who could not find “any shred of happiness” in her life. It felt, she says, “like a curtain coming down a little farther every day until it shut all the joy down.”
What it was, in the end, was something that wasn’t on Ingram’s radar: Perimenopause. Hormonal shifts can begin up to eight years before menopause — the average age for the last period is 51 — and research shows it can have profound effects on the brain.
While many women are familiar with symptoms like night sweats, hot flashes and irregular periods, there’s a gaping knowledge gap when it comes to the impact perimenopause and menopause can have on your mental health.
“It’s a myth that it’s just about hot flashes,” said Janet Ko, the Menopause Foundation of Canada president and co-founder. “It is a profound hormonal change that will impact your entire body, and when you don’t understand that mental health can be part of that, you may be experiencing these challenges and not connecting the dots on the why.”
Only slightly over 40 per cent of women knew that depression and anxiety could be caused by menopause, according to a 2022 report by the foundation, while 70 per cent of the women knew about the physical symptoms.
“This can lead to women being very negative on themselves, having feelings of self-blame, feeling like they’ve lost themselves,” Ko said.
Risk for clinical depression with perimenopause or menopause is higher if you’ve experienced it earlier in life, or had postpartum depression. “Suicide rates for women in this country are highest between the ages of 40 and 59,” said Ko. “Women should not feel like they’re going crazy, or somehow this is all in their head. It’s time that we stop gaslighting women.”
Part of the problem is a lack of education among health care professionals. “Many women are presenting to their health care practitioner and saying, ‘I have low mood, I have crying spells, sometimes I get angry,’ and rather than talking to them about perimenopause and understanding other symptoms that they are having, too often women are prescribed an antidepressant as a first line treatment,” Ko said. “And that is not a first line treatment for hormonal change associated with perimenopause or menopause.”
So what is happening in the female body at this point in life? “Your brain is basically being assaulted by all these changes in your hormones,” said Dr. Alison Shea, an OB-GYN and menopause expert at McMaster University. “Your brain is not functioning the way it was before, so it really is a roller coaster.”
For example, you may experience fluctuating levels of estrogen, or estradiol, during perimenopause, before the significant decrease that comes with menopause. “Estradiol is very intimately involved in your serotonin, your happy chemicals,” said Shea of the neurotransmitter that antidepressants like SSRIs interact with.
There are estrogen receptors in many area of your brain — hypothalamus, hippocampus, amygdala, prefrontal cortex — associated with mood regulation, controlling impulsivity and irritability. Estrogen fluctuation affects your ability to control your reactions and calm yourself. “People will say that they feel like they just snap or lash out,” said Shea.
Another major hormonal player is progesterone, which breaks down into something called allopregnanolone, and that crosses the blood-brain barrier and binds to your GABA receptors. “This is the same place where things like Ativan, Valium and clonazepam bind,” Shea said. “So when you get fluctuating levels of [allopregnanolone] or when that starts to get lower, you get less of that calming hormone.”
These fluctuations can be quite erratic in perimenopause. “You might feel really well for a few days, then really off for a few days,” said Shea. The “most vulnerable” time for these mood changes tends to span from when you start seeing irregular periods to a few years after your final period.
Behaviours stemming from these hormonal changes can impact women’s lives. “People will say that they’re yelling at their kids, they’re getting in more arguments with their partner,” Shea said. “They’ll say, ‘I’ve gotten in trouble at work because I just spoke my mind but I probably should have had more of a filter.’”
This can be compounded by other symptoms, such as the impact of hot flashes on sleep quality, leading to depression.
“People don’t often realize they’re actually depressed until you go through the symptoms with them,” Shea said. “They say, ‘No, I’m just tired, I’m just stressed.’” She said 50 to 60 per cent of people going through menopause will experience symptoms of depression, while 20 to 30 per cent meet the clinical criteria for a psychiatric diagnosis of depression. That’s double the incidence of postpartum depression.
There are things you can do to alleviate these symptoms: exercising regularly, eating a healthy diet, prioritizing sleep. Medications include hormone replacement therapy, which Shea said is not a panacea but can smooth out the bigger bumps.
“The analogy I like to use is that you’re wearing a life-jacket,” she said. “You may still have some of those fluctuations, but you’re going to have a background level of serotonin and those good neurotransmitters so that you’re not feeling these huge swings.”
At Dr. Shea’s office, Sandra Ingram eventually found a treatment plan that worked for her. It turned out that the type of blood clot she’d experienced while on birth control didn’t, in fact, rule her out as a candidate for hormone-based medication.
“Life is not perfect. I still have days where I struggle, like anyone,” Ingram said. “What I know now is that it’s not every day, and it’s not so bad that I think the next won’t be any different.”
If you’ve seen yourself in her experiences, Shea wants you to know that “you’re not crazy,” and there is support available.
“The biggest thing I beat myself up about before seeking help was, ‘What do I have to be depressed about? Why would I feel bad?’” she said. “The way you feel is valid, and you deserve to find out what’s going on, and to get the support you need to make it through this in the best possible way.”