E116: The Emotional Domain of Perimenopause

Kirtly: "When I was 1, I had just begun. When I was 2, I was nearly new. When I was 3, I was hardly me. When I was 4, I was not much more. When I was 5, I was just alive. And now I am 6, I'm as clever as clever. So I think I'll be 6 now, forever and ever."

This is the famous poem "Now We Are Six" by A. A. Milne, who created the world of Winnie the Pooh. And this may seem a strange place to start a discussion on the emotional domain of perimenopause, but it was my first introduction to the idea that there was a perfect age when I was the best I could be, and I wanted to stay there forever.

I'm Dr. Kirtly Jones from Obstetrics and Gynecology at the University of Utah, and I've taken care of women throughout their lifespan from when they were embryos to when they were 90.

My take on thoughts about age is that in your 20s, you think you can do anything. And in your 30s, you can do everything, and some things better than anyone. In your 40s, you discovered that you can't do everything. In your 50s, you realize you don't have to do everything. And in your 60s, you realize you don't want to do everything.

Of course, this framework is usually different for everyone. Women who are raising children might recognize it. Women who work outside the home might recognize it. And women who are doing both are living it.

And so reaching these milestones comes with emotional reactions. And as we're focused on the 7 Domains of Perimenopause, we're really thinking about the 40s, and we're focused on the emotional domain of the perimenopause.

With me in the virtual Scope studio, as always, is my insightful and experienced co-host, Katie Ward. Katie is a professor in the School of Nursing and has practiced in midlife women's health. She also has a PhD in anthropology.

So, Katie, did you always want to be 6 or 20?

Katie: One, I want to say you and I both share a fondness for A. A. Milne, don't we? And the real-life story of Christopher Robin is actually really interesting and charming, but that's a story for another day.

But I was thinking about that poem and thinking the author hadn't been 7 yet. And certainly my own perimenopause was a hard time. I got divorced in my 40s. But I don't think I got divorced because of perimenopause. It was just the context of my life. But now that I'm in my 60s, I definitely want to stay 60 forever and ever. It is really pretty great.

Forty-five is just the bottom of the U-shaped curve of happiness. And I don't know what my life would've been like if the divorce hadn't happened, but 60, or this version of 6, is the best time of my life, and I'm really happy to be here. So, yeah, I like that framework.

Kirtly: Right. Also in the studio with us is Dr. Anna Nash. Dr. Nash is a physician assistant in women's health. She graduated from the University of Utah PA program in 2006, and she has a PhD in clinical sexology. And her practice here at the university is a mix of menopause management, sexual health, and vulvar dermatology.

Welcome, Anna. And to put you on the spot, is there a decade you think was your best or is it your current decade?

Anna: I definitely feel like I am entering that stage. Coming back to work in my mid-40s has been extremely rewarding for me. As a woman, we have the time we spend going to school and educating ourselves, starting out in a practice. I ended up staying home and raising children and living in Asia for 10 years, and took that time away from my practice, then got the PhD, and I'm now back at work now in my late 40s.

I agree, I think there are things you let go of. There are things that you recognize are more important. And I'm hopeful that by the time I reach Katie's 60, that I will be feeling like I'm in the best place yet. But I think things have just gotten better and better over time.

Kirtly: I love that. Well, we're born with our genetic and epigenetic makeup for our emotional strengths and vulnerabilities. And over that, we lay our experiences, good and bad.

Then at about 40, we add aging. And I think there are many signs of aging, but one of the common ones not related to perimenopause is needing reading glasses. The average age to start needing reading glasses for the condition called presbyopia, or old eyes, is 40 to 45. It's a condition caused by aging and hardening of the lens in our eyes. So it isn't as flexible. Our eyes aren't, and we need reading glasses.

Our tendons and ligaments in the rest of our body are stiffer too. So we add, on top of aging, our genetics, our epigenetics, our experiences, the aging ovary, the perimenopause.

So back to the emotional domain. Katie, what are the most common emotional concerns you hear in your practice?

Katie: Oh, man. I guess the thing I hear most commonly is something along the lines of, "I just don't feel like my same old self anymore." And that shows up differently for different people. So some people are telling me that they cry easily, they cry at everything, and other people tell me they're short-tempered with their spouse or their children or people at work.

I think the challenge for providers in this space is that perimenopause may be the obvious context that's going on, but, and we've talked about this before in the physical domain, it's important not to assume that that is the only thing that's happening. I see that a lot in the community as people end up in these hormone clinics, and that's the only tool they have, is hormones.

But I want to make sure people are otherwise healthy, and they don't actually screen positive for depression or anxiety disorders, or they're not having thyroid problems, and they're not anemic, or they don't have some other health issue that's contributing.

And also, looking at what are the other life circumstances? Are they going through a divorce? Did they just go back to work? I mean, hormones can only fix so much, right? We're asking a lot of a little hormone, and people have busy lives. And so I definitely want to know about the whole picture.

Kirtly: Anna, we mentioned before in the physical domain that once upon a time, there were ads in women's magazines that for women of this age, if you were feeling either anxious or tired, amphetamines and Valium-like drugs were often prescribed. And we don't do that so much anymore, but I'm sure you see these things in your practice, the same common, "I'm not myself anymore."

Anna: Oh, absolutely. I think that sometimes there are things people can't put words to, they just know something is off or feels different. Maybe they're not feeling like they're accomplishing as much as they used to accomplish, or they're getting distracted more easily.

I think we certainly have a propensity for liking youth, especially here in the United States. And I think that for a lot of women, they really struggle with the idea that they're starting to get older and really hanging on to the idea that they can keep their youth. As we've established already so far today, there's real beauty in aging. And sometimes just helping them accept their new state is a part of the role that Katie and I share in the clinic as well.

Kirtly: I felt I got status when I got to 50. I was taken seriously. Instead of just being a blonde, young doctor, I finally got status.

Well, I think the data from large longitudinal studies show that women have concerns of depression, anxiety, and I'll add irritability.

So let's start with depression. In longitudinal studies, studies of women before, during, and after menopause and the menopause, the peak incidence of depression is actually in the late 30s. It's the combination of genetics, and epigenetics, and social situations, and personal situations, and overall health.

One can argue that some women begin the perimenopause in the late 30s, but certainly women who've had depression before, especially with PMS or postpartum, may be more likely to have another bout of depression in the perimenopause.

And women don't always come to their clinician with this complaint. As you said, Anna, they're too depressed. But we have a standard depression test that we use if we're concerned, and we should be asking every person.

And we have very good data that treating depression with estrogen and progesterone hormone replacement is not very successful. It can certainly help with the sleep disturbances that come with hot flushes that could be part of the perimenopause, but hormones shouldn't be the first-line therapy for depression. We need cognitive and behavioral therapy, social support, acknowledgement, lifestyle modifications, and maybe some antidepressants.

Katie: I just think that perimenopause comes along at a really tough time for people. You were just talking about some of those other windows of vulnerability, PMS and postpartum. But perimenopause is happening when you're . . . If your life sort of follows the trajectory of most people, you've got young adult children, and that can be a challenge because they're expensive if they're going to college, and you can't fix everything for them anymore with a band-aid and a hug.

So you've got pressures from the children that you're raising, and it's also most likely the case that your parents are aging and starting to have health issues, and that becomes a different pressure. We talk about people being in the sandwich generation.

And then, Kirtly, like you were saying, you're kind of at the peak of your own career, and you're getting some status, but with that status comes work pressures. So perimenopause just comes at a really inconvenient time in the course of your life, right?

Kirtly: Yeah. Well, as more women are having kids a little later, meaning starting in their late 20s, early 30s, many women in the perimenopause have kids in puberty and adolescence.

We talked about puberty in the physical domain of perimenopause, and it just isn't fair that perimenopausal women have to deal with pubertal children, I think.

Katie: No.

Kirtly: Right?

Well, let's go on to anxiety. Some people are born with anxiety, and some grow it with difficult times. And as you take on more responsibility and actually try to care for the people around you that you've lovingly accumulated with time, and you think about global climate change and political unrest and war, why, for goodness's sake, aren't we all anxious?

For women who begin to experience anxiety in the perimenopause, it's important to look for medical causes, underlying illnesses such as thyroid and anemia. But if it's a new-onset anxiety in the perimenopausal years, there are possible reasons related to hormonal fluctuations.

The same neurohormone that can be part of hot flushes, norepinephrine, can cause rapid heartbeat, palpitations, and even an arrhythmia that can feel like a panic attack. And this needs a careful history, maybe a heart evaluation.

But if hot flushes are part of the symptoms, then some hormone suppression of the ups and downs might be helpful. However, it's a careful process that requires some fine-tuning, including some medications for anxiety and cognitive behavioral therapy and lifestyle changes, more exercise, less caffeine. Sometimes one intervention can do it, but often it takes a medical and a social village.

Katie: Yeah. Think about that anxiety you were just saying, all the things that we're paying attention to in the world right now, I sometimes wonder if it's perimenopause or just that people are paying attention.

And we don't give ourselves a minute to just be anymore. We've talked about the idea of white space in other episodes, but you just see it everywhere, people on their phones. When you're at the doctor's office and you're in the waiting room, on the phone. You're eating a meal, you're also on your phone. You're standing in line, and you pull out your phone to pass the time.

And I see people at stoplights just picking up their phone because that one second, you better check and see what's going on. So we're taking in information at every single second, and I don't know if our brains were ever built to hold all that much at once.

And so I sometimes wonder if the brain fog and the anxiety is part of just constantly being bombarded with information every single time and not giving ourselves even the slightest quiet moment. We're not getting that downtime right when we need it.

Kirtly: Bathtub time. My son, when I was in my 40s, used to recommend, "Mom, isn't it time for you to get in the bathtub?" I mean, get out of our lives and get into your own.

Anna, what are your thoughts on this?

Anna: Oh, goodness. I think absolutely agree with both of you. We really are bombarded. There's stuff coming at us from every direction all the time. And I think particularly things that are beyond our control can trigger a lot of anxiety for people. There's not a whole lot that we can do about our political situation or sometimes our health, and so that certainly can provoke a lot of anxiety.

And I think at this stage of life, agree, you enter perimenopause and you may have teenage or young adult children who are making choices, or just even them growing up and being more independent can provoke some anxiety.

So I certainly think this is a time of life where there can be a lot of overlap, which is why it is so important for us as clinicians to be able to sort through what's actually going on for people.

And in addition to that, the access to social media. Katie and I have talked about this a lot. Social media gives them an expectation of hormone therapy that isn't always realistic.

And sometimes when you make the recommendation for a patient that an SSRI might be a good option for them, sometimes they feel frustrated. "If this is just my hormones, why would I need an antidepressant?" or, "Why would I need anxiety medication?" It puts us as clinicians in a little bit difficult place because we're competing with the messages that they're getting in social media, and that can be an additional challenge as well.

Kirtly: Yeah.

Katie: Boy, is it.

Kirtly: Well, that gets us to irritability, my favorite emotion for the perimenopausal years. This is the poster child emotion for the perimenopause. Crabbiness, anger, being moved to tears for no good reason, these can be the manifestation of an irritable brain. The lights are too bright. The noise is too loud.

Of course, a person in their 40s has a thousand reasons to be irritable. No, I won't list them all, but help with dishes always was the starting point for me. Women often stuff a lot of things into a box of irritations, like a jack in the box. And then sleeplessness, hot flushes, hormone withdrawal will open Pandora's box, and out pops all the things that you were totally ticked off about.

Some women experience this as PMS, the irritable brain just before their period starts. And there's some recent neuroendocrine evidence that falling progesterone can make the brain more irritable, that time before the period when progesterone and estrogen fall. And there are some good animal models.

This is another emotional response that roots in the social and psychological and aging brain with fewer inhibitory neurons to keep the brain a little quiet and fluctuating hormones.

So, Katie, what do you do when people just aren't themselves, but they're crabby, they're tearful? What are your options here?

Katie: I mean, as we've kind of talked about, my approach is to try and get the right diagnosis first. So I'm going to ask people a lot of questions about what's happening with their menstrual cycle. The hallmark of the perimenopause is that typically people are still cycling. So I want to know if they're experiencing this on a cyclic pattern. That tells me it's really involved with those kinds of predictable rise and fall of the hormones that control the menstrual cycle.

In which case, I really do feel strongly that turning off the menstrual cycle is going to be the best approach. And often, our approach to that is going to be some kind of hormonal contraception, so a combination of estrogen and progesterone, or progesterone only, but something that turns off that normal fluctuation. Then we can add in something for anxiety if those issues are still left over.

But the point is there are a lot of approaches, and no two people are exactly the same. And there isn't a single test that tells us exactly what's going to be most effective. So I think the important thing is having a provider that you can work with, and who will evaluate things, and continue to make changes.

But I do sometimes worry that people attribute everything to hormones, and there may be other causes that we need to seek out and treat. As Anna was saying, that best treatment might be an anti-anxiety medication or an SSRI or treating another underlying health condition. So what works for one woman isn't going to necessarily work for another.

Kirtly: Well, let's turn to another common concern of women in the perimenopause. And in fact, it may start in the 30s in your clinical practice. Concerns about libido and your intimate life.

So, Anna, what are the common questions you hear from your perimenopausal women about their intimate lives, about their sex lives? What's on the list of things that you hear?

Anna: One of the luxuries of just doing gynecology is that you get to see some things that you wouldn't otherwise see in an OB practice. One of the things I started seeing frequently was concerns with sexual activity, whether it was pain, whether it was sexual dysfunction. I had never seen that historically in my practice, so this was something new for me.

And I started realizing, the more that I talked to people, that there weren't enough resources on this topic. At that time, I was practicing down in Provo, and we didn't even have a sex therapist in the area.

Kirtly: No, you didn't. And when I tried to find someone for people, there was nobody. So, de facto, it was me or it was Katie or . . . Yeah.

Anna: Yeah, absolutely. So I would say number one is low libido. People are definitely starting to notice a shift from their younger years that sex just isn't in their brain as much anymore. They could go weeks, months without sex and it wouldn't bother them, but it's more of an issue for their partner. So I would say libido is probably the first thing.

Second thing that I would say we see very commonly is women starting to notice some changes in their genital tissue. Dryness, where maybe during their reproductive years they didn't need to use a lubricant and now, all of a sudden, they're having to use a lubricant more often. And there can be some itching and discomfort that is coming along with that dryness that is impacting their sex life.

Kirtly: I think the major insight for me 20 years ago as I was learning more about women's libido was that there is spontaneous libido, meaning you're out walking the streets looking for someone cute, and then there's responsive libido, meaning you don't have a libido until your partner comes to you in the right way, at the right time, with no teenagers walking in, and then with the right prompt, you're responsive. So do you talk about the difference between responsive and spontaneous libido? And what do women want?

Anna: Absolutely. I think this is a common conversation that we have, mainly because if you think about the media that we experience, we visually see and hear about spontaneous desire or spontaneous libido, right? That's what we see in the movies and on TV, and that's what we think is normal. Many women have never heard of responsive libido or responsive desire, and had no concept that that was a normal way to experience their libido.

Kirtly: How do you help a patient through this concern?

Anna: I think just explaining to them the difference. So I like to use the analogy of a party. There are some people who are always open to a party. If somebody gives them the invitation, they will be there, and they know they're going to enjoy it every single time. And that's that spontaneous libido or spontaneous desire. It doesn't take much, just an opportunity, and they're ready to engage.

For that responsive person, they sort of could take it or leave it. They're starting in a more neutral position. Going to a party isn't necessarily at the forefront of their mind, but it's important to their partner. They have friends that are going to be there, so they decide that they'll go.

And when they get there, they start socializing and interacting and enjoying themselves and realize that, "Huh, I really do like going to parties sometimes."

This is important when we think about desire. If a patient comes in and tells me that they fall into the second category, that they start out in a more sexually neutral place, normalizing that for them is sometimes all you need to do. They've just never been told that that was a normal way to experience desire before.

So that's where I always start, is just giving them the words to describe what they've been experiencing.

Katie: People say they have low libido, and we talk about that person you just mentioned that just says, "I could go weeks without thinking about it." I often suggest to people that they schedule it, and I always say to them, "I know this sounds silly, but like everything else in your busy life, if you put it on your calendar and it's sacred that you say, 'This is important time that I'm going to carve out to spend with my honey,' this human being that you do unique things with that you don't do with other people . . ."

But you really do sort of have to say, "This is sacred time that I'm going to put on the calendar." And then you've got that date in your head, and you can play with it a little bit as opposed to just going along, never thinking about, "When is the next time we're going to have an intimate occasion?" Make it important.

Kirtly: We're talking about perimenopausal women whose ovaries are still cranking out a fair amount of hormones, just erratically. But the whole testosterone thing is all over the media. And we're not talking about postmenopausal women or women who've had their ovaries removed, but women come in wanting testosterone. Anna, what are your thoughts about this?

Anna: We know that testosterone starts to decline in our 30s, similar to men. We know from an abundance of data that testosterone is helpful for libido in some cases. I think the jury is still out as to whether or not testosterone is needed for everyone. And I certainly, in my clinical practice, see that not everybody tolerates testosterone the same way.

It is certainly something that is discussed. People are hearing it, as you said, in the media and their social media.

The data that we do have on testosterone shows that testosterone is not a silver bullet for libido. And I think, in many ways, that just shows the nuance of the complexity of libido.

We have to look at it from this biopsychosocial model. So if we've got a situation where we've got some relationship issues or we've got other things factoring into the low libido, all the testosterone in the world isn't going to be helpful. And I think that's what we see in the testosterone study outcomes. Fifty percent to 60% of women experience improvement of libido with addition of testosterone.

And so I think that needs to be also part of the conversation, is expectations, as well as also dealing with potential adverse effects from being on testosterone, which they aren't being told on their social media platforms. There are potential side effects to being on testosterone that we also have to keep in mind when we're going to start somebody on it.

Kirtly: And we don't really have a great testosterone product for women, do we?

Anna: No, we don't.

Kirtly: So we end up carving up men's patches or putting it in a petrolatum and using it on the vulva.

Katie: The approved use is for postmenopausal women with low libido not explained by anything else. It doesn't mean I won't start a perimenopausal woman on it. If I've had a conversation with somebody and this seems like the only thing that might be different . . . I usually start that conversation with, "When was your libido great?" And so if somebody tells me, "It was back when it was my teens," I'm not sure that that's a testosterone issue.

But somebody who's just in the perimenopause where lots of things about their cycle are changing, and their relationship is otherwise great, and they've done the work on their relationship and we're not finding other issues . . .

It's not that I have an "absolutely you must be postmenopausal to try this." But again, as Anna was saying, it is a really nuanced prescribing decision that involves spending a fair amount of time with my patient and kind of getting into what's really going on.

But it's a hard place to be practicing right now because people are seeing this so much on social media and there are expectations that we've just got a product that's going to take them from 0 to 100 and with no side effects and no risks. So there's a lot of education that needs to go on around this.

Kirtly: For the few pre-menopausal women that I prescribed it for . . . And I certainly had women who had their ovaries nuked from chemotherapy or had their ovaries removed, but we're talking about women who still have functioning ovaries, just unreliably. For the few women I offered it to, I'd say, "I want to see you in a month, and you'll know in a month."

Now, the problem is in a month it could be placebo effect. So we'll try it for a month and if she says, "Yeah, this has been great," then I'll say, "All right. I'm going to give you two more months, and then I want to see you again, and see if it's . . ." Because the placebo effect doesn't last forever.

I make it a very nuanced and gradual assessment. I don't say, "Oh, yeah, you're going to take this and come back and see me in a year," because I don't think it works that way.

Well, thanks, Anna, for helping us think about the common concerns about sexual intimacy and the perimenopause. And thank you all for listening, of course.

We don't wish we were still 6 forever and ever. Or for Katie, now I am 60 and as clever as clever, and I want to be 60 forever and ever. I was remarkably engaged and happy when I was 20, but I don't want to go back there.

The perimenopause is a complicated time worth examining and living in and talking about. And if this conversation has revealed a concern that you have, speak to your primary clinician. I cannot suggest that you follow every single influencer. We can suggest seeing a clinician trained in menopausal and midlife women's health.

You can follow with us as we go through all of the 7 Domains of the Perimenopause and all of your other "7 Domains of Women's Health" issues and interests wherever you get your podcasts, or at womens7.com. Thanks for joining us.