The Hidden Mental Health Journey of Menopause and Perimenopause | S5E3

Summary

Podcast Summary

Turning Points: Navigating Mental Health
Episode: The Hidden Mental Health Journey of Menopause and Perimenopause (S5E3)
Date: October 22, 2025
Host: Frances Solis (Tufts Health Plan | Boston Globe Media)
Guests: Annalisa Fry (Yoga instructor, lived experience), Dr. Tara Iyer (Medical director, Menopause and Midlife Clinic, Brigham and Women’s Hospital; Harvard Medical School instructor)

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Main Theme & Purpose

This episode explores the often-overlooked mental health impacts of perimenopause and menopause. Centering on the firsthand story of Annalisa Fry and insights from menopause specialist Dr. Tara Iyer, the episode seeks to break the silence around the emotional and psychological challenges many women face during this transition. It highlights why these experiences can be so destabilizing, why they are still so rarely discussed, and what support and solutions are available.

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Key Discussion Points & Insights

1. Annalisa’s Personal Journey: From Unexplained Anxiety to Understanding Perimenopause

[00:02–07:36]

• Annalisa, formerly seen as stable and energetic, began suffering from new and severe anxiety, insomnia, mood swings, brain fog, and even social withdrawal in her late 40s.
• At first, she assumed COVID-related stress was to blame, but as symptoms persisted and escalated, she realized something physiological was at work.
• The classic menopause symptom, hot flashes, arrived, but emotional symptoms were more disorienting, making her feel "like I'm going crazy" ([00:52]).
• Annalisa felt completely unprepared. Menopause hadn’t been openly discussed in her Italian-American family or among friends.

Notable Quote:

“I was like, oh my God. I’m so mad all the time for no reason...I feel like I’m going crazy.” — Annalisa Fry ([00:52])

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2. Lack of Knowledge & Conversation: The Cultural Silence

[05:07–06:11]

• Annalisa describes how her mother and sisters hardly discussed menopause growing up. Cultural norms enforced secrecy.
• She became the first among friends to broach the subject, helping demystify the experience for others.
• She suggests that knowing more beforehand would have helped her seek medical help sooner.

Notable Quote:

“If I knew in advance what was going to happen...I would have already seen the physician I ended up seeing last year who put me on HRT and, like, literally saved my life.” — Annalisa Fry ([05:14])

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3. Impact on Identity, Relationships, and Work

[07:36–10:29]

• Annalisa lost her usual confidence, organizational skills, and drive. Socializing and even daily chores felt overwhelming.
• Her brain fog, lack of motivation, and mood swings deeply affected her work, relationships, and her sense of self:

“I didn't feel at 100% capacity, you know when you’re...killing it at work. I did not feel that for like two years.” ([09:46])

• She journaled her distress and considered medication, despite disliking pills.

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4. Finding Anchors: Coping and Recovery

[10:41–12:42]

• Exercise, especially strength and bone-building activities, was crucial not only for physical but for mental health.
• Yoga, meditation, and sound healing also provided relief.
• Maintaining social connections, even when difficult, made a difference. Friends noticed her withdrawal and checked in.
• Eventually, hormone replacement therapy (HRT)—despite initial medical concerns—transformed her well-being: improved sleep, mood, and sense of self. After three months, gradual improvement; after a year, a full return to herself.

Memorable Moment:

“Now I’m just like, back to myself...after three months of HRT, I started getting better.” — Annalisa Fry ([12:48])

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5. Rediscovering Perspective and Empowerment

[14:53–16:10]

• Annalisa reframed the experience: no more periods became a silver lining.
• The death of a friend her age emphasized that growing older is a privilege, deepening her gratitude and shifting her perspective on aging.

Notable Quote:

“Getting older is a privilege...I was devastated [by my friend’s death], but it put it in perspective—we should all be really grateful that we actually get to see 50.” — Annalisa Fry ([15:28])

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6. Why Mental Health Symptoms Are So Distinct in Menopause

[16:15–20:34]
Dr. Tara Iyer's Expertise

• Emotional symptoms (depression, anxiety, irritability, brain fog) are among the top struggles during the menopause transition.
• Estrogen’s fluctuations and decline directly affect brain neurotransmitters (e.g., serotonin) responsible for mood regulation.
• Indirectly, menopause symptoms (e.g., poor sleep, night sweats) increase stress and fatigue, impacting mood further.
• Environmental/life stresses at midlife compound hormonal effects—what Dr. Iyer calls “the sandwich generation.”

Notable Quote:

“There’s a high prevalence...Probably the top five symptoms are mood related...Estrogen has significant functions in the brain, particularly toward certain neurotransmitters that can modulate mood.” — Dr. Tara Iyer ([18:24])

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7. Demystifying Perimenopause vs. Menopause

[20:34–23:16]

• Perimenopause can begin as early as late 30s, with unpredictable hormone swings and cycle shifts; this phase can last 5–7 years.
• Emotional symptoms often precede changes in bleeding.
• Menopause is diagnosed after 12 months without periods, at which point hormone levels are consistently low.

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8. Diagnosis and Distinguishing Hormone-Driven Symptoms

[23:16–24:30]

• Tracking the timing of symptoms (e.g., depression worse before periods) helps distinguish hormone-driven conditions from primary mental health disorders.
• Blood tests are less helpful during perimenopause, due to daily hormonal swings.

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9. Treatment Options & Holistic Approaches

[24:54–26:57]

• Hormone therapy (HRT) can provide relief even for mental health symptoms, but is only one solution.
• Other options include:
  • Antidepressants/anti-anxiety meds (SSRIs, SNRIs)
  • Cognitive behavioral therapy/psychotherapy
  • Lifestyle modifications for sleep, exercise, and stress management

Notable Quote:

“Hormone therapy can be helpful, but I do want to point out it’s just one of multiple treatment options.” — Dr. Tara Iyer ([24:54])

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10. Potential for Reflection & Empowerment

[26:57–28:08]

• The menopause transition can also serve as a catalyst for women to prioritize their long-term health, reevaluate life choices, and take charge of bone/heart health.
• Dr. Iyer calls menopause a “midlife inflection point” that can inspire self-advocacy and self-care.

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11. Core Message: Advocacy and Self-Prioritization

[28:08–30:25]

• Dr. Iyer urges women to advocate for themselves, seek physicians with menopause expertise, and not be embarrassed to pursue care or support.
• Cultural and systemic gaps persist in medical training and research for menopause care—so self-awareness and empowerment are critical.

Memorable Quote:

“Advocate for yourself...This is a critical time where things are shifting...recognize those symptoms, advocate for yourself, and prioritize yourself during this time.” — Dr. Tara Iyer ([28:14])

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12. Advice for Others: Where to Start

[31:03–32:15]

• Annalisa encourages:
  • Proactive research (e.g., TheMenopauseSociety.org)
  • Seeking specialists, even if waitlists exist
  • Challenging physicians who lack menopause knowledge
  • Seeing the profound interconnection of hormones, body, and mind

Notable Quote:

“Do your own research...advocate for yourself...There’s so much information, even though there’s still a lack of articles on women’s health, which is ridiculous.” — Annalisa Fry ([31:03])

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Notable Quotes & Moments with Timestamps

• “I feel like I’m going crazy.” — Annalisa Fry ([00:52], [09:11])
• “If I knew in advance what was going to happen...I would have already seen the physician….who put me on HRT and, like, literally saved my life.” — Annalisa Fry ([05:14])
• “Estrogen has significant functions in the brain, particularly towards certain neurotransmitters that can modulate mood...” — Dr. Tara Iyer ([18:24])
• “Don’t underestimate the power of hormones because they will mess you up.” — Annalisa Fry ([14:22])
• “Advocate for yourself...recognize those symptoms, and prioritize yourself.” — Dr. Tara Iyer ([28:14])
• “Getting older is a privilege...we should all be really grateful that we actually get to see 50.” — Annalisa Fry ([15:28])
• “I would most want them to know first, do your own research...advocate for yourself. ” — Annalisa Fry ([31:03])

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Key Takeaways

• Perimenopause and menopause may trigger very real and severe mental health symptoms—including mood swings, depression, anxiety, and profound identity shifts—that are still rarely discussed or understood, even by healthcare providers and close family/friends.
• Normalization, open discussion, and accurate information are essential. Cultural stigma and medical gaps in knowledge leave many women blindsided and isolated.
• Treatment is multifaceted: HRT helps many, but therapy, lifestyle changes, and sometimes psychiatric meds are vital options.
• Advocate for yourself, seek experts, and don’t underestimate the interplay of hormones and mental health.
• Menopause is not the end of a “stable” self—the right support can make this a time of reclaiming agency, wisdom, and well-being.

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Resource Mentioned

• TheMenopauseSociety.org — For locating menopause-trained physicians and information.

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Structure & Flow

This episode is an engaging blend of intimate personal storytelling (Annalisa’s real struggle and return) and contextualized science (Dr. Iyer’s clear breakdown of symptoms, root causes, and medical/holistic solutions), balanced with practical advice and compassionate guidance throughout.

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For anyone navigating (or caring for someone navigating) menopause and perimenopause: You are not alone, your symptoms are real, and reclaiming your well-being is possible—sometimes beginning with a single conversation or question.

Transcript

[A]

At first, Annalisa Fry thought it was just the stress of the COVID lockdowns. But at 47, she was facing a kind of anxiety she'd never felt before, one that didn't go away with rest or reassurance.

[B]

I, like, didn't even want to go grocery shopping. I was just like, oh, my God, I have to go grocery shopping. I mean, no one really wants to go grocery shopping, but you don't, like, feel paralyzed before you have to go grocery shopping, which is what happened to me.

[A]

Annalisa was always the one holding it all together, the go to in her big Italian family. But almost overnight, something shifted. Her mind felt foggy. She was waking up angry for no reason. And night after night, she'd lie awake, lucky to get two or three hours of sleep.

[B]

I was like, oh, my God. I'm like, so miss mad all the time for no reason. I wrote, I feel like I'm going crazy. And I said to my husband, I think I have to take, like, anti anxiety meds.

[A]

What Annalisa was experiencing but didn't yet realize was perimenopause. It's the transition before menopause, when hormones start to fluctuate wildly before eventually declining. This process can last for years, affecting not just the body, but also deeply impacting mental health. I'm Frances Solis, and this week on Turning Points, we're understanding the mental health side of perimenopause and menopause. It's a transition that nearly every woman will go through, and yet it's still one of the least talked about. For many women, the emotional symptoms, anxiety, depression, brain fog, and mood swings can be just as overwhelming as the physical ones. Today you'll hear from a woman who lived through it and from a medical expert who specializes in menopause care. Together, they help us understand why this biological shift can have such a powerful impact on mental health and why so many women feel blindsided when menopause hits. Annalisa Fry is now 52 years old and lives in Amesbury, Massachusetts, with her husband Matthew, and their two dogs. She's a yoga instructor and works full time, living what many would consider a balanced, active life. But for several years, that balance was completely disrupted by perimenopause and menopause, a journey she says she was never prepared for. So can you take me back to the beginning of your menopause journey? What were the first signs that something was changing for you?

[B]

So I would say back when I was still kind of in perimenopause, and I kind of Knew I was in it because when I met my husband in 2019, I was already 46. And so we had discussed potentially having children. So I went to see a physician and she took my FSH levels, I believe it's called. And she basically was like, oh, you know, if you want have kids, you have. It's going to be difficult for you because your hormones are not at the right stage. Which I already knew because I was obviously a little bit older. By 2020, or I guess the end of 2019, 2020, Covid happened. And so I started getting more stressed, and I just assumed it was because of COVID But then I started getting hot flashes, which, you know, I'd read about. That's really the thing that people talk about or they used to talk about with menopause, like, are you going to get hot flashes? And that's it. But. And so I was like, oh, I'm getting hot every night at the exact same time. 10 o', clock, I would be on the couch and it would be like the winter, and I would throw my blanket off because I'd get hot for like, you know, a couple minutes. Once Covid sort of went away, if we were out to dinner and I'd have red wine, I feel hot. I also really started having trouble sleeping through the night, which was never a problem with me ever. So then I was like, I think this has to do with changing hormones and actual menopause. And then I realized, oh, shoot, I'm in menopause now because I haven't had my period for a year. And then I really had a lot of trouble sleeping after that. Like, a lot. I could not sleep. And. And I. I was like, I don't know what to do. Like, I was, should I take sleeping pills? Which I, you know, I never. I'm not a pill person. And, you know, obviously my mom went through it. One of my older sisters had already gone through it, but I didn't. They didn't really talk about it, and my mom didn't really talk about it. I mean, I was a lot younger than. My mom is 79 now, so I think she was 50. So I was like, I can't believe people don't talk more about this, especially women. And I think because I was like, one of the first ones of my friends to actually go through it, I was the one that started talking to them about it because they didn't really know what was to come.

[A]

So I'm curious if this transition had been normalized or openly discussed what might have been different for you?

[B]

Well, I think I would have known in advance to, like, be on the lookout for when, you know, paying attention to when my last period was. And my mom, you know, she had four kids. She has five kids, actually. My brother's the youngest, but she had four daughters. My mom went through it, I think, at the age of 50. I was younger. I was, I was in college, so I wasn't really around. Also, my mom, both of my parents were born in Italy, so it's also kind of a cultural thing. Like, my mom doesn't even know I'm doing this. She'd probably be like, why are you talking about menopause in public? She doesn't even know what a podcast is, so whatever. But she'd be like, what are you talking about? Because they didn't talk about it. I'm sure she didn't talk about it with her mom or her sisters or her friends, because you just didn't do it back then. And so I think if I knew in advance what was going to happen, I would be like, I would have already seen the physician I ended up seeing last year who put me on HRT and like, literally saved my life.

[A]

HRT stands for hormone replacement therapy. This therapy is one option to ease the symptoms of menopause.

[B]

She thinks I'm like the poster child for hrt because I saw her this past June and I had seen her the first time last June, and I was like, I don't know what to do. I can't sleep, I can't think. I'm so anxious. There's like this, all this anxiety that happens that again, I'm not an anxious person. I'm the third of five children. We had a very great childhood. I'm very close with my siblings. We all have lunch at my mom's house every Sunday. There's like 25 of us with my nieces and nephews and boyfriends, girlfriends and whatever else. And I've always been like the stable one in my family. Everyone calls me if there's an issue. But in that three year span, basically from 2020, well, more than that, maybe five years, from like 2020 to this past year, I was very stressed. Didn't even want to go grocery shopping. I was just like, oh my God, I have to go grocery shopping. I mean, no one really wants to go grocery shopping, but you don't feel paralyzed before you have to go grocery shopping, which is what happened to me. Some of it was because of lack of sleep, because I slept two to three hours a night. It was really bad. And so I was really on edge. I was moody. I mean, the mood swings are really bad too. The menopause, I feel like they were worse than perimenopause. But in menopause too, I was like, oh my God, I'm like so mad all the time for no reason.

[A]

How did all this impact just your sense of self, your relationships, your work and maybe your confidence?

[B]

So, yeah, it impacted all of it. And I didn't want to go out when I'm very social person. We're having a party tomorrow, which, like a big pool party. And I don't even think I could do that two years ago because I couldn't handle like the setup of it. But I'm. I've always been a planner. I like planning everything. We just planned my dad's 80th birthday party. I was like the showrunner of it all. But two years ago, I wouldn't have been able to do that because I wasn't thinking like I normally do. Like, I'm a very type A. I make a lot of lists. I get things prepared. And I just wasn't doing it because my brain just wasn't working like it used to. And I was like, I don't understand what's happening to me. I also felt, and people say this and you kind of are like, I don't know if that's really true, but you feel like you're not in your own body. Which part of it was, you know, I had gained that weight. I mean, it's since gone, but like, you just feel different. And I like, didn't want to wear clothes. A. I didn't really want to go out again. In the wintertime. I don't really go out that much, but even in the summer, like, I didn't really want people to come over to use the pool. My husband was like, why don't you want to go out and like, do stuff you used to do? And I was like, honestly, I just don't. I don't want to talk to people. I'm very social. I didn't even really want to teach yoga because I didn't want to, like, go out of the house. It's very strange. But it's also because I have a terrible memory. It feels like it didn't really happen. But I know it did because I like, you know, I write in journals a lot. And I wrote. I feel like I'm going crazy. And I said to my husband, I think I have to take anti anxiety meds even though I hate to that hate meds. I don't even like painkillers if I get my tooth pulled or something. And he was like, are you sure you want to do that? And I said, I think I'm going to see my old physician. She went into private practice or, like, concierge medicine, and I used to love her, and so I went to see her, and she was basically saying, I need to go on hrt. Well, not I need to, but it was my choice. I was a little concerned because I had. I have factor five Leiden, which is. It's like a. It's like, condition that basically means you can get blood clots easier than the regular person. And you can't be on the pill, which I wasn't on the pill anymore. You can't smoke, you can't be sedentary, and you can't be on oral hrt, because oral HRT is similar to the pill. So I was afraid to go on the patch. But, you know, everything worked out fine because my brain fog and, like, me not thinking clearly. I mean, I worked still. Obviously, I still work. I work for New England Journal of Medicine. I've been telling them to do some more articles on menopause, But I worked, but I didn't feel at 100% capacity, you know when you're, like, killing it at work and you're doing a great job. I did not feel that for, like, two years. I was like, I'm doing a good job, but I wasn't doing the best job I could do.

[A]

So how did you manage those two years? Were there any specific practices or aside from, you know, working with your doctor, Was there anything else that sort of helped you feel a bit more anchored?

[B]

Yes, I continued working out, so I'm a very active person because of menopause. It makes you really tired, and so you don't really want to do anything. But I would book all my classes and basically force myself to go. Also, during COVID I worked out a lot at home. You kind of missed that social connection. So I was like, I want to go to my classes because then I can see people that I know and I can talk to them. Because I work from home. I don't talk to anybody all day besides my dogs and, like, people that I see when I walk my dogs. So I forced myself to keep working out, and I optimized strength training, which is something that you really need to do. You have to worry about your bone density. This morning I went to a bounce class, which is like a rebounder class, which is also very Good for bone density. So I kept up with my workouts even though I didn't want to necessarily do them. But that really helped. I started teaching and going to yoga more often. I started doing yoga at home. I did some sound healing classes that I attended, which is like, also great. It just puts you in like a real nice meditative state. The vibrations totally relieve stress in your body. It's. I don't know how they do that, but it does. So I did that a lot. And I did. Every morning I do like a 5 to 10 minute meditation before I get up. I tried to not be on my phone so much. That was another thing that was kind of stressing me out. When I was in my two year crazy. I don't want to call it a crazy period, but just like the period where I wasn't myself. I was not even interested in like looking at what my friends were doing or talking to them. I have a really close college group of friends and they kind of noticed that I wasn't responding to our group text messages. And so one of them reached out to me and said, are you okay? Like, how come you're not responding to anything? I would just like, do like a like or something, but I wouldn't write back anything. And I'm usually the talkative one of the group. So she, like, came to visit me. She's like, do you want to meet me? And I was like, no, I'm good. And she's like, I'll just come to your house. And she doesn't even live close to me. She lives like an hour from me. But she just came to, like, check up on me and hang out it.

[A]

Looking back now, how are you different from the version of yourself who is just beginning this journey?

[B]

Oh, how much different? I wouldn't do this podcast if I was back then because I would be like, so stressed out. I wouldn't even figure out what to wear. I'd be like, what am I going to wear to this? What am I going to say now? I'm just like, back to myself. Yeah, my family has noticed. My younger sister is the one who said, you should go see Dr. Wax about the ICRT because you're actually crazy. You're crying for no reason. You're all stressed out. So I do the patch twice a week now and I take progesterone, which has helped me sleep. So I was not the same person for like five years that I was. And now I'm back to the same person, just like a little older and a little wiser. Than I was. And now I'm like, after three months of hrt, I started getting better. And then a full year later, like June of 2024 to June of 2025, when I saw my physician again, she even said to me, you look and act so much. I don't want to say better. Because she knew me before she was my physician at Amesbury, before she went private. She was like, you're just you. Do you feel back to yourself? And I said, oh, I totally do. Totally back to myself. I'm not anxious. I can sleep now. And if on the rare occasion I don't sleep fully, like I Woke up at 4:30 yesterday morning at my sister's beach house just because the sun was kind of coming up. And I was like, I don't care. I went to bed at like 9:30. But when I was real bad in the post menopause stage, I was going to bed at like 11 because I couldn't sleep. And then waking up at 2 and not going back to sleep. And I wasn't even stressed about anything. Nothing was even happening. So I was like, why am I waking up? My husband was like, why are you waking up?

[A]

Because your hormones were.

[B]

But I just could not handle it. And I was like, I can't believe that hormones is the reason. It's just like when kids are teenagers and they're like, you know, my friends are like, my daughters are so mean to me. And I was like, I think I was mean to my mom when I was a kid, when I was a teenager too, because your hormones are crazy. And I said, do not underestimate the power of hormones because they will mess you up.

[A]

What did this chapter give you? What parts of yourself did you discover or maybe even reclaim along the way?

[B]

I was so excited I would never get my period again, that I was like, that really makes up for everything. My sisters and I all had really painful periods. That part was the best part, I think, of not doing it and not having. Not being bloated when it's the time of the month and all that, all the stuff that comes with the period that's gone is like really good. I mean, I am just getting older. Like if you look at me now and you looked at me at 22, I obviously look a lot younger when I was 22 years old. To me, getting older is a privilege. A really good high school friend of ours passed away two years ago of cancer. She had five children. And, and that, that was like in the middle of my menopause situation too. And I was like, all of us were devastated, but I was tough, really devastated at the fact that she didn't even reach the age of 50. And we're all complaining that we're looking old or like getting old and our joints hurt. It put in perspective when my friend Charlotte passed away that we should all be really grateful that we actually get to see 50. So my husband and her husband ended up throwing us a 51st birthday party. We pretended we were 50, whatever. And I was. We were like, it's a delayed birthday party. And it was so fun. But I wouldn't have been able to do it the year before because I was like in my whole menopause situation. So I wouldn't have enjoyed the party.

[A]

So what do you wish more people understood about the mental health side of menopause?

[B]

Yeah, I think people don't really get. And you know, I've read a lot of statistics and my physician even told me that so many women around this age just think that they're anxious or are anxious and think that they need anti anxiety meds. And I know personally a few of my friends that take it because they haven't been sleeping and they're anxious. And I was like, honestly, I would have gone that route, but I just didn't want to because I was trying to be like more holistic about it. But probably 95% of the times it's because of your hormones. And if you started taking HRT or some other sort of alternative, you would feel like this was me and now this is me. Like I'm so much more. Even so, I don't think you necessarily need the anti anxiety meds. There's also a stat that women in menopause get divorced at a higher rate. And I'm not surprised because they are annoyed with everything. But, like, nobody really talks about the fact that the hormones, your estrogen, your progesterone, everything and your testosterone. I do testosterone gel on my arm every day, everything. It gets dumped in the toilet when you're in menopause. And how is that not going to affect your mental health? It literally affects your body. Like, you need those hormones to like protect your heart, protect all your organs, everything else. And it obviously affects your brain. I mean, all of those hormones are working with your brain as well. That's why you have that brain fog. That's why I couldn't really think clearly. And that's why I think I got super anxious because I was lacking the hormones that I desperately needed because I used to have them. And then all Of a sudden, I didn't have them anymore.

[A]

To better understand the science behind what Annalisa experienced, I spoke with Dr. Tara Iyer, the medical director for the Menopause and Midlife Clinic at Brigham and Women's Hospital and an instructor at Harvard Medical School. Dr. Iyer specializes in helping women navigate the complex hormonal and mental health challenges of perimenopause and menopause. So let's talk a little bit about what's going on in the brain. How does perimenopause or menopause affect someone's mental health?

[C]

Yeah. So there is really a high prevalence, and I'd put this in sort of the top, probably the top five symptoms that I see in women who are undergoing the menopause transition and start to see hormonal fluctuations that really impact their mood. Typically, what I'm seeing is a higher incidence of issues like depression or anxiety or symptoms associated with them, certainly more irritability as well, in part due to these hormonal changes. The biggest impacting factor we really feel is estrogen and how estrogen fluctuates wildly in perimenopause and then, of course, declines closer to the end of perimenopause and is really minimal when we're at postmenopausal, almost undetectable serum levels. And we know that estrogen has significant functions in the brain, particularly towards certain neurotransmitters that can modulate mood, like, for example, serotonin. Right. But that's, I think, only scratching the surface a little bit. So we know there are the direct impacts of these hormonal changes and how they can impact mood. But then there's the indirect impacts that certain other symptoms in this transition can have on mood. Like, for example, if we have significant sleep disruptions, hot flashes, and night sweats, this can create fatigue. More stress on the body can really then impact mood. And the other thing that I think sometimes is minimalized is this tends to be a high stress time for women. Right. Midlife. You know, people often talk about the sandwich generation, where we've got kids that we're raising, we've got aging parents. You might be at the peak or of your career, a changing pivot point in your career. And there's a lot of burden just on women in terms of environmental stressors, which can also additionally play a large impact on mood.

[A]

Yeah. So it's not just the menopause transition, but just like you said, it's just like life is shifting. And so you almost have to look at yourself through such A deep holistic lens from all sectors of your life.

[C]

And that's something that I talk about with my patients all the time when we're thinking about management, like, it's usually not as simple as, okay, well, I can write you one prescription and we're done. Usually we do have to kind of take a step back and look at all of the impacting factors.

[A]

Can you actually walk us through the difference between perimenopause and menopause, especially when it comes to, like, how it impacts mental health?

[C]

Yeah, absolutely. So perimenopause, this is something that more typically can occur really as early as sort of like your early 30s. But most commonly, if we're going to see it start in the 30s, it'll be your late 30s. And more commonly even than that would be into the early to mid to late 40s. And what we really start seeing here is changes in hormones, in particular, estrogen being probably the most significant, though progesterone is also affected. And how this really sort of is going to reflect for women, what they're going to see often is changes to their menstrual cycle. In the beginning of that, it may be just as simple as, you know, a change in, we're still bleeding the exact same time every month, but it may be a little bit heavier or a little bit lighter. Or some people start to see changes in the cyclicity, right? How frequent they're getting periods. They could start coming. Used to be your like clockwork, every four weeks. Now it seems like it's every three weeks or you got two periods in a month or, you know, or we start seeing the opposite, where we start to expand. But I even see symptoms before these menstrual cycles occur in many patients as well. Where we see the highs of estrogen can sometimes be higher, creating symptoms. The lows of estrogen certainly get lower, creating more symptoms. And this really sort of changes how women start to feel. And so this is a pretty long process if we're talking about on average several years, about five to seven years, where you could have changes in your menstrual cycle, changes in hormones that then impact symptoms. Again, really common to that would be mood disturbances like increasing depression, irritability, anxiety, sleep disruptions, vasomotor symptoms such as hot flashes and night sweats, brain fog or cognitive changes. Joint pain, I.e. diffuse headaches are really common in this phase for many women. And as you get towards the end of that perimenopause transition, we start to see, well, it's less that we have this Volatility of our menstrual cycle, where the highs are highs, the lows are lows, and it's all over the place. And we get more and more into that phase of we're just really having low levels of hormones. And so it feels like symptoms are really just more steadily prevalent until we have our final menstrual period. And then 12 months after our final menstrual period, where we think, okay, we did not ovulate during this, this entire amount of time, or release an egg. Right. Is where we would classify classically, look back and define that as okay, now we are in menopause.

[A]

How do you tell if it's menopause related depression or anxiety versus something that's not hormone driven?

[C]

Yeah, that's a great question. It can be really difficult, frankly. The best way that we can really tell in perimenopause in particular is, you know, if we can track symptoms a little bit. So if we can use the period as a, say, a marker. Right. We know how our hormones supposed to be shifting. Right. So for example, in what we call the luteal phase of the menstrual cycle, which is about the second half. Right. We know about the 7ish days before you actually start bleeding, before you actually start having your period, is when estrogen is at its lowest. So if we see that, you know, people have symptoms, you know, particularly that seem to be really concentrated right before their period, when estrogen is dropping, or it seems like these come in a cycle every month and that cycle really is related to when they are bleeding. That usually shows us and gives us strong indication that there's a whole big hormonal component to their symptoms as opposed to if they were having the same symptoms every single day and they didn't really massively fluctuate.

[A]

Hormone tests can help identify if someone is in menopause, but they aren't specifically useful during perimenopause because levels can swing dramatically from day to day. A single blood test only captures a snapshot, not the bigger hormonal pattern your body is moving through. What do things stand now, especially when it comes to using hormone therapy to help with mental health symptoms?

[C]

Yeah, so this is actually a field that I think is garnering more and more attention and more and more research. I've seen multiple studies over the past few years, particularly in women using hormone therapy in perimenopause, seeing that it can be. So we know that you may have an increased risk of developing, say depression or anxiety disorders during this time and the utilization of hormone therapy can be a helpful treatment option in this space. But I do want to point out it's just one of multiple treatment options. Right. So we have plenty of non hormone mood medications that I would also, in addition to hormone therapy, consider as a first line option to treat mood in this space. And things like cognitive behavioral therapy or psychotherapy, lifestyle changes that are also extremely helpful in this space as well.

[A]

So for those who are curious, what are the options for treating menopause related mental health symptoms beyond hormones?

[C]

Yeah, so I would say really, when we're thinking about prescription medications, so there are, you know, non hormone mood medications that I would also consider first line in this space. So things like antidepressant medications, anti anxiety medicines, most common, I think that most people would have heard of, that are really commonly used here would be medicines like SSRIs and SNRIs that are really commonly used for anxiety disorders, depressive disorders, even outside of hormonal, the hormonal transitions that occur in perimenopause and in menopause. I would say, apart from the prescription medicine space, I also very commonly talk to my patient about lifestyle behaviors, how can we optimize sleep? And we discuss things like sleep hygiene, are we exercising regularly, which has been consistently shown to be helpful to impact mood in a positive light. And then, of course, psychotherapy is something that I consistently discuss with my patients and many of my patients engage in.

[A]

And for some people, this chapter brings identity shifts and emotional upheavals, especially like, what's wrong with me Kind of thing. But can it also be a time of reflection or even empowerment?

[C]

I absolutely think so. And I'm seeing the shift in my patients where they want to sort of take hold of their health at this point, and not only for the present time and how they feel, but also looking out towards the future. For example, we know estrogen and the decline in estrogen in the menopause transition can impact our bones, right. And so we lose a significant amount of bone within the first couple years of menopause. So I'm often having these types of discussions with women as well, who think about, okay, well, what can I do to maximize my bone health so that I can think about myself now, but about myself in 10 years, about myself in 20 years, and live, you know, sort of this healthiest version of myself in the future as well. This really is an inflection point at midlife where we kind of have to take charge of our health and, and look towards the future to prevent a lot of the diseases that we know may occur that we are at higher risk of just with chronologic aging.

[A]

So if you could leave people with one big takeaway about menopause, perimenopause and mental health, what would it be?

[C]

I think my biggest takeaway would be advocate for yourself. Because we are in this critical time where things are shifting. We're trying to prioritize women more, we want to do more research in that space, and we want to really manage care for women in the best way we possibly can. But as we know, particularly in medicine, a lot of those things take time. When we're doing more and more research, it may be 10 years, 15 years, 20 years before we really see so much of the fruits of that labor. And right now, I think what women can do for themselves is make sure that they are looking for these symptoms, trying to recognize them, and then advocate for themselves in making changes, both with the help of their physician, including whether that be medications or suggestions for therapy or suggestions for modifications in the lifestyle and really prioritizing themselves. I see this a lot with my patients too, right where we're in sort of this built as women that we are going to take care of everyone else first and, you know, leave our own health and our own well being till the very, very end of. And usually that doesn't leave much, right? But it sort of has to be a little bit more of a shifting dynamic where, you know, like we think about on airplanes, right? You put your, you put your oxygen mask on first, where you can show up and be the best version of yourself so that you can more profoundly help, you know, in all those other aspects of your life. So I think my biggest takeaway here for women is recognize those symptoms, advocate for yourself, and prioritize yourself during this time. And if you are starting to see that you are having mood disruptions, sleep disruptions, more stressors, and if you need to reach out for help, do not be shy about that. Do not be embarrassed about that. Please bring this to people who can help you. Your physicians, your primary care doctor, your OB gyn. Seek out a specialist in, in menopause care and see what options are available to you and build those support structures and systems.

[A]

What Both Annalisa and Dr. Ira make clear is this. The mental health effects of menopause aren't something women just have to live with. Support exists from treatments to resources to community. But often getting the right care means speaking up, asking better questions, and finding providers who truly understand what this incredibly complex transition can feel like. If someone's listening and they're where you were once. In the middle of that confusion or anxiety, what would you most want them to know?

[B]

I would most want them to know first, do your own research, which I didn't maybe. And do it, like, sooner rather than later maybe, so that you can maybe figure out a solution before I did, because I was, like, two years into it before I figured it out. Go to themenopausesociety.org, i believe they have a whole list of physicians that are trained in menopause in your area. There's probably, like, a wait list for them now because there's not that many of them, but I would try to find them as soon as possible. You have to advocate for yourself, unfortunately, even if you have a physician that you've really liked and maybe have seen for 20 years, like, they're not gonna know what you're going through necessarily unless they've been trained in menopause. I would just say that and just, like, do research. There's so many. There's so much information that we have, even though there's still, like, a lack of articles on women's health, which is, like, ridiculous. I just feel like more education, more funding for women's health, more funding for women's mental health. Figuring out that everything is connected. The hormones are dealing with your body, your face, your organs, and your mind. The sooner you know that, the better you will be.

[A]

Annaliese's experience is a powerful reminder. While this transition is common, it's not meant to be carried alone. When women are seen, believed, and supported with accurate, compassionate care, menopause doesn't have to feel like the end of stability. It can be the beginning of self reclamation. Her journey alongside Dr. Eyre's expertise reveals what too many women are never told. These mental health symptoms are real. They're widespread. And with the right support, healing is not only possible, it's transformational. I'm Frances Leese, and this has been Turning Points. Thank you for listening. Visit globe.com1word for more information on mental health care and resources. Turning Points is produced by Tufts health plan, a 0.32 health company, and the Studio B team at Boston Globe Media in partnership with POD People. With a commitment to personal service, Tufts Health Plan provides quality coverage and dedicated support to help guide and empower healthier lives. Stay healthy in mind and spirit.