Driving through town on the way to complete some mundane errand. All Too Well by Taylor Swift playing for the millionth time through the car speakers. I stare blankly at the road ahead wondering what it would be like if I wasn’t here anymore. The tiny thought of death almost slipped past me in an endless stream of thoughts about the day.
As this bleak winter morning unfolded, the tiny thought of death deteriorated into an acute health crisis. The room spun around even with my eyes closed, making me so dizzy I couldn’t walk. Depression delivered dark and intrusive thoughts I hadn’t experienced since being a teenager. My body was itchy. The fatigue was unshakable. Emotions churned inside me and spilled out uncontrollably–leaving me sobbing or burning with rage. Within a few hours I was physically and emotionally debilitated by the number and intensity of my symptoms.
Thankfully, my kids were away and I had taken some time off work.
Standing in the kitchen, pushing my hips into the counter, the cold stone pinching my skin against my hip bones, allowing me to feel something true while the rest of me unspooled. My beloved gently offered that I’d seemed a bit down the last few months. Pointing out that perhaps this isn’t who I am. I responded by becoming emotional and defensive, further proving his point.
A thick malaise of exhaustion and depression had been creeping up on me slowly for months. The transformation is almost undetectable, yet profound. Until now, changes so subtle and gradual they had fused with my identity. I start to wonder when I began the long slide into perimenopause.
With the room spinning around me, I steel myself, open my phone to research my symptoms. Within a few moments I learned that dizziness is one of the most common symptoms of menopause1. Familiar with the silence that shrouds women’s bodies, I still felt the sting of being tricked again.
When I asked my doctor about menopause at my annual physical last year, she breezed over it, suggesting it wasn’t something I needed to worry about right now. I’m 43. The average woman goes through menopause between 45 and 55 years2. Fast forward six months and I was in the middle of a physical and mental health breakdown, trying to dig myself out alone. Thankfully, I’m equipped with the resources, knowledge and privilege to start shoveling.
I was aware of the benefits of Hormone Replacement Therapy (HRT)—typically estrogen, often progesterone and sometimes testosterone, depending on the individual3— and I understood HRT would likely be the first line of treatment for anxiety and depression caused by hormonal changes. A number of studies have shown that a combination of HRT and antidepressants promotes the best therapeutic outcomes for people experiencing anxiety and depression during menopause.4(12)(13)
So I reached out to my physician and OBGYN to find out if they would consider writing me a prescription for HRT. My doctor informed me that prescribing HRT for perimenopause isn’t standard practice and is typically reserved for menopausal or postmenopausal women5.
I was prepared for my doctor's response—nope, sorry, nothing for you.
In 2002, a study of women, a decade beyond their final menstrual cycle, found the risks for HRT outweigh the benefits. The study was prematurely discontinued, creating fear and panic in the community, with many doctors no longer prescribing HRT. (although, the study has since been reanalyzed, new studies have shown that HRT in younger women or in early postmenopausal women had a beneficial effect), and the American Association of Clinical Endocrinology menopausal guidelines now recommend hormone therapy as the most effective treatment due to its improved quality of life and benefits;6 women are still unable to get HRT prescribed by their doctors and OBGYNs.
I figured menopause was going to be difficult, but nothing I couldn’t handle—until I was violently and abruptly thrown into an acute mental health crisis. I touched the depths of distress and despair women are living with on a daily basis without acknowledgement or support. I clearly understood how untreated menopause symptoms could jeopardize my ability to function, parent and work.
Within a few hours of receiving the email from my doctor, I quickly switched gears and scheduled an appointment with a private doctor specializing in hormonal treatment for perimenopause and menopause. Within 48 hours, I had started hormonal treatment for my symptoms and was feeling much better. Actually, I felt better than I had in years.
I am lucky enough to have the training, knowledge and resources to serve as my own health advocate. I can afford to pay for a private consultation with a doctor, have a flexible work schedule to meet with specialists or take time off as needed, and I have access to the internet allowing me to meet with a private doctor via telehealth. Essentially, I have a lot of privileges that allow me to swiftly resolve my health crisis.
Most women are ignored by doctors who lack basic training in menopause, are denied the HRT treatment and don’t have the knowledge, financial means and support from employers to find relief and access necessary accommodations. Women are reluctant to disclose their experience of menopause to the employer due to fear of discrimination and stigmatization,7 so they resort to cutting back their work hours, taking sick days, quitting their jobs, or retiring early.8
Menopause disproportionately impacts Black and Brown women, who are three times more likely than white women to report adverse work outcomes and more severe menopause symptoms, lacking access adequate adequate information or support.9 Unsurprisingly, there is no research on how menopause impacts LBGTQIA+ and autistic individuals, despite the fact that these communities are already at greater risk for suicide.
Don’t get me wrong, I’m not saying that HRT is a magical solution for everyone going through menopause. I’m suggesting that people going through menopause shouldn’t have to live with thoughts of dying.
As therapists and health care providers we should get curious about menopause coming at the time in life when women have the highest rates of suicide (ages 45 to 54)10 and are most likely to give up their job and sacrifice their income because they are suffering, unable to manage and don’t have a place to turn for support.11
As clinicians we should be assessing all women and AFAB clients between the ages of 35-55 from a developmental perspective. Considering the possibility that intrusive thoughts, suicidal ideation, depression, anxiety, lack of sexual desire, insomnia, mood changes, headaches and irritability may potentially be related to the hormonal changes that take place during this phase of life. We should have basic education and training in best practices and recommended guidelines to support clients through this developmental phase from a physical, mental, emotional, sexual health perspective with education, treatment and referrals.
If you or someone you know is struggling with thoughts of suicide, it's crucial to seek help. Here are some suicide prevention resources:
National Suicide Prevention Lifeline: Call 1-800-273-TALK (1-800-273-8255) to speak with a trained crisis counselor 24/7. This service is free and confidential.
The Trevor Project: A leading organization providing crisis intervention and suicide prevention services to LGBTQ+ youth. Call 1-866-488-7386 or text "START" to 678678.
International Suicide Hotlines: If you're outside the United States, there are suicide hotlines available in many countries. You can find a list of international hotlines at https://www.opencounseling.com/suicide-hotlines.
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Terauchi, M., Odai, T., Hirose, A., Kato, K., Akiyoshi, M., Masuda, M., Tsunoda, R., Fushiki, H., & Miyasaka, N. (2018). Dizziness in peri- and postmenopausal women is associated with anxiety: a cross-sectional study. BioPsychoSocial Medicine, 12(1). https://doi.org/10.1186/s13030-018-0140-1
World Health Organization. (2022, October 17). Menopause. www.who.int. https://www.who.int/news-room/fact-sheets/detail/menopause
McCall, D., & Dr. Naomi Potter. (2022). Menopausing: The positive roadmap to your second spring. HarperCollins UK.
Graziottin, A., & Serafini, A. (2009). Depression and the menopause: why antidepressants are not enough? Menopause International, 15(2), 76–81. https://doi.org/10.1258/mi.2009.009021
While I have used the term woman throughout this post, I want to acknowledge that the themes of this post are relevant to AFAB individuals, non-binary people, gender non-conforming and trans folx.
Randel, A. (2012). AACE Releases Guidelines for Menopausal Hormone Therapy. American Family Physician, 86(9), 864–868. https://www.aafp.org/pubs/afp/issues/2012/1101/p864.html
Faubion, S. S., Enders, F., Hedges, M. S., Chaudhry, R., Kling, J. M., Shufelt, C. L., Saadedine, M., Mara, K., Griffin, J. M., & Kapoor, E. (2023). Impact of Menopause Symptoms on Women in the Workplace. Mayo Clinic Proceedings, 98(6). https://doi.org/10.1016/j.mayocp.2023.02.025
We Can Do Better by Women Experiencing Menopause. (2023, October 18). Time. https://time.com/collection/time100-voices/6325393/menopause-health-care/#:~:text=Fewer%20than%20one%20in%20five
We Can Do Better by Women Experiencing Menopause. (2023, October 18). Time. https://time.com/collection/time100-voices/6325393/menopause-health-care/#:~:text=Fewer%20than%20one%20in%20five
Curtin, S., Garnett, M., & Ahmad, F. (2023). Vital Statistics Rapid Release Provisional Estimates of Suicide by Demographic Characteristics: United States, 2022. https://www.cdc.gov/nchs/data/vsrr/vsrr034.pdf
Faubion, S. S., Enders, F., Hedges, M. S., Chaudhry, R., Kling, J. M., Shufelt, C. L., Saadedine, M., Mara, K., Griffin, J. M., & Kapoor, E. (2023). Impact of Menopause Symptoms on Women in the Workplace. Mayo Clinic Proceedings, 98(6). https://doi.org/10.1016/j.mayocp.2023.02.025