Perimenopause and Mental Health: Depression, Anxiety, Brain Fog, Sleep, and Hormone Therapy

Dr. Bergink, a leading expert in women's mental health, joins the podcast to unpack the complex links between perimenopause and mental health, including new-onset or worsening depression, anxiety, panic attacks, brain fog, sleep disruption, and irritability driven by hormone fluctuations rather than simply low estrogen. Discussion surrounds evidence-based insights on distinguishing hot flashes from panic, the real benefits and limits of hormone therapy (HRT) versus SSRIs or CBT-I, myths about testosterone and surgical menopause, elevated risks in bipolar disorder, and why cognitive changes are usually temporary.

Speaker names marked ? are inferred from speaking time and the show’s known hosts — they are not voice-verified.

• 0:14David Puder?

  All right, welcome back to the podcast. I am joined with Dr. Verily Berchink. She is an expert in all things women, mental health, and was on a prior episode on postpartum psychosis, is coming on today to talk about menopause. And we're going to be trying to go through some commonly asked questions and maybe some myths that I found on the internet and seeing what kind of truth we can give to an audience that is often barraged by falsities. So, welcome to the podcast.

• 0:50Speaker 01

  Yes, very happy to be here. Yeah, there's lots of information out there, but also, as you say, some myths and it's difficult for women, for patients, to navigate that landscape, right?

• 1:03David Puder?

  Yeah, I think the first topic we'll talk about is can perimenopause or menopause cause anxiety or panic attacks?

• 1:13Speaker 01

  Yeah, the short answer is yes, right? So, most women go to perimenopause without anxiety and depression, but there is an increased risk both for first onset anxiety disorders or depression, or it's often, of course, mixture of both, as well as women who had this in the past, depression, anxiety are at higher risk. They are at the higher risk at any time in their lives, right? But then specifically in perimenopause. So, that is actually the period before the last menstruation. So, I think that's the first myth, that post-menopause, you know, menopause after the last menstrual

• 1:55Speaker 01

  period is the risk period, but it's actually the years before in most women, starting, you know, end of their 40s, basically.

• 2:06David Puder?

  Okay.

• 2:06Speaker 01

  And what we know now is that the risk might be specifically high for women with bipolar disorder, for having good instability. So, among all psychiatric disorders, those women have specific sensitivity, maybe for those hormone fluctuations.

• 2:27David Puder?

  Okay. So, one of the myths that I found was that new midlife anxiety is always caused by low estrogen.

• 2:36Speaker 01

  Yeah, yeah, that's a great myth. I mean, when we were nine, estrogen was low and it was not a period of high anxiety, right? So, it's mainly the fluctuation in hormones that causes mood symptoms, if acne, again, many women go through perimenopause, you know, not having depression and anxiety. I think we shouldn't dramatize it too much, and it's not a matter of low estrogen, but some women are vulnerable for the fluctuations. And yeah, I wish it was as simple as low estrogen, right?

• 3:16Speaker 01

  Because hormonal therapy, such as an estrogen patch, is not a magical bullet. You know, some women might help a bit with their sleep, with their mood symptoms, but it's, yeah, it's not a matter of fixing low estrogen.

• 3:35David Puder?

  Yeah, also, how do you differentiate between like hot flashes, which themselves can mimic anxiety, sweating, racing heart, rapid breathing, and anxiety itself?

• 3:48Speaker 01

  Wow, that's a very difficult question, really on two levels, as an expert. But also personally, I have to be honest with you. So, yeah, just to give some personal background, I did not have psychiatric history until perimenopause, in which I, for the first time, had quite severe panic attacks. And those started as hot flashes. So, well, at least my body couldn't differentiate between the two. You know, both a gynecologist and a psychiatrist asked like, yeah, but are these hot flashes?

• 4:26Speaker 01

  Or is it a panic attack? And I answered, yeah, all that I know is, you know, that I feel very hot, that my heart is racing, and then I start panicking, even though I somehow know that this is a panic attack or a hot flush. So, I think that's different to differentiate for those women who have anxiety. But having said that, that is, of course, many, not everyone has hot flashes during perimenopause, but I think most women do, and the severity is enormously variable.

• 5:06Speaker 01

  Those are worse during perimenopause and after post-menopause, they're a bit less. But they're worse during perimenopause, and there is a huge variety in the severity of these symptoms. And yeah, most women do not have what I had, like, you know, a panic attack coupled to a hot flush. But that happens, that, you know, the women other than myself, you know, also feel anxious, or not. But in any case, if it occurs during the night, then it can be a major sleep disruptor,

• 5:46Speaker 01

  which in itself, we know is of course a risk factor for all kinds of psychiatric misery, basically. If you don't sleep well, then you're more vulnerable. And yeah, that makes it sometimes, I think, also for us, a psychiatrist, a bit difficult to differentiate what is what, right? Is the sleep disturbances, is this, you know, cause perimenopause? Is it, you know, part of the symptomatology of a depression, for example? So, it's a mixture of symptoms.

• 6:28Speaker 01

  But I think for psychiatrists, it is already major, if people think about women in their 40s or, you know, beginning 50s, that this all plays a role. And really ask about it, like, you know, how is your cycle? Are you using contraceptants or Myrna IUD or hormonal therapy? You know, is your cycle regular or not? Do you have hot flashes? Do you have other perimenopausal symptoms? So, when we try to diagnose anxiety, depression, and yeah, we also need to ask about those symptoms.

• 7:11David Puder?

  What was most helpful for you when you saw help? What was helpful from the professionals that you saw? What do you feel comfortable sharing? It's okay if you're like...

• 7:21Speaker 01

  Yeah, no, I'm totally comfortable sharing, and I saw lovely professionals, but they...

• 7:30David Puder?

  Or maybe they...

• 7:31Speaker 01

  They don't know either, in a way, right? So, I first saw a gynecologist, then she put me on hormonal therapy. And at that time, that was oral hormonal therapy, and that made my mood worse. That happens sometimes in women, right? There are also women who are sensitive for, for example, Myrna IUD or contraceptives that is associated with depression. So, that wasn't so helpful. And then I got hormonal therapy, a patch, and that was helpful for perimenopausal symptoms, such as, yeah, hot flashes

• 8:15Speaker 01

  and feeling stiff in the morning and all kinds of other symptoms. But my anxiety responded well to an SSRI. So, for me, the hormonal therapy was not solving the panic attacks.

• 8:36David Puder?

  Okay, yeah, that, actually, one of the myths I found on Reddit was that HRT fixes anxiety within the first 24 hours.

• 8:47Speaker 01

  Yeah.

• 8:47David Puder?

  For almost everyone, for almost everyone.

• 8:51Speaker 01

  Yeah, no, I know. As I said, it's not a magical bullet, you know? We, I think over the past decades, you know, we went from a phase where the recommendation was to most women, like, you know, everyone should go on hormonal therapy, because, you know, it's, it's, it keeps you young, and it might give cardiovascular protection. And, you know, then we had this Women's Health Initiative studies coming out, saying like, okay, no, it increases risk for breast cancer and even dementia. And, you know, no one should be on hormonal therapy. And it turned out, you know, there is a lot to say about these studies,

• 9:34Speaker 01

  that this alarming message was really not justified, right? That these risks were overestimated, that it was investigated in older women and not younger women, you know, with different forms of hormonal therapy. Yeah, and now we're in this age in which we see both, like, calls for over-treatment, like, yeah, it's, you know, it helps for everyone, and, you know, it keeps you young and happy and healthy, and all women should use it. And yet, at the same time, we also see that not that many women use it in the end,

• 10:13Speaker 01

  that there might be a group of women who have like really severe perimenopausal symptoms and who could really benefit from hormonal therapy and who not get it. So, we see now a mix, but the nuance has been gone a bit out of the debate.

• 10:33David Puder?

  There's another myth that if the hormone therapy does not fix anxiety, the dose must be simply increased.

• 10:43Speaker 01

  Yeah, I think the dose finding is a bit challenging. It's a bit trial and error, but you start by the lower dose. But you're so right. It's not, it's not that it immediately gonna fix it. I have to say there are women who have, you know, a whole broad variety of symptoms. And, and we start hormonal therapy and, and describe it as a, as a game changer, right? Like, okay, you know, this really worked well for me, but that is on an individual base. Um, yeah, we know from studies that it sometimes can help, you know, to prevent depression or, you know, it can do something on, on sleep and depressive symptoms.

• 11:26Speaker 01

  But we also know that for, yeah, that major depression or a more severe anxiety disorder still needs to be treated by us as psychiatrists. Uh, yeah, just in the same way as we do at other times. But yeah, you, I, I think, yeah, for some women, it's worth trying again because there are women who describe like, okay, you know, I feel really much better after hormonal therapy.

• 11:57David Puder?

  Right. I, I think, I think one of the sort of the recurring myths is like anxiety medication and psychotherapy to treat anxiety during this time period doesn't work because it's a hormonal issue. And one of the studies I saw, Brown, two thousand twenty-four, is that CBT cognitive behavioral therapy actually does help with, um, sleep disturbance, phase of motor symptoms. So even, even therapy is helpful. Any thoughts on that?

• 12:27Speaker 01

  Yeah, absolutely. Therapy is very helpful and, uh, and CBTI is a short therapy. It, it works well and, and people should try it because it also learns you not to focus too much on your sleep, right? Paradoxically, and, and I think that really helps. And, and that is part of it also is accepting that sleep might not be that ideal in that period and creating the right circumstances that you actually can get some sleep. So CBTI works really well. At the same time, uh, and we know this for therapy at other times as well, uh, most people do not get it, right?

• 13:10Speaker 01

  Because they, they think it's difficult to access to or, you know, are not motivated to do it.

• 13:17David Puder?

  What other medical problems can sometimes mimic or be similar and should be ruled out, like things like thyroid disease, cardiac symptoms, maybe even?

• 13:28Speaker 01

  Yeah, I, um, I think thyroid disease is a, is a, is a problem which occurs mainly in women, right? So that, that plays a major role during this age and needs to be excluded, uh, because that further complicates it. Um, and, uh, yeah, uh, cardiovascular symptomatology is, is important as well. And, um, and, and, yeah, I, I, I think that needs to be ruled out, of course, if there, if there are palpitations or someone is anxious that there is an underlying somatic cause that, that needs to rule out, especially in this period. And, and, and that's, by the way, also another reason to treat depression in perimenopause

• 14:11Speaker 01

  because we know that, that there's also a risk factor for adverse cardiovascular outcome in women later in life. So, so that, that is a reason to treat it. Um, but yeah, but I struggle something within, in my, you know, seeing women and I also had that question myself, what do you start first, right? So if you, let's say you're not on, you, you, you have severe symptoms, of course, if it's sleep and cognitive behavioral therapy works, that's beautiful. But if that is not sufficient, should you first try, uh, hormonal therapy if you can?

• 14:53Speaker 01

  If you don't have like clotting disorder or an increased breast cancer risk? Or should you try, uh, start again SSRI?

• 15:02David Puder?

  Hmm. And what do you think?

• 15:05Speaker 01

  Yeah, I, I think it's important not to do both at the same time.

• 15:10David Puder?

  Okay, okay, that's fair.

• 15:12Speaker 01

  Because then you don't know what is working.

• 15:15David Puder?

  Right.

• 15:16Speaker 01

  And, and the problem is, you know, we know for our medication as a psychiatrist that it takes weeks to, to work and, you know, to get a good idea, like, is, is this helpful or not, right? For SSRI, we need, we need so long. But for hormonal therapy, it's even worse, right? It's sometimes like months you want to evaluate what, what it does. So it takes some time. At the same time, in terms of side effects, I mean, SSRI, at least some of them or most of them come with some side effects, we, which are also especially problematic during

• 15:55Speaker 01

  this phase of life, such as weight gain or, um, lack of libido, which is, you know, a major symptom of perimenopause. So, so I think that is also a reason, if it's mainly driven by sleep loss and phase of motor symptoms and perimenopausal symptoms, to, to first see what happens if you do, if you start hormonal therapy and, uh, and, and then see what is left of symptoms. But having said this, of course, if someone has a more severe depression or a more severe anxiety disorder, you know, we should treat that because we know that, that, that needs

• 16:41Speaker 01

  treatment. So it's really dependent, I think, on the severity of the symptoms.

• 16:46David Puder?

  Yeah. And I think as a clinician, you should get kind of like baseline libido. And so you can re-ask and see if there are changes. If there are changes, maybe it is the medication. And if it is, you know, some people have worse issues than other people. If they have worse issues, then you could consider a different medication or a different treatment.

• 17:07Speaker 01

  Yeah. Well, I like the concept baseline libido, but you know, even women, sometimes that is a bit challenging as well, right? Because that can also be variable with the cycle.

• 17:17David Puder?

  Right? Yep.

• 17:19Speaker 01

  Yeah, but still, yeah.

• 17:20David Puder?

  I mean, like, yeah, you could ask in like the last three months, like, you could ask questions around how high the different aspects of libido or, you know, so that you know if you're adding an SSRI and is the SSRI causing the issue or is the issue there beforehand? That's all I'm saying.

• 17:37Speaker 01

  Yeah, no, and that's absolutely true because we all so have these patients which actually have more libido, right? Because, or libido, because their depression was causing this. So then we should ask, you know, also, you know, in, in times when they felt well, when their mood is well, and, and then that is the baseline. And I, I think that is, that is very important, especially because there is now also a lot of information about testosterone, right? That this would be a fix for women and that, that women should be using in addition to

• 18:16Speaker 01

  estrogen and progesterone, because women with a uterus should use progesterone as well, that they should also start on, uh, testosterone.

• 18:27David Puder?

  Testosterone, what do you think about that?

• 18:30Speaker 01

  Yeah, I, uh, again, I think for, for some, the, the evidence is, is, is not there, right? So it's, it's not that, uh, I think it's a myth that, that women lack testosterone, right? That that needs to be fixed. Because a, actually, if you look at women after menopause, their ratio of estrogen and testosterone is, is higher post-menopausal. So it, it, I think it's a myth that everyone, you know, should be using testosterone and they're, they're more energetic and, you know, their, their libido is great and, you know, they're, they, they feel amazing. Um, because especially in higher dose, it also comes with some side effects like excessive

• 19:15Speaker 01

  hair growths or, you know, um, other testosterone related side effects. So I, I think that it, it should be cautiously used.

• 19:25David Puder?

  Right.

• 19:25Speaker 01

  Um, but I have to say if low libido is not caused by depression and, you know, sex life is not improved by estrogen patch or vaginal estrogen, then for some women, it can really help. And, um, and, and I, I, I think that is frustrating that we do not know beforehand that this field also is so much trial and error.

• 19:54David Puder?

  Yeah.

• 19:55Speaker 01

  Um, yeah, and, you know, we, we also, we know that someone's, uh, past history, reproductive past history can give a clue, right? If someone had a postpartum depression or so, or if someone have had like re-bads, PMS, premenstrual symptoms, and that person might be vulnerable for hormone fluctuations. So that person might be vulnerable during perimenopause. Uh, and we know this is true, that, you know, especially women who are, you know, were vulnerable for those hormone changes. Uh, there, there are some new studies there suggesting that there is a, a mood disorder

• 20:37Speaker 01

  subtype consisting of women vulnerable for, for those, um, hormone fluctuations. But, but it's very unpredictable. There, there are many women, fortunately, who, who have gone through postpartum depression and, and their perimenopause is not bad at all. And, you know, I'm the example of the other way around. I, I didn't see that coming. I did not have postpartum depression nor premenstrual disorder. And, um, I really struggled through perimenopause, still do. So, yeah, I, I think it's, it's really unpredictable in a way and, and therefore very interesting.

• 21:18David Puder?

  Yeah.

• 21:19Speaker 01

  Yeah, and, and I wanted to say same for, because women have that question a lot as well, what, what contraceptives to use?

• 21:27David Puder?

  Okay.

• 21:27Speaker 01

  Because that is associated with anxiety, depression as well. So there are really women who are on contraceptives and stop and feel better. Uh, same for Myrna IUD, that is associated, you know, getting that.

• 21:45Speaker 01

  As contraception that is really associated with also having the onset of depression. But but we do not know for the patient in front of us if this holds true for for this person, right? So the only way to figure that out is sometimes to remove the I O D or stop the oral contraceptives and see if someone feels better.

• 22:13David Puder?

  Yeah.

• 22:13Speaker 01

  Uh, but then you also have then a problem like, yeah, but what about birth control?

• 22:21David Puder?

  Uh, like what would be other options, right? Is that what you're saying?

• 22:23Speaker 01

  Yeah, the other options are not always great, right?

• 22:26David Puder?

  Mm hmm.

• 22:28David Puder?

  Yeah, I think this is where an outpatient practice, we try one thing at a time and see if it makes them worse or better. Or when we're getting the history as a psychiatrist, it's like, when did you start a new medication? When did you get your I D placed? When did you get your, you know, oral contraceptives? When did you start these different things? And did that timing fall in line with the worsening of symptoms?

• 22:50Speaker 01

  Yeah, absolutely. And, and, um, well, I, I don't know about you, but when I was in, in my training during residency, I, I didn't learn that as part of the things I, you know, we learned to ask for psychiatric symptoms, right? Depression, anxiety, psychosis, mania, and then all kinds of somatic symptoms. But part of that was not like, okay, you know, are, are, do you have symptoms associated to the cycle? Do you feel worse before your menstruation? Are you using contraceptives? Did you notice a worsening in mood? And for women in perimenopause? No, I, I never learned that. So, uh, yeah, I, I think it's,

• 23:35Speaker 01

  it's really important thing to think about because again, for some women, relative simple interventions can, can make a major change in, in how they feel.

• 23:52Speaker 01

  Yeah. So, yeah, I, I, um, and, and especially in perimenopause, I, I, I, I think it's also good to know that,

• 24:03Speaker 01

  yeah, the, the period is very variable. For, for some women, it takes a year, for others, maybe 10 years, but somehow this period will end. And that is good for women to know that, you know, that, that it's only a period they go through, you know, comparable to puberty, but someday, uh, it will end, at least for me on a personal level that, that gives me hope.

• 24:29David Puder?

  Well, um, I've, I've seen a lot in my practice, like women that have total hysterectomies, have their ovaries taken out overnight, right? And then immediately develop mood type symptoms. Any thoughts on that population specifically or? Um, like

• 24:44Speaker 01

  Yeah, absolutely. I mean, that's, that's, uh, that's quite dramatic, uh, for, for women to, to enter uh, menopause on, on a younger age and also so acute. So we do know that, that, that is, and I'm so happy that you bring that up, that it is, um, uh, yeah, even higher risk period for having mood symptoms if it's so abrupt than, um, than natural perimenopause. Uh, and I think there's also a shift. I mean, for some women, they don't have a choice, right? They might have cancer or they might have like serious underlying reason

• 25:26Speaker 01

  uh, to, to get their ovaries removed or, you know, to go through a surgical menopause. Um, but in history, for long terms, it, you know, so many women get an ovaryectomy or hysterectomy without clear reasons other than having some kind of psychological symptoms or even back in the days emotional symptoms as, as that would cure it. And I, I think nowadays more and more becomes obvious that, I, I mean, it comes at a high cost. If it's really needed, you should do it. Again, if you have like serious medical disease or cancer or there is a reason, but I, I at least see a shift in, in that,

• 26:12Speaker 01

  that happening less, less often.

• 26:16Speaker 01

  Yeah. And, and I think especially at the younger age, we know, uh, then, then I would not wait and see how you feel during this period, but start um, hormonal therapy right away. Uh, so, um, uh, yeah.

• 26:37David Puder?

  Okay.

• 26:37Speaker 01

  I don't know if the, the patients you treat were on hormonal therapy or they, or they first felt worse and then saw you?

• 26:45David Puder?

  Yeah, yeah, they first felt worse and, uh, they went from doctor to doctor. I mean, this one person in particular not only had mood issues, but, um, had like burning mouth syndrome. I, I ran a, for 10 years, I ran a program that was like an I O P partial program for people with, um, physical issues and psychiatric issues. So it's kind of like, you know, more psychosomatic

• 27:07Speaker 01

  Yeah.

• 27:07David Puder?

  stuff, more, you know,

• 27:11David Puder?

  kind of odd symptoms that normally we wouldn't see even, you know, like burning mouth syndrome. But I put her, I put her on, um, estrogen and progesterone and it made the biggest difference. But then I couldn't find an outpatient O B G Y N that wanted to refill it because they were afraid to refill it because like of old evidence, you know, like from that old study you said, but I was like, but no, like, I like, I like looked at the risk factors. I, I looked at all of the risk things. I put it before her. And the burning mouth was like, she was like, I'm going to kill myself because this is that bad. That's how bad it was. And, and yet these doctors wouldn't refill it because she was like,

• 27:57David Puder?

  because of what, what, you know? So like, we finally

• 28:00Speaker 01

  No, no, I, and now you say it. I also have patients who have, you know, some issues with finding healthcare provider for hormonal therapy. So I prescribe it, but it is a bit of discussion among psychiatrists whether we should be the ones, uh, prescribing it. So do you do it? Do you prescribe, uh, hormonal therapy? Are you comfortable prescribing patches or, you know, oral micronized progesterone or you never do it?

• 28:28David Puder?

  Uh, sometimes, you know, if the, if the, if the O B wants to do it, I'll let them do it. If, um, if, sometimes I'll, I'll do topical testosterone as well. Because it, you know, with some people, just, it's not the first line. You know, injections of testosterone for some men who are low, I obviously measure their levels and then measure

• 28:51Speaker 01

  Oh, for men, you prescribe it, not for women?

• 28:53David Puder?

  For men and women, uh, as kind of like an adjunct. For some, it's, it's made all the difference. For some, it's disappointing. It doesn't do anything. And for some, it's for sarcopenia, if they have really low muscle mass as, as a way of kind of helping them get back on track after like a severe medical illness. Remember, I saw a lot of people with medical illnesses and like

• 29:17Speaker 01

  Right, right.

• 29:17David Puder?

  for them, sarcopenia, you know, in and out of the hospital. It's like they're just fighting against this thing. And so I get, get creative and sometimes they're already on an antidepressant, already on, you know, it's like, what, what else can you do at this point? So, yeah, sometimes get a little bit.

• 29:33Speaker 01

  No, I agree with you. It's worth trying because there are patients, as you say, for, for which it is a game changer, whether it's hormonal therapy with estrogen or whether it's low, low testosterone, you know, not for everyone, but sometimes it can help. So if we do, if we do this cautiously and, uh, start not too high, right? I think we as psychiatrists can also uh, do it if comfortable. I discussed it with the gynecologist in our hospital and they say, yeah, sure, you can do it. But the other way around holds true as well that I tell them that they, for example, can prescribe

• 30:12Speaker 01

  uh, S S R I's during pregnancy if someone is, you know, really, uh, not well and has a major depression and they're also have a preference that, you know, psychiatrists do it. So I, I, I think, yeah, if the patients get the best care if, if, you know, either the, that care is coordinated or yeah, or, or professions feel comfortable to prescribe both.

• 30:36David Puder?

  Yeah. So it, it's like, if, if I'm going to monitor someone very closely and watch symptoms very closely, week to week or every other week, you know, an O B G Y N might be seeing them once every three months. That's like the pace or that they may even be able to just get them in at that pace. That's the only pace they'll be able to get them in. So you know, maybe I start something and then I ask them, hey, we're out of stable dose. You're doing well. Can, can you see if your O B G Y N would, you know, continue to fill this?

• 31:04Speaker 01

  Yeah, that's hugely helpful. And well, a question I've struggled with is for bipolar women and they, and they asked me about this, right? So should, should, um, uh, or, or women who had had a postpartum psychosis in the past, as in groups of women with high vulnerability for endocrine transitions, should they start it preventative? So before any symptoms occur, should, I, I, I know that, um, uh, some patients, also women in bipolar patient organizations say, you know, I, I didn't even want to wait until I had the first symptoms of perimenopause. I was so anxious

• 31:45Speaker 01

  of getting depression again or hypomania or destabilizing that I choose to, you know, to, to start hormonal therapy as prevention quite early in the game. So I, I don't know what to recommend, right? If it, if, if we, yes, should first see how it goes or, or some high risk groups, um, al- already start. You see what I mean as prevention? So not as treating perimenopause symptoms.

• 32:16David Puder?

  The, the only sort of thing that I would kind of question on that is, you know, during, you know, post-birth period, there's a lot of things, not just the hormone issues, right? So it's like inflammation and then you had the, um, the immune suppression, now the immune overactivation. So is it just the hormonal issue? Is it, you know, multiplicity of issues, right? And so because our understanding of it is multifactorial, does that change how you might approach this question with the patient?

• 32:51Speaker 01

  Yeah, that's true. So yeah, the, the, uh, after childbirth, it yeah, it can be, yeah, it, it's, it's multifactorial, but the endocrine galls play a role. And yeah, there is some evidence, there is a new, uh, UK bio bank study or not that new, it's last year or so, showing that for bipolar disorder, it has a bit of a peak, but it, it's not an enough evidence to, to start, uh, treating as, as prevention. But yeah, I, I don't know, I, um, I, I, I also really understand those women I spoke to who have bipolar disorder who said, you know, I, I, I started early, right away when I had the first symptoms,

• 33:36Speaker 01

  or when, when my cycle started to be irregular a bit, right? Because that, that's the other difficult thing, at least for childbirth, that's a very clear event. You know, when that happens and you know, the weeks after, the perimenopause is so blurry and vague, you know, it's, it's, uh, yeah, the cycle's starting irregular and then there are women, you know, who had an irregular cycle to start with, or as I said before, women were, were using, uh, my Reina IUD, so they, they hardly have any, um, uh, menstrual bleeding and, you know, they're, they're women on atypical antipsychotics,

• 34:20Speaker 01

  what might mess up the prolactin and, and their cycle. So it's, it's sometimes a bit difficult to determine where someone is, if that makes sense.

• 34:32David Puder?

  Yeah, I, I don't like to leave people with high prolactin from like a risperdal. Uh, that would be one thing that I think I would, if, if someone did have, if they were messed up in their cycle from, cause is that what you're thinking, right? Like the prolactin goes up with something like risperdal?

• 34:48Speaker 01

  I mean, for women, some antipsychotics are more, uh, uh, yeah, riskful in that respect than others, right? So I think we should think about it and, because all have side effects. So we should, we should wait those side effects.

• 35:04David Puder?

  Right, right.

• 35:05Speaker 01

  Yeah.

• 35:06David Puder?

  Okay, let's, let's move on to, um, can menopause cause depression?

• 35:13David Puder?

  And so I think we, we answer this to some degree, but let me, let me, maybe I'll just read some of the myths that I found, and this is like mostly on.

• 35:19Speaker 01

  Oh, wow. Yeah, yeah.

• 35:21David Puder?

  Places like Reddit's. So myth, depression during perimenopause is only a hormone problem. Low mood proves estrogen deficiency. Uh, HRT cures all perimenopause depression. If depression persists despite HRT, the person is using the wrong dose rather than having another condition, depression automatically disappears once periods stop. So those are all the different opinions that people professed emphatically on Reddit.

• 35:58Speaker 01

  Yeah, and I also heard some, some women call themselves perimenopause survivors. Well, that is, that sounds severe, right? Like I said, so many have perimenopause without, the majority of us, you know, are, are doing just fine. But, uh, yeah, I, I think if you, um, yeah, if the depression is severe enough, then hormonal therapy probably is, is, is not gonna make women feel better in most women, so they, they need to treat their depression or severe anxiety disorder as well. And, um, yeah, and now we're talking, uh, only about the biology,

• 36:42Speaker 01

  but let's not forget that it's also, you know, getting older comes also with all kinds of, and this is your specialty, physical problems and, and other disorders. And this phase in life also, for women who have children, they leave the house. It's, you know, it's, it's not an easy period to, this, uh, transition and, and children being in their puberty themselves or being older. Um, for, for some women without children, they, they might struggle also with aging, uh, you know, for that reason, as in not having children. So both ways,

• 37:20Speaker 01

  it's a difficult period. And then there is, ah, yeah, the, the problems people are having with their parents and, you know, either losing them or them going so. And at the same time, you know, men and women often being at the top of their career, as in being in a position that they work hard and I think all these things together also form the baseline. And that holds true for men and women. And then women on top of that might have, um, uh, yeah, all, all these perimenopausal symptoms, um, which, which also I, I hear also a lot from, uh, I don't know if you hear about it,

• 38:04Speaker 01

  but from men that they struggle as well with the perimenopause of their lives, because some women really get irritable, right?

• 38:13David Puder?

  Hmm.

• 38:14Speaker 01

  As, as in very irritable. So I, I think that is also good to, to realize that that is a symptom that is highly variable over time. But what many women describe is that, you know, that is strange and that gets better over time. Um, but, but we know that this period, um, not only comes with depression, but also sometimes dysphoric depression or irritability or, yeah, almost more of a mixed state as in feeling agitated and, and restless. So not the, the, the classical melancholic depression as being low and, but more something that women also, uh, uh, prescribe as having

• 38:58Speaker 01

  before their, uh, menstruation, being like really dysphoric and irritable and, and sometimes even suicidal, right? We know that, you know, that, that both suicides and homicides peak in, in, in this, uh, uh, these days and, uh, be, before the cycle. So, uh, yeah, I, I think it makes it difficult. Uh, also for women themselves, of course, they, they really struggle also with this, um, uh, they, they struggle with low mood, but I also hear a lot of women struggling with irritability and, and, and anger and, yeah.

• 39:41David Puder?

  Yeah.

• 39:44David Puder?

  Um, I want to ask you if that was something you experienced or?

• 39:48Speaker 01

  Myself? Oh, yeah, absolutely. Yeah. Yeah. No, I, I, I experienced, well, not so, as I said, not so much PMS, but, um,

• 39:58David Puder?

  Just eh.

• 39:58Speaker 01

  Uh, yeah, uh, more irritability and impatient. And I never was the most patient person on earth and that got worse to the level that it's like, okay, now you're so impatient, that's just unbearable, also for myself. So yeah, of course, that, that is a reason to, um, to, to try what, what helps for that. And also, um, it's good to know that those, some of these symptoms pass naturally, right? So, yeah, I, I think that's good to know.

• 40:34Speaker 01

  As in the irritability and that, you know, there's some sleep issues that, that, that just makes a difference post-menopausal.

• 40:44David Puder?

  Yeah. What do you think about estrogen? You know, isn't FDA approved for mood in post-menopause? You know, do you, do you think it's just not effective for depression specifically in menopause, in menopausal women? Or is it perimenopausal women? Is it another option? What's your perspective?

• 41:04Speaker 01

  I, I think perimenopause.

• 41:06David Puder?

  Perimenopause, okay.

• 41:07Speaker 01

  That is, yeah, I, I think that is, uh, yeah, that, that is what the, the most evidence is pointing that it can do most in, um, in perimenopause. And not so much like having, being low on, on your hormones and estrogen. Again, women had that before puberty as well, right? That was, you know, being low estrogen is not in itself a risk for, um, uh, low moods. Um, and, and as far as I know, there is not good evidence for, you know, elder women being post-menopausal and then starting hormonal therapy, that being beneficial,

• 41:50Speaker 01

  um, uh, for depression. I think those, those longitudinal studies showing, uh, benefits also in prevention of depressive symptomatology, especially in perimenopause.

• 42:04David Puder?

  Specifically perimenopause.

• 42:06Speaker 01

  It's, it's a bit difficult to investigate because again, what, what I said, it's, it's, it, it, the, the duration of perimenopause is so variable, right? Can be one year, can be 10 years. So, and then to do any study and follow up women so many years, ideally you want to know how they are before, during and after. Well, that's a bit more simple during childbirth, for example, field I worked in. We know, you know, pregnancy of childbirth, you know how many weeks postpartum you are. So from a research perspective, that is challenging. And if we look at big databases, then you can of course look at, you know,

• 42:45Speaker 01

  all those women who use hormonal therapy and the, you know, all kinds of psychiatric disorders and see what the association is. But it doesn't say much about causality, because then you will find that women on hormonal therapy have more often depression, anxiety. But that is maybe because they started because they had these mood, mood symptoms. You see what I mean?

• 43:09David Puder?

  Yeah, yeah. This, this is the, this is the difficulty of looking at a study that's not a randomized controlled trial. It's like, okay, is, are they putting women who have more depression, anxiety on hormonal therapy? Uh, yes, of course they are, you know?

• 43:27Speaker 01

  Yeah.

• 43:28David Puder?

  And so is the depression or anxiety completely treated compared to the general population? So maybe they still have some signs and symptoms and? Yeah. Or in these big studies, like what they can see is they can see like an I C D ten code in the chart. They can see, but they can't necessarily see what their current level of depression or anxiety is.

• 43:53Speaker 01

  Yeah, yeah, no, that's true. And those studies really measure an I C D code, which is in, in a way, the tip of the iceberg, of course, of depression and anxiety. On the other hand, you know, depressive and anxiety symptoms, we do not want to treat everyone with depressive and anxiety symptoms. That just doesn't make sense. We also know that, you know, especially among older women, the use of S R is sky high. It, I, I think it's almost one out of five women being on a necessary, right? So, and it's, it really, for me, as a researcher, but also as a woman, is really questionable

• 44:33Speaker 01

  whether that is justified, because we also know that many of these medications in many women, eh, yeah, it's, it's either they're not that effective, or it's a placebo effect, right? If you start at the lowest point, you feel better over time. So, yeah, I don't know. Uh, we want to have a nuanced message out. Yes, sure. Treat the depression if it's severe or anxiety disorder, but, but, but not immediately anyway, because, you know, some of these perimenopausal symptoms may pass or will get way better when you start hormonal therapy. That might be a very first step, good first step. If your, if your symptoms are, you know, not, not severe,

• 45:18Speaker 01

  uh, then you might want to start there. So, uh, yeah, but, now I have to say, it helped me, uh, a lot going through this myself and also struggling with, uh, you know, is, is this perimenopause, is this anxiety? You see what I mean? It's, um, it's interesting. Yeah.

• 45:39David Puder?

  Okay, here's another big question that's kind of like out there online. Is menopause brain fog an early sign of dementia?

• 45:50Speaker 01

  Yeah, that's, that's one of my big anxieties as well, by the way.

• 45:55Speaker 01

  Uh, no.

• 45:58Speaker 01

  No, of course not. And we can, we can, we should reassure all our patients that it's very normal, physiological event, and it's very normal. It doesn't mean that you're, uh, getting, uh, Alzheimer's. At the same time, I've also read those studies that those women with the most severe vasomotor symptoms are a bit at increased risk also for uh, dementia later in life. Um, but I think, uh, if I look for me personally, um, uh, it would have helped me if, if I knew better that that was happening to me, that brain fog, because I, I had that.

• 46:39Speaker 01

  And that also, you know, increased anxiety at some point that you, you can't find the word. You're in a meeting and especially, you know, sometimes we do a lot on Zoom meetings. You're in a Zoom meeting and, and, um, uh, and, and you want to say something, everyone's looking at you and, and you just cannot find the word. That, that is really anxiety provoking. So for me personally, it would have helped if I, if I had known this earlier in life that that would happen to me. I, I, I never thought about that. I didn't see it coming. I could always totally rely on my memory. One thing. And in an ideal world, it would be ideal if, um, if,

• 47:25Speaker 01

  if, if we would all be a bit more mild to ourselves and just comment on it like, oh, I, you know, I have some brain fog and that's happening to me now and, you know. And, um, I, I think that would be huge if, if women felt like comfortable enough to bring that up and that other people would not respond as in, oh, that is weird. You see what I mean?

• 47:50David Puder?

  I, in, in one study of sixteen thousand women, forgetfulness complaints rose from thirty one percent before menopause to forty four percent in early perimenopause, then stayed at forty one percent after perimenopause. And then they, they showed that the testing of, you know, learning, memory during perimenopause that was a little bit impaired actually recovered in menopause.

• 48:22Speaker 01

  Post-menopause, yeah.

• 48:24David Puder?

  Post-menopause, yeah. After menopause.

• 48:27Speaker 01

  Yeah, yeah, that's hopeful, right? It's, it's the same with the pregnancy postpartum dementia. That will pass as well. Because if you does, if you look at cognitive functioning in the third trimester of pregnancy and a postpartum, that's really bad. That, that's making women anxious as well, you know, they have this baby, they go back to work. They're like, oh my God, I'm totally incapable. And, and then that bounces back. So it's good to know that that happens in perimenopause as well. Um, but the difficult thing is, especially if perimenopause, just as in my case, I'm, I'm in it now for, I know, eight years, like an insane amount of time. So at the same time, we age, right?

• 49:10Speaker 01

  So not sure if, if it bounced back to the level we were before, because everyone, men and women have some, yeah, we have to live with that, that our cognitive peak is, is in our thirties. Um, even you are past it.

• 49:27Speaker 01

  And that from then onwards, uh, we're going slowly down to, who knows? But, um, yeah, I, yeah, again, for me, talking about that weirdly enough is, is a bit anxious, anxiety reducing. As in saying, okay, you know, I can't, I can't remember, but that is brain fog or, you know, um, I, I, I think that's just helpful if, if people, um, talk about it and, um, and yeah, that it, that it becomes more normal.

• 50:04David Puder?

  Yeah, I think, um, I'm, I'm glad this is anxiety reducing to talk about it today.

• 50:11David Puder?

  Is that what you're saying? Today specifically or?

• 50:14Speaker 01

  For me it is. I, I'm, I'm not sure if you saw it, but I even saw, uh, there, there is this man working for television and he's presenting and, uh, he's, as, as he is presenting, is having a panic attack.

• 50:30David Puder?

  Okay.

• 50:30Speaker 01

  And I will show you the link. And then he says, you know, oh, what is happening to me now is that I having a panic attack. And, uh, and the people around them say, okay, you know, just, you know, stay calm, breathe. And he's like, okay, I'm over it. And, you know, I, when I watched this, that was also really liberating for me. It's like, wow, this is next level, right? Because I, yeah, I, I think part of the anxiety uh, at that moment is that you feel like, okay, you know, I'm, you know, I'm not functional, I'm not doing well, you know, I'm crazy. What will other people think? You kind of take that away.

• 51:09David Puder?

  Right, right.

• 51:09Speaker 01

  You address it yourself. If you're comfortable enough to say, okay, you know, this is what I have. It's not that serious. It will pass. It doesn't make me less of a professional or, you see what I mean? So, yeah, I think it's important.

• 51:26David Puder?

  The, the meaning we attach to things and the shame we attach to it make it worse, right? And this is where like, this becomes like a little bit of a behavioral exposure event to like lessen the thing that you're anxious about maybe. Or it's like, it's, it's like, when we have anxiety, avoidance is not a good long-term strategy for overcoming the anxiety. We have to like expose ourself to the thing that we fear progressively over time in a way that is not overwhelming or traumatic, but then it can, you know, improve.

• 52:02Speaker 01

  Yeah, no, and, and it takes time. I mean, um, I, I think if you, if you just have it then, it takes time, but in, in time, if you can learn and, and we know this from not only anxiety, but I think, uh, from other psychiatric disorders as well, that it really helps some people or patients to, to talk openly about it and, and for sure it helps others. So, um, yeah, on a personal level, it helps, uh, for my own perimenopausal symptoms and anxiety to talk about it. And hopefully it helps for others a bit as well as

• 52:43Speaker 01

  learning that, you know, that can happen, that's treatable, it will pass. And, uh, yeah, part of it, uh, as you say, is sometimes is what it is, right? And, you know, it's not completely gone, but you, you make, you, you make sure that your life is not impacted

• 53:04Speaker 01

  that much, because that is the avoidance. Sometimes anxiety is not a problem, but that, you know, some women even quit their job in perimenopause because they feel so, you know, non-functional and having brain fog and the symptoms and,

• 53:19David Puder?

  Yeah.

• 53:20Speaker 01

  I think that's, I think that's a loss for everyone, right? Because, uh, yeah, those are experienced people in the workforce and, and also, yeah, that.

• 53:34Speaker 01

  I I I I have to say I understand it. You know, it also crossed my mind, of course, if you if you have many symptoms and you think, okay, you know what, I call it a day.

• 53:47David Puder?

  Right.

• 53:47Speaker 01

  I I stopped doing what I'm doing, but I I think in the end, that's that's not the the best way to go.

• 53:55David Puder?

  I thi- I think a lot of patients have like the more the anxiety that their cognition is worse than it actually is.

• 54:02Speaker 01

  Yeah.

• 54:03David Puder?

  You know, I always tell my patients with with the anxiety and the depression, and then they have the the cognition issues, and they're anxious about like, oh, gosh, am I, do I have dementia? It's like usually the dementia pa- patients are the ones who are confabulating and not worried about their memory.

• 54:26Speaker 01

  Yeah.

• 54:27David Puder?

  You know, are you having any memory decline? Oh, absolutely not, doctor. Why would I have memory decline?

• 54:33Speaker 01

  Yeah, no, that's true, but that's maybe also later. No, but it's true. It's uh.

• 54:38David Puder?

  Sure.

• 54:38Speaker 01

  And and also, it's it's often uh not so much a a memory problem as it is an attention or concentration problem.

• 54:48David Puder?

  Attention concentration.

• 54:49Speaker 01

  Yeah. And I think that is that is underestimated as well, because we know also from perimenopause that also women who already had HDHD or, you know, are on the spectrum, because, you know, so some have those those traits, that those traits also specifically peak in perimenopause. So then it's not a cognitive deficit, as in, you know, not having access to your memory or or storing things, but it's purely sitting down and getting work done and and concentrating on the thing you're doing instead of being

• 55:30Speaker 01

  uh distracted by all the things happening around you, because that is what I hear from women as well, right? They're easily uh they could work in a bit of a noisy room. Now, they just cannot stand noise anymore, which doesn't go well with kids in their puberty, or they they it, you know, it it has to be calm, and so they they get they they're more sensitive uh for those things, and that causes the feeling of cognitive deficit, where it's actually more of an attention concentration problem. I don't know if you recognize that, but um.

• 56:09David Puder?

  You so how do you treat the attention concentration problem, perimenopausal woman?

• 56:14Speaker 01

  Well, that's a good one. If if anyone knows, then, well, um, I don't know. Yeah, what I do myself is that I uh the things that need like most concentration and attention, I do them in the morning.

• 56:31David Puder?

  Okay.

• 56:32Speaker 01

  And early in the afternoon and not late afternoon or in the evening, whereas back in the days, I could also be fully concentrated at eleven P M. and, you know, write something beautifully, and that's not going going to happen anymore. So um uh yeah, but yeah, what people in general say, like, yeah, you know, be mild to yourself, uh get some more rest, make sure that you don't act ask the max in work, because, you know, if you have to multitask and constantly shift focus, then it's harder to get things done.

• 57:10David Puder?

  Hmm.

• 57:10Speaker 01

  Uh but having said this, you know, sometimes that doesn't work, because, you know, some women just have have a job that is quite hectic, and, you know, you, yeah, you have to face with the circumstances you're in. So then it's really about, uh uh I think it it already helps a lot if you're mild to yourself, if you're if you're notice that if you cannot do it, that you think, okay, then I'll try tomorrow, or I will do it in the morning. But yeah, you have solutions. How how to how to how to treat this HDH type of symptoms?

• 57:48David Puder?

  Um, I I think your I think your points are are well received. I mean, if you can optimize sleep, if you can optimize exercise, like, uh look at like what they're eating, you know, if they're eating a huge meal midday, you know, that might not be the best for focusing later in the day. And so simple things like that, you know, are where I would go first. And then, yeah, secondarily, like, are they scheduling the highest energy tasks in the morning? Because I think that's like everyone, um, like, I have to do that, too, you know? Or, yeah, probably then, you know, if they have a history of ADHD, is that being treated? Or do they have ADHD? You know, like, do they need testing? Or is it obvious? If it's obvious, then, you know, go over the risks and benefits of different medication

• 58:33David Puder?

  classes for it.

• 58:34Speaker 01

  Yeah, that's true, because there are some women who uh HDH traditionally, you know, being under diagnosed in some women a bit, and they enter perimenopause, their HDH symptoms getting worse, maybe over the threshold that it becomes clinically significant. At the same time, it might be that their children have been diagnosed with HDH, and then they start wondering themselves. I don't know if you recognize that, but I I had quite a few patients like, oh, you know, maybe I am the, you know, I'm, we know that it's highly genetic, so maybe I carry one of those risk genes, and and maybe I have some of these symptoms uh myself.

• 59:18Speaker 01

  So, yeah, and I, yeah, I think it's good, as you say, it's good to know, because ultimately, if you have other symptoms as well, then you might lean more into medication that is also better for ACHD, or, yeah, you could also, of course, trying uh using HDH medication. But I have to say, I do not have a lot of experience with starting this first time in perimenopause in women with those symptoms. So I don't know.

• 59:49David Puder?

  Yeah, it it's not a normal thing that I've I've done either, but, you know, we're presenting a scenario that, you know, we're trying to figure out what we do under this given scenario here. Okay, so, wow, I think we covered a lot. I think people's brains might be saturated at this point.

• 1:00:10David Puder?

  Yeah, any any other sort of final reflections on perimenopause, treatment, you know, things you would want clinicians to know?

• 1:00:19Speaker 01

  Yeah, clinicians to know, ask about it, and women going through it, it will pass. Yeah, and there are good options out there, yeah.

• 1:00:31David Puder?

  Awesome. Well, we will leave it there for today. Thank you so much for coming on. I feel like there was a lot to to take away, and I'll put some links to articles you recommend, so people can continue learning, and we'll leave it there for today.

• 1:00:47Speaker 01

  Yeah, thank you so much.