Pauline Maki has made her career about women and mental health. As a professor of psychology, psychiatry and OB-GYN at the University of Illinois–Chicago College of Medicine, as well as the director of women’s mental…
Pauline Maki has made her career about women and mental health. As a professor of psychology, psychiatry and OB-GYN at the University of Illinois–Chicago College of Medicine, as well as the director of women’s mental health research and associate director of the Center for Research on Women and Gender, she knows what the research says about these issues. In fact, she has conducted quite a bit of it herself, for which she received the 2018 Woman in Science Award, given by the American Medical Women’s Association.
But Maki also knows where the research gaps are, and about three years ago she found a big one that she decided to fill.
There were, at that time, no comprehensive mental health guidelines for practitioners to follow when caring for women in perimenopause, also called menopause transition. The North American Menopause Society says that this transition may last four to eight years, beginning long before menopause, which is one year after the final menstrual period.
Until recently, the biological processes behind perimenopause were not well understood. “We tended to understudy and underdiagnose women” in perimenopause, says Dr. Maureen Sayres Van Niel, a reproductive psychiatrist in Cambridge, Massachusetts, and president of the American Psychiatric Association Women’s Caucus. “The different symptoms were just considered an inconvenience to be endured with grace.” But in the past few years, new research has looked into the various symptoms and their treatments. “We now realize there are serious processes here that need attention,” Van Niel says.
Maki saw this new research as well, and she decided it was time to put it all together. “There had never been any guidelines, so we created the first ones on this topic,” she says.
In 2015, Maki served as president of the NAMS. As president, she got to decide “what that year’s big project should be. I had this great opportunity to leverage that position.” She chose perimenopause guidelines. NAMS paired with the National Network of Depression Centers, specifically the Women and Mood Disorders Task Force. “We thought it would be a wonderful partnership to bring together these experts to do these guidelines,” Maki says. First, the task force conducted a systematic review of all the literature. “We wanted practitioners and women to understand what we think the best approach is to this,” she explains.
The final guidelines, published this September in the journal Menopause and the Journal of Women’s Health, have been endorsed by the International Menopause Society. Maki is the co-lead author, along with Susan Kornstein, professor of psychiatry and obstetrics and gynecology at Virginia Commonwealth University. The task force they co-chaired reviewed the scientific literature on depressive disorders and symptoms in perimenopausal women and focused on five areas: epidemiology, clinical presentation, therapeutic effects of antidepressants, effects of hormone therapy and efficacy of other therapies such as psychotherapy, exercise and natural products.
One of the most important things they note is that symptoms of perimenopause and depression are often the same. Sleep disturbances, for instance, can be exacerbated by hot flashes or night sweats; poor sleep also can be a symptom of and can contribute to depression. Stress is often heightened during this time of life, as women juggle parental duties or sending kids off to college, work responsibilities and caring for aging parents, which can add to symptoms of both perimenopause and depression. Loss of appetite, mood swings, loss of interest in sex and problems with concentration are other symptoms common to both. “So the question becomes, how do you suss out the differences,” Van Niel says.
A Window of Vulnerability
The guidelines suggest how to tell the difference between perimenopause and depression. “The most important finding, the lowest hanging fruit, is that perimenopause, like puberty and postpartum, is a window of vulnerability,” Maki says. “Within that window, it is important to distinguish between two types of mood disorders.” Providers need to be most concerned about major depression, which involves symptoms that affect function in a significantly debilitating way, she says. “In addition, since every woman goes through menopause if she lives long enough, it is important to talk about symptoms that don’t meet the criterion for major depression but still impact quality of life, well-being, work and interpersonal quality, what we call elevated depressive symptoms.”
The risk for elevated depressive symptoms applies to all women, regardless of their own history of depression. “This is something all women need to be aware of,” Maki says. However, major depression is largely confined to women with a prior history, the data show. “This is important because 58 percent of women with a history of major depression will experience a worsening of mood when transitioning to perimenopause,” she says.
The guidelines also state:
— Proven therapeutic options for depression (antidepressants, cognitive behavioral therapy and other psychotherapies) should remain as front-line antidepressive treatments for major depressive episodes during perimenopause.
— Clinicians should consider treating co-occurring sleep disturbance and night sweats as part of treatment for menopause-related depression.
— Estrogen therapy is ineffective as a treatment for depressive disorders in postmenopausal women.
The recent suicide of the designer Kate Spade, at age 55, is one example of the seriousness of mental health issues in midlife women, a group that has shown a 45 percent increase in suicide rates over the past 15 years, Maki says. Van Niel calls the new guidelines “very important. Some of the things they found confirmed things we knew, and others gave us more information. They elucidated risk factors, so we can ask about things like significant stress and a history of depression. They will really shed light on our practice. We finally have a gold standard for treating women in menopause transition.”