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Med J Aust 2000; 173 Suppl 6 November: S103-S104

As women approach midlife they are likely to experience physiological changes associated with menopause along with changes to family relationships, body image, role and purpose in life.¹ For some women, these changes may cause depression, anxiety and lowered self-esteem.

Depression

A study of over 10600 Australians found that up to 8.5% of women aged over 40 experienced depression, and that women were nearly twice as likely to experience an affective disorder as men (4.2%).²

The reasons why women experience depression more than men may include biological, psychological and social factors. Research on the effects of menopause on depression remain inconclusive. Whether changes to oestrogen levels influence neuropeptides and neurotransmitters,³ or whether the oestrogen receptors found in the limbic system and hypothalamus are influenced by oestrogen withdrawal (resulting in depressive symptoms), has been debated by researchers.^4,5 The only consistent finding to date is that women who have undergone surgical menopause are more likely to suffer from depression than women who have had a natural menopause.^3,5-7

The role of testosterone on depression is an also important focus of current research. One study found that surgically menopausal women who were given androgen had lower depression scores than those given placebo.⁸ While other studies have also reported positive effects of testosterone therapy on mood in naturally menopausal women, large longitudinal studies are needed.

Depression in women aged 40 and over may be a secondary reaction to physical symptoms such as hot flushes and sleep disruption at the menopause.^9,10 However, many studies suggest that psychosocial factors are more likely to account for depression in women aged over 40: these include a negative attitude to ageing and menopause, lower socioeconomic status, negative body image, relationship dissatisfaction, prior experience of negative mood, low levels of physical exercise, smoking, and role loss.^1,11-16

Body image

There has been little research on body image in women aged 40 and over. A decrease in metabolic rate with age, along with decreased physical activity, may affect weight and create a negative body image.^17,18 The negative attitude of society towards ageing may also influence women in this age group to feel more negative about their body image. The most consistent finding on changes in body shape as a result of menopause is that there is a shift in fat deposits from the lower to the central body without any change in total fat mass. Women often report they feel "depressed" and saddened about this change in body shape. The role of diet in depression and cognitive function is discussed in Question 7.

Interpersonal relationships

It is important to consider the relationships women have with their partners when assessing emotional issues in women aged 40 and over. Women who are depressed during their midlife and menopausal years are more likely to have experienced a difficult relationship, or to be dissatisfied with their partner.^6,19 One study found that women were more likely to take hormone replacement therapy if they thought menopause made their relationships with their partner and children more difficult.²⁰

Midlife and menopause signify the end of childbearing years, and this is often the time when children are leaving home. Findings on the impact of children leaving home are inconsistent, with some studies suggesting that this event has a negative impact on women in midlife,²¹ with other studies reporting positive or no effects.^19,22 One study found that, in the first five years after menopause, women were more dissatisfied with the relationship they had with their children and wanted to see their children more often, while, beyond five years, women were more satisfied with their relationship with their children.²³

Role in life

Purpose in life, or role, is an important aspect in the understanding of the emotional issues relevant to women aged 40 and over. As children become more independent and leave home, some women experience a change in their roles. The quality of the role women have in their work and family, and their capacity to care for people, are predictors for greater wellbeing and better objective health outcomes in later years.^24,25

Summary Emotional issues can influence the health of women aged 40 and over. Important factors are: - psychological functioning; - interpersonal relationships; - body image; and - role changes.

References

1. Wilk CA, Kirk MA. Menopause: a developmental stage not a deficiency disease. Psychother 1995; 32: 233-241.
2. McLennan W. Mental health and well-being: profile of adults, Australia. Canberra: AGPS, 1997.
3. Genazzani AR, Stomati M, Spinetti A, et al. Neuroendocrinology of the climacteric period and hormonal replacement therapy. In: Wren BG, editor. Progress in the management of menopause. London: The Parthenon Publishing Group, 1997: 380-384.
4. Dennerstein L. Depression in the menopause. Obstet Gynecol Clin North Am 1987; 4: 33-48.
5. Sherwin, BB. Impact of the changing hormonal milieu on psychological functioning. In: Lobo RA, editor. Treatment of the postmenopausal woman: basic and clinical aspects. New York: Raven Press, 1994: 119-127.
6. McKinlay JB, McKinlay SM, Brambilla D. The relative contributions of endocrine changes and social circumstances to depression in mid-aged women. J Health Soc Behav 1987; 28: 345-363.
7. Saletu B. Does the menopause change the psyche? In: Birkhauser MH, Rozenbaum H, editors. Menopause: European consensus development conference. Paris: Editions Eska, 1996: 79-93.
8. Sherwin BB, Gelfand MM. Sex steroid and affect in the surgical menopause: a double-blind, cross over study. Psychoneuroendocrinology 1985; 10: 325-335.
9. Baker A, Simpson S, Dawson D. Sleep disruption and mood changes associated with menopause. J Psychosom Res 1997; 43: 359-369.
10. Gath D, Osborn M, Bungay G, et al. Psychiatric disorder and gynecological symptoms in middle aged women: a community survey. BMJ 1987; 294: 213-218.
11. Kuh DL, Wadsworth M, Hardy R. Women's health in midlife: the influence of the menopause, social factors and health in earlier life. Br J Obstet Gynaecol 1997; 104: 923-933.
12. Collins A, Hanson U, Eneroth P. Postmenopausal symptoms and response to hormonal replacement therapy: influence of psychological factors. J Psychosom Obstet Gynaecol 1983; 2-4: 227-233.
13. Dennerstein L, Lehert P, Burger H, Dudley E. Mood and the menopausal transition. J Nerv Ment Dis 1999; 187: 685-691.
14. Greene JG. Bereavement and social support at the climacteric. Maturitas 1983; 5: 115-124.
15. Hunter M. The south-east England longitudinal study of the climacteric and postmenopause. Maturitas 1992; 14: 117-126.
16. Slaven L, Lee C. Mood and symptom reporting among middle-aged women: the relationship between menopausal status, hormone replacement therapy and exercise participation. Health Psychol 1997; 16: 203-208.
17. Poehlman ET, Toth MJ, Gardner AW. Changes in energy balance and body composition at menopause: a controlled longitudinal study. Ann Intern Med 1995; 123: 673-675.
18. Voda AM, Christy NS, Morgan JM. Body composition changes in menopausal women. Women Ther 1991; 11: 71-96.
19. Kaufert PA, Gilbert P, Tate R. The Manitoba project: a re-examination of the link between menopause and depression. Maturitas 1992; 14: 143-155.
20. Abraham S, Perz J, Clarkson R, Llewellyn-Jones D. Australian women's perceptions of hormone replacement therapy over 10 years. Maturitas 1995; 21: 91-95.
21. Huerta R, Mena A, Malacara JM, de Leon JD. Symptoms at perimenopausal period: its association with attitudes toward sexuality, life-style, family function, and FSH levels. Psychoneuroendocrinology 1995; 20: 135-148.
22. Krystal S, Chiriboga DA. The empty nest process in mid-life men and women. Maturitas 1979; 1: 215-222.
23. Deeks AA, McCabe MP. Relationship between menopausal stage and age and quality of relationships with partners, children and friends. Climacteric 1998; 1: 271-278.
24. Collins A. A psychological approach to the management of menopause. In: Wren BG, editor. Progress in the management of menopause. London: The Parthenon Publishing Group, 1997: 94-98.
25. Vandewater EA, Ostrove JM, Stewart AJ. Predicting women's well-being in midlife: the importance of personality development and social role involvements. J Pers Soc Psychol 1997; 72: 1147-1160.

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