If you are in midlife (typically between 35-50 years old), your melatonin production has already gone down substantially. By the time you’re in your 40s and beyond, your melatonin will never return to what it was in your younger days. Melatonin is associated with the circadian rhythm, that is, the sleep-wake cycle.

One study shows that the drop in melatonin production coincides with the onset of perimenopause, even if women are still having regular cycles and may be years from menopause. In “Decrease in melatonin precedes follicle-stimulating hormone increase during perimenopause,” researchers studied 77 healthy female volunteers, ages 30-75 years old. They found that, within the study group, those ages 30-39 had the highest levels of melatonin, but women in the next age bracket (40-44) excreted 41 percent less melatonin! Older women also experienced another sharp drop in melatonin production, going down by another 35 percent between ages 50-59.

This means that melatonin and follicle stimulating hormone, or FSH, have an inverse relationship as it pertains to the onset of perimenopause. Melatonin levels sink way before FSH levels (a measure commonly used to determine if a woman is in menopause) rise. High FSH levels are a sign of impending or completed menopause. That melatonin production declines before FSH climbs is yet another signal that a woman is in perimenopause. Since most doctors don’t test patients’ melatonin levels, there are some signs that a woman in midlife may be experiencing a reduction in natural melatonin, such as:

• Experiencing more difficulty getting to sleep
• Having nighttime awakenings
• Waking up too early

Not so coincidentally, these are the very same type of sleep problems perimenopausal women commonly experience. Sometimes these sleep disruptions occur in tandem with other perimenopausal symptoms like night sweats or anxiety, but often they exist in isolation. Sleep issues as a midlife perimenopausal woman, then, are not dependent on perspiring while asleep or having a mood disturbance, such as depression or anxiety.

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Nighttime melatonin levels by age, Source: Cultura Pierpaoli
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Multiple melatonin studies on perimenopausal and menopausal women show that it may be beneficial to supplement melatonin. In one study, subjects receiving melatonin at a nightly 3 mg dose reported sleeping and feeling better. Another study found that the time it took to go to sleep lessened in a group being treated with melatonin, and participants did not develop a tolerance to melatonin or experience a return of insomnia when melatonin administration was discontinued.

Overall, some researchers say that “short-term usage of melatonin is a rational therapeutic approach for the alleviation of insomnia or circadian phase disorders of peri- and post-menopausal women, as these periods of life are characterized by changes in sleep quality and circadian rhythms.”

What “short-term” usage means has not been clearly defined, as studies on melatonin have yet to define precise guardrails around its use. It is generally well tolerated and deemed safe. For those who take supplemental melatonin, experts suggest taking it between 8-10 p.m., as that helps it coincide with its natural peak in the body between 2-4 a.m. Also, doses up to 5 mg have been most studied, with general current guidance suggesting that doses over 5 mg are not necessarily more helpful.

Melatonin is available over the counter (OTC) in the U.S. in a variety of forms – gummies, liquid, capsules, caplets and extended-release versions. Though OTC medicines and supplements don’t require a prescription to purchase, since supplements and vitamins are not regulated like prescription drugs, it is advised to consider using a third-party source to evaluate the safety of supplements. ConsumerLabs is a paid site that performs research-based quality checks of various vitamins and supplements, often by brand.

Kitty Anderson is one of the few nationally Board-certified health coaches in the U.S. specializing in menopause education and recovery. By her count, there are only seven similarly credentialed health coaches in the United States.

When I first stumbled across her YouTube Channel, Create a Menopause Recovery, I knew that Kitty was someone special. As an ardent researcher myself, and as a woman just months into her own HRT treatment and recuperating from interludes with a medical system with few knowledgeable practitioners, I was immediately impressed by Kitty’s comprehensive approach to sharing information, truly helping women and focusing on multifaceted solutions. Kitty is not only a menopause expert, she has also been using hormone replacement therapy (HRT) to address her symptoms and improve her quality of life for 14 years.

Kitty Anderson graduated from The Mayo Clinic College of Science and Medicine’s accredited coaching program and passed the National Board Certification Exam, the same body that licenses physicians. In order to maintain her credentials, Kitty takes continuing education courses and is bound to adhering to precise ethical rules and a defined scope of practice. She has also completed coursework in health, psychology, neuroscience, counseling, wellness and nutrition, among others, at Wright State University and Sinclair College.

Kitty’s current paid offerings include one-on-one consultations and webinars, focusing on HRT, stress reduction, nutrition, relationships, movement, sleep and more.

I recently caught up with Kitty to discuss how women are dealing with – or rather, not really dealing with perimenopause – with a special emphasis on her concept of menopausal care as a social justice issue. While many online menopause evangelists may have a decided bent towards naturopathic or conventional medical remedies, or may seek to abandon to idea of any treatments since menopause is a “natural event,” Kitty is the first I’ve encountered who adds a socio-political and socio-cultural element to her advocacy.

Why do so few women seem to know about HRT, let alone use it, for their perimenopausal and menopausal symptoms?

Hormones do hundreds of things in our bodies, and that's how the body works. Only three percent of American menopausal women are getting HRT. Many women are denied HRT by their (conventional) OB/GYN. It is NOT the standard of care to offer HRT.  That means we can't sue our doctor if they say no. 

What about alternative ways to get HRT?

A functional medicine doctor or a functional pharmacy will be more generous with HRT, but it is more expensive. They may or may not counsel on diet. We pay extra for these services, and the product quality is lower than the FDA-approved products.

It seems like so many women are on various prescriptions, potions, supplements or unproven lifestyle changes to get relief from menopausal symptoms. Why?

Our algorithms make it impossible to find valid consumer-friendly information. Everyone is selling something to replace HRT. There is just not a logical reason to use these other products in my mind. They are not the identical molecule to the hormones you used to make.

And there aren’t many accessible examples of women successfully navigating menopause in real life either, right? At least not in terms of symptomatic women talking openly about their symptoms and sharing what worked?

Women tend to look to other women, and there are few examples of women thriving on HRT. If you don't have a friend using HRT, you don't see the benefit. It seems unnatural. But the identical molecule is natural, right? Replace what's lost -- in a form that your body uses.  

There are various formulations and preparations out here that are all classified as HRT. How can there by so much variability in the market?

The broad category of drugs called HRT don't all perform equally for sleep, mental health and cognitive health. Our menopause society (North American Menopause Society - NAMS) doesn't focus on brain health. The research outcomes are focused on menopause symptoms and future bone health. Doctors treat all drugs in the HRT category as equal, and they are not. Our medical system allows this.

Research shows that women of color, and Black women in particular, may have a more difficult and earlier transition to menopause. How does this factor into your concept of menopause treatment as a social justice issue?

Women of color and low income women are about 30 percent less likely to have an HRT prescription. Health information and products are not as available. I think that the lesser quality and less expensive oral estradiol is available on Medicare as the first line of treatment. I have heard of some women getting transdermal estradiol, which is better. 

What are some other barriers to women’s success with hormone replacement therapy?

Not all women trust the medical industrial complex . . . for good reason, right? We have some drugs that are worse than the disease. It is a for-profit system. This works to our detriment. Seventy percent of women stop their HRT in the first year without talking to their doctor. And 70 percent of women do not read the directions to apply their HRT correctly. They are under-dosing.
 
Even smart, successful women are having a hard time getting quality information and the right treatments. Many end up with cabinets full of supplements, vitamins, tinctures and herbs. Others are prescribed medications that don’t fundamentally address the hormonal loss.

I have talked with extremely educated women who know research inside and out. They did not figure out that HRT was critical. The information never made it to them. I know female health coaches in their 50s and 60s, and they did not know what HRT does. They were not using it. 

How can they lead women to wellness without it? There are currently only seven menopause coaches with the Board Certification of NBHWC. There is no training for our Board-certified coaches. I created my own training from a multitude of sources.

What does this do to women over time, this lack of informational access and proactive engagement from their healthcare providers?

When a woman over 60 years old comes to me to talk about hormones, she is really broken. She has arthritis, she has autoimmune problems, she has fatigue, she lacks confidence and motivation, and she is fearful. Her body has gone without hormones for a decade. It has changed. In some ways, she will not recover. She just didn't get the right information at (or before) menopause. It's so sad. 

It seems like some of this is socially conditioned as well as structurally induced, within the systems of healthcare, education and media, this lack of open treatment discussions and awareness for women. Hence, this is really is a social justice issue, like you said. It involves equity, access, investment and repairing the fissures in our medical system.

Most women just think they should "tough it out" or “not bother anyone.” Women are accustomed to self-sacrifice and giving the doctor control of the outcome. They don't understand how to work the system to get what they want. No one is telling them that they are in charge of their health outcome. Doctors are looking for compliance typically, but they don't talk to us about whether or not we are getting enough HRT. 
They don't ever phrase this as, “HRT is good for you. You should feel really well.” And for some reason, there are no testosterone products off the shelf for women. Testosterone is a controlled substance. NAMS doesn't even cover testosterone in their training. (Editor's note: The International Menopause Society does address supplemental testosterone for women.)

I feel like we have to know more than our doctor to get this to work well. All three hormones – estradiol, progesterone and testosterone – are important and all are low at menopause. You can't expect your body to work with 1/20th the amount of reproductive age hormones at menopause.


You can learn more about Kitty Anderson at https://www.jumpstartaip.com/. She offers paid 1:1 consultations and webinars.

Highlights from her YouTube Channel are:

Perimenopause and Menopause HRT for Infection, Weight Loss, Alzheimer’s, Diabetes
Higher Dose HRT Works Best for Mental Health: How HRT Works
100 Ways Hormone Loss Gets to You: HRT Prevention and Recovery
HRT and Personality Changes: What to Expect – My Story, My Clients and Universal Laws of Hormones
No Rules for Menopause? Well, Guidelines, Yes.

Anxiety and depression are common, though lesser talked about, symptoms of perimenopause and menopause. For the first time in their lives, women may begin feeling out of sorts, as if they can no longer function as they used to or take on the world with the same sort of ease and vigor they once did. They may feel distant, aloof and alone, and they might even stop enjoying things that once brought them incredible joy, inspiration and satisfaction.

To be blunt, many women begin to wonder if they are losing their minds.

Anxiety and depression that first manifest during perimenopause and menopause without any history of mental health conditions and may look and feel like typical anxiety and depression in other people, but the cause is not quite the same. Mental health concerns during perimenopause and menopause are truly, at the root, a symptom of hormonal dysfunction – primarily the withdrawal of estrogen (estradiol) and progesterone from a woman’s body during this phase of life.

To put it simply, erratic fluctuations of estrogen and progesterone throw the body into a topsy-turvy round of unpredictability. This erratic tailspin causes most of the well-known perimenopausal physical symptoms, such as night sweats, vaginal dryness, hot flashes, sore breasts, irregular menstrual cycles and much more. And it also causes first-time onsets of anxiety and depression. But why?
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The most credible and oft-cited hypothesis is that declining levels of estrogen lead to reduced levels of key brain neurotransmitters, especially serotonin, which is responsible for feelings of happiness and well-being. Serotonin is also connected to sleep, appetite and digestion. If or when estrogen starts to bottom out, it can have the opposite effect on cortisol, also known as the stress hormone, which begins to rise. A higher level of cortisol combined with a bottoming out of serotonin (which, in turn, came from low estrogen in the first place) leads to unpleasant and devastating mood symptoms, like anxiety or depression. As if these factors were not enough, production of melatonin, the sleep hormone, can dip by this age, too – amping up the insomnia associated with anxiety.

What Is Anxiety?

Some level of anxiety is normal in our lives and is simply part of being alive. But when minor daily worries torpedo into life-altering rumination and the inability to cope, that’s a sign that there may be more to it than routine everyday concerns.

Symptoms of anxiety include (but are not limited to) irritability, restlessness and hypervigilance, or a sense of being on guard. Women may feel they are trapped in a fight, flight or freeze mode. They may not be able to switch off their minds, no matter how much they want to relax and wish to sleep. Anxiety shows up in an inability to concentrate, too. Physical symptoms like heart palpitations, inner tremors, insomnia, shakiness and shivers may appear as well. Women find that when investigated through routine medical checkups, deeper-level testing and thorough bloodwork, no physiological anomalies show up related to, or that explain, these symptoms.

What Is Depression?

Depression is more than just having a bad day or feeling sad for a legitimate reason. Depression has emotional, physical and cognitive identifiers, including a loss of pleasure in activities, mood swings, excessive crying, insomnia or fitful sleep, loss of appetite, fatigue, changes in weight, social isolation, apathy and even suicidal ideation*. Studies show that women who’ve previously experienced post-partum depression or premenstrual dysphoric disorder (PMDD) are at greater risk / likelihood of experiencing a relapse of depression with the onset of perimenopause or menopause. Still, some women with a history of depression describe hormonal depression as feeling “different” from their prior depression and unresponsive to prior medications and methodologies.

* If you are feeling suicidal or thinking of harming yourself, please call the National Suicide Hotline at 800.273.8255 and get in touch with a friend, family member or trusted confidante.

What to Do

If anxiety or depression are new to you, you may have no idea where to turn or what to do. The first step is honestly acknowledging that there is an issue and that it’s not your fault. Though stigma still surrounds mental health issues, hormonal anxiety or depression has a true medical cause, which is assuring to some who may think of it as a personal weakness, personality flaw or “crutch they need to get over.” After all, more than 40 percent of those taking antidepressants in the U.S. are woman ages 45 and up – the very age range that corresponds to the onset of perimenopause and menopause.

Treatment plans should be individualized. What worked for a friend or relative may or may not work for you. A combination of lifestyle, naturopathic, hormonal and / or pharmaceutical treatments are options that have proven effective and given many women “their life back.”

While this is no substitute for official medical advice, treatments for perimenopausal anxiety or depression may include:

• Hormone Therapy
• Cognitive Behavioral Therapy (CBT) / Counseling
• Physical Movement – aerobic exercise, yoga, resistance training
• Lifestyle Changes – stress reduction, meditation, mindfulness
• Supplements
• Medications – SSRIs and other classes of antidepressants; other medications prescribed off label to treat insomnia, night sweats and anxiety *

*The decision to begin taking medication is a serious one that should be made with full, clear transparency about potential side effects, expected duration of treatment and discontinuation protocols, if applicable. Some suggest that initiating medications like antidepressants or benzodiazepines should be made with informed consent.