Perimenopausal Anxiety Doesn’t Really Fit the DSM, But That Doesn’t Mean Antidepressants Won’t Help

Anxiety is one of the most pernicious and surprising symptoms of perimenopause. In fact, though it is well-documented as one of the most common symptoms of this hormonal transition, many women are shocked by it or undergo treatment for a false diagnosis of clinical anxiety or depression before it is properly recognized as part of perimenopause.

In fact, anxiety and depression are also known as menopausal “side effects.”

This doesn’t mean that women who experience this symptom aren’t displaying anxious or depressive behavior, but it does mean that the cascade of symptoms are tied to this hormonal stage of change, not the prototypical clinically psychiatric variety. The Diagnostic and Statistical Manual (DSM) is the “Bible” of psychiatry.

It classifies anxiety as a “disorder class” that also includes several different anxiety disorders, some of which may include obsessive compulsive disorder (OCD) and panic attacks. Some features of anxiety, per the DSM, include:

• Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least six months, about a number of events of activities (such as work or school performance)
• The person finds it difficult to control the worry
• The anxiety or worry are associated with three or more of the following six symptoms: restlessness or feeling keyed up or on edge; being easily fatigued; difficulty concentrating or mind going blank; irritability; muscle tension; and sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep)
• But this particular point is what makes perimenopausal anxiety different from garden-variety, psychiatric clinical anxiety: “The disturbance is not attributable to the physiological effects of a substance (e.g. a drug of abuse, a medication) or another medical condition (e.g. hyperthyroidism).”

Herein lies the fine print. Hormonal changes are a medical condition. And that’s what perimenopause is. Therefore, perimenopause and menopause could be considered as a “medical condition,” even though it is as much a natural biological transition or life stage. Hence, this makes it stand apart from how clinical anxiety is defined or labeled by psychiatry. In fact, it is treated as a medical condition by the gynecologists, endocrinologists and women’s health physicians who specialize in treating such women with various modalities, like HRT and non-hormone medications.

This delineation may bring some women experiencing anxiety a measure of comfort, especially as they may face the prospect of being offered or prescribed antidepressants for the very first time in their lives.

The problem is that perimenopausal women are often misdiagnosed as being clinically depressed or anxious by mental health therapists and psychiatrists who have not taken into account the probability of perimenopause and, therefore, miss the ball on getting the full spectrum of care and treatments that will really help address the underlying root cause. Consideration of perimenopause should certainly be  on the table for any woman presenting with first-time anxiousness between their late-30s to early 50s.

In fact, many don’t realize they were really perimenopausal until much later – sometimes years down the line. This also means they may be under-treated in ways that would optimize their current quality of life and future-state health.

As the same time, the experience of perimenopausal anxiety often dredges up yet another symptom, and that symptom is called denial. If we’re feeling nervous, flying off the handle for no reason, have a mind busy and thinking of random topics for no purpose, many of us flinch to think of labeling it as anxiety. We don’t want to be medically mislabeled or, worse, written off as “crazy.” Furthermore, many women are loathe to take antidepressants based on the stigma of the drug class, even though these medicines are used to treat conditions from nerve pain to migraine headaches, irritable bowel syndrome, smoking cessation and appetite stimulation for cancer patients.

So what came first – the chicken or the egg? Is this a matter of the cup being half empty or half full? Are we working with 12 eggs or a full dozen? And, if a woman is truly seeking help and trying to live her best life, does it even matter?

According to psychiatrist Dr. Swapna Vaidya, MD, definitions and distinctions DO matter. At the recent WisePause Wellness Global Experience conference in March 2022, her presentation was titled “Got Menopause Brain? Managing Brain Fog, Anxiety and Mood Swings.”

She said: “Mental health changes during menopause and the type of symptoms you may see in perimenopause and menopause might not be the same as you might see when you diagnose mental illness with the Diagnostic Statistical Manual (DSM). For instance, women’s brains actually age differently than men’s brains. This is because the brain and ovaries are part of a neuroendocrine system. So the health of our brain is related to the health of our ovaries.”

 Dr. Vaidya also offers an explanation of what, exactly, mental health is according to a global definition: “Mental health, according to the World Health Organization (WHO), is a state of well-being in which the individual realizes her own abilities and can cope with the normal stressors of life and can work productively and fruitfully, and is able to make a contribution to her community.”

What helps to strike this balance during perimenopause?

• Stress management
• Regular exercise
• A healthy, nutrient-dense diet
• Supplemental hormones (usually estradiol and progesterone, also known as HRT)
• And also medications.

Yes, medications. Dr. Vaidya plainly stated that 50 percent of perimenopausal women will seek treatment for their symptoms and “will need go on an antidepressant at some point in their lives.”
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“Our job is to destigmatize mental health. Menopause itself, being a life-changing event, can induce anxiety and can induce symptoms of depression in women. Mental health problems are very common during menopause.”

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