Rosemarie Shaheen Healy endured plenty of life changes in her 40s and early 50s.
She moved twice and went through a divorce. Her sons grew up and left home, and she had a hip replacement. On top of all that, Healy, of San Jose, was juggling a private therapy practice and a full-time job as academic dean of an all-girls private high school.
Still, her mood swings, irritability and insomnia didn't feel like normal responses to difficult life transitions. Healy says they felt "physical" -- outside of her control and totally beyond anything she had ever experienced.
When she noticed girls at her school become sad and moody around the times of their periods, it dawned on her that it might be raging hormones that were messing with her mental health.
Sure enough, after finding a nurse practitioner willing to prescribe hormone therapy, Healy started to feel less "snappish" and could deal better with most everything else. "One of the nice benefits was that I could sleep much better," she says.
Many women of a certain age can relate to Healy's struggle with baffling and disabling mood symptoms. Fortunately, a growing number of doctors and mental health professionals are honing in on the significant role hormones play in midlife women's mental health. By factoring in the hormonal component, health care providers are able to develop treatments that may be better tailored to each woman's symptoms. The treatments often include old standbys -- anti-depressants and hormone therapy -- but in combinations or dosages that can be more effective and less likely to bring on adverse risks and side effects.
"Unfortunately, anxiety and depression often go hand in hand with perimenopause," says Dr. Leah Millheiser, a clinical associate professor in obstetrics and gynecology at Stanford's School of Medicine. "There's definitely no 'one size fits all.' "
A natural transition
Perimenopause is a woman's natural transition to menopause -- when menstruation and fertility permanently stop. Women may start perimenopause as early as their late 30s or as late as their early 50s, and it can last anywhere from a few years to more than a decade.
During this time, estrogen and progesterone no longer cycle in "a modulated rhythm of synchronized harmony," says Diana Taylor, a professor emerita at UC San Francisco's School of Nursing and early pioneer into research on women's menstrual cycles. Rather, she says, hormones sputter erratically or "peak and crash," affecting many body functions, including sleep, memory, mood and energy.
These hormonal shifts also bring on depression and other mood symptoms in women who never before dealt with these conditions, according to Dr. Louann Brizendine, founder of UCSF's Women's Mood & Hormone Clinic. She estimates that just 15 percent of women will breeze through perimenopause. Fifty to 60 percent will experience symptoms some of the time, and 30 percent will suffer major discomfort.
No laughing matter
The idea of hormonal changes making women's lives miserable is nothing new. Back in the 1970s, the TV comedy "All in the Family" got mileage out of jokes about Edith Bunker's hot flashes.
But the disabling psychological effects related to hormonal dips and surges are no laughing matter to many, including Susan, of Walnut Creek.
"I felt like I was losing my mind," says Susan, who asked that her real name not be used. As a bookkeeper and volunteer at her daughters' schools, Susan, then 49, first thought she was stressed out due to overscheduling. But the symptoms -- the perpetual mental fog, the blanking out on words and directions to familiar destinations -- were so dramatic, she thought it might be early onset Alzheimer's. Her Kaiser ob-gyn suspected she was in perimenopause and prescribed hormone therapy in the form of a transdermal patch containing estradiol, along with a course of progesterone.
"I do have clarity, and I'm able to function at a good level now," she says.
Not all women get help right away. Even a sympathetic ob-gyn may dismiss their complaints as merely annoying features of perimenopause that will pass. It's not unusual for a mental health professional to prescribe anti-depressants and other medication, without considering the hormonal factor.
For nine years, best-selling author Ayelet Waldman lived with a diagnosis of bipolar disorder and dutifully dosed herself with a cabinet full of anti-depressants and mood stabilizers. Then she came across a clinical study on PMS. In comparing her mood swings and sleep patterns to her menstrual cycles, she saw how she always became depressed and irritable in the week before her period. A psychiatrist referred to her by the UCSF Women's Mood & Hormone Clinic suggested she try just two medications: a low dose of an SSRI, a class of anti-depressants, to be taken just the week before her period. The other was an anti-anxiety medication to be taken as needed.
The Berkeley resident was able to go off all the other medication, with the new regimen stabilizing her moods for the next two years. Unfortunately, the dark moods returned with the beginning of perimenopause. Waldman, 49, added an estrogen supplement to her treatment. She now holds out hope that her moods will finally quiet down when she enters menopause.
The psychiatrist who originally diagnosed her bipolar disorder was highly competent; he simply wasn't trained in women's reproductive health issues, she says.
Waldman believes all professionals who treat female patients should educate themselves about hormones' role in women's mental health. "This should be part of the treatment for any woman with a mood disorder," she says.
Millheiser says it's unfortunate that some physicians and women still worry about the safety of hormone therapy in the wake of the Women's Health Initiative study. Back in 2002, the study found that a popular hormone replacement increased the risk of heart disease and breast cancer in women well past menopause.
A 2013 final report subsequently concluded that hormone therapy -- usually estrogen alone or in combination with progestins, a natural or synthetic progesterone -- is safe for controlling moderate to severe perimenopausal symptoms in younger women.
"Hormone therapy, in the well-chosen patient, still plays an important role in improving the quality of life of peri- and post-menopausal women," Millheiser says.
Taylor says women can do a lot to help themselves. The first step is to keep track of their moods, sleeping and eating patterns and energy levels to see how those coincide with their menstrual cycles. Sharing that information with a health care provider can lead to a more accurate diagnosis and treatment.
She adds that women shouldn't see hormone therapy or any other medical intervention as "a magic bullet," especially since these midlife biological changes usually happen around the same time women are dealing with major shifts in their family and work lives. Women can also benefit from seeing a therapist, exercising more, eating better, meditating, taking calcium supplements and making other healthful lifestyle choices.
For Healy, her "midlife crisis" was ultimately productive and led her to enjoy life more. While the hormone therapy helped even out her moods, she also cut back on her hours in her private practice, took up bike riding and yoga and started a blog, onehipdiva.com, about her midlife journey.
"I don't think there is any easy way to go through this life transition," she says. "You have to rethink the way you're doing things. You throw things up in the air and see what sticks."