Teri Hines was in her mid-40s when she started to notice that her body was changing.
Her period became irregular and more intense. "It increased in frequency, it increased in intensity and it increased in duration," she says.
She began to have hot flashes, gained weight and her energy levels took a nosedive.
"I just did not have the energy to do the things I wanted to do," she says, like the long morning walks she loved to take with her dogs, or planning solo travel.
At the time, Hines lived alone in Philadelphia where she worked as an assistant principal at a school. She struggled to get out of bed and go to work, and she began to withdraw from friends.
Looking back, she remembers feeling isolated and unmoored. "It was such a fog over who I was, what I wanted, where I was going, what I was capable of accomplishing," she says. "I just could not find my footing."
Hines knew she was likely going through perimenopause, that is the years leading up to menopause, when women's monthly hormonal cycles become erratic as their bodies prepare to stop menstruating.
What she didn't realize — and many women don't know — is that the hormonal changes of perimenopause can bring changes in mood, and for some, a heightened risk of anxiety and depression.
"Women who have a previous diagnosis of major depression or anxiety disorder are going to be at a greater risk during the perimenopausal time," says Jennifer Payne, who directs the Women's Mood Disorders Center at Johns Hopkins University.
And she warns that for these women, it's something to take seriously. "If you're having serious depression, and your functioning is affected, if you're having suicidal thoughts, or you feel completely hopeless, that is a major depressive episode that absolutely needs treatment," she says.
A vulnerable time
Perimenopausal mood swings often resemble symptoms of premenstrual syndrome; women might feel sad, or sluggish, or irritable.
"I've had people say that they feel like they have PMS all the time," says psychiatrist Hadine Joffe, who leads the Connors Center for Women's Health and Gender Biology at the Brigham and Women's Hospital in Boston. "They just don't feel like they're in control of their mood and they feel edgy."
Generally though, these mood swings are manageable, she adds. "The good news is that most women will navigate their perimenopause without serious mental health issues."
But a significant number of women — about 18% among women in early perimenopause and 38% of those in late perimenopause — experience symptoms of depression. And symptoms of anxiety appear to be more common during this time leading up to menopause, including panic attacks.
Those most at risk are women with a history of mental illness, as well as women whose moods are particularly sensitive to hormonal fluctuations.
"Women who had postpartum depression or have always had significant mood changes premenstrually are going to be at risk of having more symptoms," says Payne.
It's not that women who develop serious anxiety or depression have any unusual or abnormal changes in hormones, she says. Rather, "it's likely that their brain is sensitive to normal, natural hormonal fluctuations."
"We know that in psychiatric illness, in general, the environment definitely plays a role," Payne adds. And during this time period, she says, there are often big life changes for women that can exacerbate their risk of having mental health symptoms
"Some women go through divorces, children go off to school, or leave the house, parents are getting older and need more caretaking," says Payne. "There are changes in career, etc."
"There's there's a lot of midlife specific stress that happens because of where people are in their life," adds Joffe.
When doctors don't pay attention
Hines was familiar with depression. She'd been depressed several times before and she had been proactive about seeking treatment.
"I had been an advocate for myself on depression and self-care and getting the right help, getting counseling," says Hines. "At times when I needed [it], using medication."
And over the years, she had learned to recognize her symptoms and triggers — often big life changes, either professional or personal.
This time though, she says, she was too focused on how her body was changing and missed the symptoms of depression.
"The physical nature of menopause consumes you and it's what we're taught to pay attention to," she says.
She did not know that her past history of depression put her at a higher risk of being depressed during perimenopause. But she did bring up her physical symptoms and her energy levels to her doctor early on during a regular appointment. But the conversation was disappointing, she says.
"I think she might have said 'you're about the age when you will begin to have these symptoms, you will begin to be perimenopausal,' " Hines recalls.
The doctor offered no tips to help with her symptoms or even any information about perimenopause, she says, not even the fact that on average it lasts for about four years, and for some women as long as 10 years.
This isn't uncommon. More than a 1,000 women wrote to NPR with their own stories about struggles during perimenopause. And a majority said that they had gotten little information or help from their physicians, especially for mental health symptoms.
"It's a very common situation for women, and doctors are not keeping up with that," says Payne.
This is partly because most physicians, even OB-GYNs, get little education about perimenopause, says Joffe.
Hines and many other women who wrote to NPR said they found they had to be in the driving seat when it comes to looking for and finding the right help or treatment.
Women need to be direct with their doctors about their mental health symptoms, says Joffe.
"Just the same as they would if they had a rash," she says. "They would make an extra appointment and that's the first thing they say: I have a rash."
Payne agrees. "The No. 1 thing that women can do is be honest with their doctors about their symptoms and what symptoms they're having and how severe they are," she says.
Treatments that work
Hines eventually got her doctor to pay attention and treat her mental health symptoms.
But it took her several years before she even realized that she might be depressed.
"That's when I made an appointment with my doctor and said, here's what I'm thinking, here's what I'm feeling, I think I might be depressed."
This time, her physician prescribed her an antidepressant. "The minute I went on it, I felt like I had the energy to tackle those other things that were ongoing," says Hines.
"Antidepressants can help a woman get out of her major depressive episodes," says Payne. "They can also be helpful for anxiety symptoms."
Research also shows that they can ease some of the physical symptoms of perimenopause, such as hot flashes and insomnia.
Hines also benefited from talk therapy, which studies show is also helpful for treating depression.
"I went on antidepressants and then I started going into counseling," she says. "Once I had it under control with counseling, then I was able to sort of wean the pharmaceuticals off, so that I could just use the counseling."
Joffe suggests women who are at this stage of life take steps to empower themselves. They should monitor symptoms carefully so they can have an informed discussion with their doctors.
Most of the time women just try to tough it out, says Joffe. "Women are tough. Women are accustomed to having to cope with physical discomforts and life challenges," she says. "And I think a lot of midlife women expect that this is a time of distress and discomfort and ill ease and that's normative."
But, she adds, it doesn't have to be that way. She points to resources like the North American Menopause Society's website, for example, which has helpful information about menopause as well as a tool to help women find local providers specializing in perimenopause.
"I want [women] to have permission," she says. "I want [women] to feel that they owe it to themselves and the people around them, that they aren't suffering."
RACHEL MARTIN, HOST:
There's a day in every woman's life when she hasn't had her period for 12 consecutive months. That day is when she starts menopause. But there are years leading up to that point. For some women, it can take as long as a decade. Those years are called perimenopause. And during that time, hormones fluctuate, periods get irregular, women can experience hot flashes, changes to their bodies, emotional ups and downs. But for many women, some of the symptoms don't stop there. Perimenopause can bring on severe anxiety or clinical depression.
NPR's Rhitu Chatterjee has more.
RHITU CHATTERJEE, BYLINE: About a decade ago, when Teri Hines was in her mid-40s, her period started to change.
TERI HINES: It increased in frequency, it increased in intensity, and it increased in duration.
CHATTERJEE: She had hot flashes, gained weight, and her energy levels took a nosedive.
HINES: I just did not have the energy to do the things that I wanted to do.
CHATTERJEE: Like the morning walk she loved to take with her dogs. At the time, Hines lived alone in Philadelphia, where she worked as an assistant principal at a school. She struggled to get out of bed and go to work and began to withdraw from her friends.
HINES: I would prefer they come to me. I would prefer to stay home rather than meeting up with everybody for an evening out.
CHATTERJEE: Looking back, she remembers feeling foggy and isolated. But she didn't realize that she might be depressed. Even though she'd struggled with depression before and had sought treatment for it, she knew her symptoms, her triggers - usually it was a big change in her personal or professional life. This time, though, she says, she was just focused on her body changing.
HINES: The physical nature of menopause consumes you and is what we're taught is what you have to pay attention to.
JENNIFER PAYNE: Perimenopause is a whole host of physical changes but can also lead to emotional changes.
CHATTERJEE: That's psychiatrist Jennifer Payne. She directs the Women's Mood Disorders Center at Johns Hopkins University. She says most women experience mood swings. They might feel blue, irritable or anxious, but women who have a history of mental illness like Hines, they're likely to experience more serious symptoms.
PAYNE: Women who have a previous diagnosis of major depression or an anxiety disorder are going to be at a greater risk during the perimenopausal time.
CHATTERJEE: There's also a higher risk for women going through major life upheavals - changes in career, a divorce or children going off to college. Payne says women who are really struggling need treatment.
PAYNE: If you're having serious depression and your functioning is affected, or you're having suicidal thoughts, or you just feel completely hopeless, that is a major depressive episode that absolutely needs treatment.
CHATTERJEE: That treatment, she says, can be in the form of talk therapy and/or medication.
PAYNE: Antidepressants can, you know, help a woman get out of a major depressive episode. Antidepressants also can be very helpful for anxiety symptoms.
CHATTERJEE: But getting a diagnosis and treatment, she says, can be an uphill battle.
PAYNE: It's a very common situation for many women, and doctors are not keeping up with that.
CHATTERJEE: That's because most physicians, even OB-GYNs, get little education about perimenopause. Hines learned this the hard way. When she first noticed her changing period, the weight gain, her falling energy levels, she mentioned it all to her doctor.
HINES: I think she might have said, yeah, you're about the age when you will begin to have these symptoms; you will begin to be perimenopausal.
CHATTERJEE: But, she says, her doctor offered no treatment or even further information, not even the fact that perimenopause can last up to 10 years. Hines did eventually realize that she might be depressed, but it took her several years of struggling with her symptoms.
HINES: That's when I made an appointment with my doctor and said, like, here's what I'm thinking. Here's what I'm feeling. And I think I might be depressed.
CHATTERJEE: This time, her physician prescribed her an antidepressant.
HINES: The minute I went on it, it felt like I had the energy to tackle those other things that were ongoing.
CHATTERJEE: Hines also started seeing a therapist, who gave her coping skills to better manage her symptoms. Hadine Joffe is the vice chair of psychiatry research at Brigham and Women's Hospital in Boston. She says women need to be direct with their providers about their mental health problems, like Hines was.
HADINE JOFFE: Just the same they would - if they had a rash, they would go in for an extra appointment. And that's the first thing they say, is I have a rash.
CHATTERJEE: Another tip she gives women - start tracking your symptoms as soon as you notice them.
JOFFE: Knowing that information, somebody can say, well, over the last six months, I only had two periods, or I had hot flashes almost every day, or my mood was bad as it gets, you know, a third of the time.
CHATTERJEE: Joffe says most of the time, women don't do this and just try to tough it out because they're used to dealing with physical discomforts and emotional struggles. But, she says, seeking help is important.
JOFFE: I want people to have permission. I want people to feel that they owe it to themselves and the people around them that they aren't suffering.
CHATTERJEE: Because with the right tools and treatment, they don't have to suffer during this time of transition. Rhitu Chatterjee, NPR News. Transcript provided by NPR, Copyright NPR.