How Are Hot Flashes Related to Depressive Symptoms?

Research sheds new light on menopause symptoms

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For ages, experts have noticed that hot flashes and depressive symptoms can co-occur during the process of menopause. However, there has been limited research tying depressive symptoms, hot flashes, and menopause together. Furthermore, aspects of this area of study remain controversial.

More light has been shed on the link between depressive symptoms and menopause, as well as the relationship between depressive symptoms and hot flashes.

Menopause Explained

Based on results of the 2010 census, 41 million of 151 million American women were aged 55 or more. Most of these women either had or were about to experience menopause. Moreover, because life expectancies have increased during the past several years—with the notable of exception of 2015—women can expect to live a bit shy of one-third of their lives after menopause.

Interestingly, although life expectancies have increased, the time at which menopause begins has changed little over time. The average age of menopause in the United States is 51.

Considerations concerning the metabolic and hormonal changes that accompany menopause have become more relevant with each passing year. Women born during the baby boom following World War II are seeking treatment for menopause and other midlife conditions. Furthermore, the majority of these women are in the workforce, making for a unique set of social conditions.

The climacteric is the phase of the aging process during which a woman transitions from reproductive to nonreproductive status. Here’s the trajectory of the climacteric:

  1. Perimenopause is the menopausal transition of the climacteric during which a woman can expect her periods to become more irregular. During perimenopause, complaints or symptoms of menopause can begin to manifest, such as hot flashes. 
  1. Menopause refers to the final menstrual period.
  2. Postmenopause refers to life after menopause.

Here are some clinical conditions associated with the climacteric:

Night Sweats and Hot Flashes

Between 60 and 80 percent of women transitioning through menopause experience night sweats and hot flashes (also called hot flushes or vasomotor symptoms). Night sweats cause episodes of perspiration and sudden flushing. In those women who experience hot flashes, 82 percent have hot flashes that last for more than a year, and between 25 and 50 percent experience them for more than 5 years.

Although hormones are hypothesized to play a role, the mechanism linking menopause and hot flashes has yet to be elucidated. Specifically, women who have higher FSH levels and lower estradiol levels have a greater likelihood of experiencing hot flashes. Furthermore, those who smoke or have higher BMIs are also at greater risk of experiencing hot flashes. Interestingly, research suggests that black women experience more hot flashes than do white women; whereas, Japanese and Chinese women report fewer hot flashes than do white women.

Osteoporosis

Osteoporosis is a skeletal condition wherein bone mass drops, and bones become more fragile and prone to fracture.

With respect to menopause, this loss in bone mass is secondary to changes in hormone levels. Certain drugs can be used to prevent and treat osteoporosis, including bisphosphonates, calcitonin, and raloxifene. In addition to medications, calcium supplements, vitamin D supplements, smoking cessation, and weight-bearing exercise can all help.

Vaginal Atrophy

Vaginal atrophy refers to the thinning, inflammation, and drying of the vaginal walls. Vaginal soreness, burning, discharge, urinary complaints, and pain during sex can occur. Initially, the vaginal walls appear red due to the rupture of small blood vessels called capillaries.

With increased capillary loss, the vaginal walls eventually become smooth, shiny, and pale. Vaginal atrophy occurs secondary to a decrease in estrogen levels. Vaginal atrophy can be treated with lubricants or topical estrogens, which are applied to the skin in the form of creams, rings, or tablets.

Sexual Functioning

Sexual functioning can become suboptimal due to decreased libido, hormone changes, and sociocultural beliefs. Vaginal atrophy contributes to decreased sexual functioning. Hormone therapy is being explored as a possible treatment for diminished sexual functioning.

Difficult Sleeping

Between 30 and 60 percent of midlife women experience sleep disturbances. Specifically, these women have trouble falling and staying asleep. Although age plays a role in these sleep disturbances, hormonal changes, hot flashes, stress, and depressive symptoms are also linked to difficulty sleeping.

Memory Loss

Research suggests that 62 percent of midlife women experience memory difficulties during menopause transition. These memory difficulties include trouble recalling numbers and words and forgetfulness. Declines in estrogen are hypothesized to play a role in these memory difficulties.

Depressive Symptoms and Natural Menopause

Whether menopause serves as a risk factor for depression is controversial. Most midlife women don’t experience severe depressive symptoms. During the process of menopause, between 20 and 30 percent of midlife women experience first-time clinical depression or recurrent episodes of depression. The risk of depression is greater during perimenopause and postmenopause than it is before the climacteric.

Depressive symptoms include the following:

  • fatigue
  • sadness
  • guilt
  • loss of appetite
  • loss of sleep
  • troubles with concentration
  • agitation
  • loss of interest
  • thoughts of suicide

In a 2014 study published in JAMA Psychiatry, Freeman and colleagues examined 203 midlife women for depressive symptoms during a 14-year period surrounding menopause (i.e., the final menstrual period). These women were premenopausal and reached menopause. They also looked at changes in hormone levels as predictors for depression during postmenopause as well as previous history of depression.

Here are some of the researchers' findings:

  • In women with a history of depression, the risk of experiencing depressive symptoms was 8 times greater after menopause and 13 times greater overall than that of women without a history of depression.
  • With relation to menopause itself, the risk of depressive symptoms was higher in the years before menopause and lower in the years after menopause. Specifically, the risk of depressive symptoms 10 years before to 8 years after menopause decreased 15 percent per year.
  • In women who first experienced depressive symptoms around menopause, depressive symptoms decreased during postmenopause, and decreased most significantly during the second year postmenopause.
  • In women who had no previous history of depression, the risk of depressive symptoms was low 2 or more years after menopause.
  • Decreases in depressive symptoms mirrored hormonal changes.

According to the researchers, here are some suggested implications of this study:

Clinician review of depressive symptoms is needed to provide treatment when symptoms are debilitating and to evaluate the effect of depression on other major disorders, such as cardiovascular disease, metabolic syndrome, and osteoporosis. Women with a history of depression may benefit from an antidepressant or psychotherapy appropriate for a chronic disorder. However, women with no history of depression may have a low risk of depressive symptoms after the second postmenopausal year and benefit from short-term hormone therapy or short-term treatments with antidepressants that have demonstrated efficacy for menopausal symptoms.

Hot Flashes and Depressive Symptoms

The majority of studies that have assessed the link between hot flashes and depressive symptoms have been flawed in a few ways.

First, test validity has been suspect, with researchers not using proper measures to examine hot flashes. Second, examiners have looked at any degree of hot flashes instead of truly bothersome hot flashes. Similarly, researchers have had trouble examining clinically relevant depressive symptoms. Third, the number of participants in studies examining the link between hot flashes and menopause has been low, and you need plenty of people sample in the right way to truly represent the population that you’re testing.

In a March 2017 study published in the Journal of Women’s Health, Worsley and colleagues surmounted these shortcomings by randomly analyzing 2,020 Australian women between 40 and 65. The researchers used valid and representative questionnaires to assess participants for hot flashes, moderate to severe depression, cigarette use, alcohol use, and psychiatric medications.

After adjusting for several variables, including age, employment, and BMI, the researchers found that when compared with women with no or mild hot flashes, women with moderate to severe hot flashes were more likely to have moderate to severe depressive symptoms, too.

Furthermore, women who had moderate to severe depressive symptoms were more likely to take psychiatric medications, smoke, and binge drink.

The major strength of this study was that it assessed participants who represented the Australian community as a whole. Specifically, the participants in this study were similar to people assessed in the 2011 Australian census with respect to ethnicity, education, partner status, and employment. One potential limitation of this study is that it used self-reported measures (questionnaires).

According to the researchers, here are some implications of this study:

By demonstrating an association between moderate–severe VMS [hot flashes] and moderate–severe depressive symptoms, this study adds further weight to the notion of a shared etiology between VMS and depression. In addition to improving VMS, estrogen therapy may improve mood in early menopause.

In other words, based on results of their study, researchers hypothesize that the causes of both hot flashes and depression may be similar, and that hormone therapy may lift depressive symptoms in those experiencing early menopause.

Sources:

Bromberger, JT, et al. Depressive Symptoms During the Menopausal Transition. J Affect Disord. 2007; 103(1-3): 267–272.

Freeman, EW, et al. Longitudinal Pattern of Depressive Symptoms Around Natural Menopause. JAMA Psychiatry. 2014; 71(1);36-43.

Karvonen-Gutierrez C, Harlow SD. Menopause and Midlife Health Changes. In: Halter JB, Ouslander JG, Studenski S, High KP, Asthana S, Supiano MA, Ritchie C. eds. Hazzard's Geriatric Medicine and Gerontology, 7e New York, NY: McGraw-Hill;

Manson JE, Bassuk SS. Menopause and Postmenopausal Hormone Therapy. In: Kasper D, Fauci A, Hauser S, Longo D, Jameson J, Loscalzo J. eds. Harrison's Principles of Internal Medicine, 19e New York, NY: McGraw-Hill; 2014.

Nathan L. Chapter 59. Menopause & Postmenopause. In: DeCherney AH, Nathan L, Laufer N, Roman AS. eds. CURRENT Diagnosis & Treatment: Obstetrics & Gynecology, 11e New York, NY: McGraw-Hill; 2013.

Worsley, R, et al. Journal of Women’s Health. March 6, 2017. Epub ahead of print.

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