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Kirtly: Moods and midlife, or moods and menopause. We're going to talk about the emotional domain of the 7 Domains of Midlife.

My name is Dr. Kirtly Jones from Obstetrics and Gynecology at the ÈËÆÞÖгöÊÓƵ of Utah ÈËÆÞÖгöÊÓƵ. My co-host is Katie Ward. Katie's a nurse practitioner in women's health and has a doctorate. She's Dr. Katie Ward in nursing practice, and she's on the faculty at the ÈËÆÞÖгöÊÓƵ of Utah, School of Nursing. She's also a certified midlife women's health clinician. And this is the Kirtly and Katie Show on Midlife.

Katie, let me rant a little bit about the term "involutional melancholia." This is a term that I was introduced to when I was in medical school, which was now close to 50 years ago. God, I can't believe that.

It was thought even back then that women necessarily, or at least white women, European white women, went through this thing in the middle of their life, whether it was hormones, some people said it was hormones, or whether it was social, where they just became depressed and they involuted. They just turned in on themselves.

And I remember thinking, "That's hogwash." And it turns out it is kind of hogwash. Although midlife does have a lot of stuff going on, it could be that there's depression throughout many of the situations that arrive in midlife. But some longitudinal research has suggested that women are more likely to get depressed and have difficulty with a major depressive episode in their 30s to 40s than in their 50s to 60s.

So I think there may be an increased risk of depression in the perimenopause and early menopause in women who have had depression before related to hormones like PMS or maybe postpartum depression. But there's not an increase of the first episode of depression.

Katie, do you have any thoughts on that?

Katie: First of all, I was going to say congratulations on "involutional melancholia." That is a mouthful. The phrase I bumped into was climacteric insanity, so . . .

Kirtly: Oh, no, that's really a good one. Oh, I hate that one too.

Katie: Maybe that's a little older phrase. That would get you a hysterectomy, which would certainly give you worse menopausal symptoms right away and make everything worse.

So I think we've come a long way in menopause, and we're starting to talk about this in much more nuanced and thoughtful ways and trying to distinguish, "What are hormonal changes and what are true mood changes or mental health issues?" And so it's still a lot of that kind of sorting out what's going to be the best evidence-based treatment for somebody.

But I think the thing I hear the most is, "I just don't feel like myself."

Kirtly: Right. "I don't feel like myself." Well, I've had the experience more than once of getting a call from a husband that was put forward to me, that he wants me to see his wife as soon as possible and fix her, because she wasn't the biddable, sweet, young thing she was when they married at 20, and something is not quite right with her. She's not what she used to be.

And part of me, not even having met the poor woman, says, "Well, Jesus, she's got a bunch of teenagers, and you're probably being a jerk." I don't say that, but I think, "Well, there are lots of reasons why you just don't feel like yourself."

Katie: It's such an interesting phrase because I think it expresses a lot of things. Then that becomes the job, is to figure out is this just a bit of irritability and anxiety? And is that just that they're paying attention to everything in the world and that's making them anxious? Is it related to other symptoms of menopause and amenable to menopausal hormone therapy? Or do they really screen positive for a significant depressive episode or a diagnosis of depression?

So those are the things I'm always trying to sort out. I'm usually giving my patients some kind of a questionnaire that looks for depression. If they're truly depressed, then we might talk about really a combination of things, including medication therapy or cognitive behavioral therapy or just therapy, as well as whether or not they're a candidate for hormone therapy.

Kirtly: Yeah. It's a really tough time, I think. This time is one of the focal transitions in women's life, Katie, I think.

You have your birth, which is a really big deal when you're born and you get all kinds of medical screenings and there are a whole lot of things changing.

And then there's your first period and your brain is completely rewiring itself. In adolescence, the brain can get a little crazy, but it's got some reasons to be crazy as well. It's a crazy world.

And then with the birth of your first ÈËÆÞÖгöÊÓƵ, that's a big rewiring of your brain. But you've also got this brand new baby, and it's a time where you don't feel like yourself anymore and you aren't like yourself anymore.

Then midlife, whether it's hormones or it's because all these things are happening to your parents and to your partner and to your kids if you've got them.

I think it takes a reasonably seasoned clinician to really listen, to find out why women just don't feel like themselves anymore.

Katie: Absolutely. I think one of the things I talk to patients about is exactly that thing that you were just describing, is that we go through these major hormonal shifts.

I might get all teacher-y here for a minute. Real depression is similar in boys and girls until puberty, and then girls start to experience twice as much of it. And most all women, when they have a baby, have something on a spectrum from baby blues to full-on postpartum depression and even psychosis. Some women sail through the menopause and some women have a hard time with it.

So I think there are a couple of things. One, there are these windows of vulnerability for depression when your hormones are undergoing major shifts like that. There's definitely some kind of hormonal connection about how our brains are working.

And I liked what you were saying about shifts in our brain. There's an author who I like who talks about it as just a little bit of pruning. Your brain is . . .

Kirtly: Pruning and rewiring.

Katie: . . . getting rid of some old connections and hard wiring some new ones. And I think that that is really consistent with what I see in the menopause. You're having a bit of a brain rewiring and once the IT work is done, most people come out with a better system or at least something a little bit more dependable.

Kirtly: For me as a neuroendocrinologist sort of wannabe, as an endocrinologist in life truly, I think of the brain state in menopause as being irritability. The business about fluctuating hormones can make someone more irritable, meaning lights are too bright and sounds are too loud. And things they used to just be able to let loose, let go of, make them irritable.

It's not kind of unlike what some people experience with PMS, meaning they're not really sick with PMS, but they just get cranky. And there are lots of reasons to be cranky. One, there's the hormonal lack of cohesion that comes when you're not sleeping well or you maybe have so many hot flushes, and then there's the crankiness of your adolescence, or there's the crankiness of your partner, and then there's the crankiness of your parents.

There are lots of reasons to be cranky, but then your brain is irritable. Estrogen withdrawal can lead to an irritable brain. Progesterone withdrawal leads to an irritable brain. It's more likely in rats to have seizures.

So part of this business of the husbands calling saying, "Fix my wife," is that she lets off steam more than she used to. She's cranky about stuff.

And I do think that although a full-blown depression should be treated very seriously as depression, the irritability might actually be better. If people are having a lot of hot flushes and not sleeping well, that might be very amenable to hormone replacement therapy when you sleep better.

Katie: Absolutely. And I think that's exactly what I hear from my patients, is that they're aware of this. They're aware that they're popping off at things that bother them, and that used to be something that they just let roll over them, but now they're not holding back.

And if it's causing conflict, they're coming in concerned about it. They're like, "I'm responding this way, and that's not what I usually do, and it is causing conflict."

You alluded to this. There are so many things going on for people at this time of life. Often, as you mentioned, you've got your career and you may be at the very peak of that, in your peak earning years, and you're busy and there's lots going on there.

And following most people's life course, you have kids that are maybe not quite launched yet, but are working on their own "how do they kind of separate from their parents and establish their own identity as individuals?" So that can be some conflict.

And odds are it's not a new marriage, and there are some years of friction built up there. Frequently it is a time when your parents are starting to have their own health challenges.

I think for a lot of women, in addition to hormonal changes, there are a lot of circumstantial changes. And then there's just the world around us, which is also a little bit stressful for everybody right now.

Kirtly: It is. And anxiety making, I think about that. So we talked about irritability, and then there's anxiety, which can also keep you awake, cause a little insomnia.

In our midlife women's clinic that I used to run, we gave a long, long questionnaire on what biggest complaints were, and they were often anxiety. There were a number of chief complaints but anxiety was one of them.

There is so much going on, and your ability to say, "I can deal with this later" . . . Anxiety can come with that irritability in the sense that normally when you're anxious about something, you can stuff it someplace and say, "I'm going to deal with this later." But sometimes when you're not sleeping well, you're really not sleeping well and anxiety becomes another issue to pull out. How much of this is situational with happenings around them, or how much is that a brain that just wants to be anxious?

And what worries me some is that I see a lot of my friends and patients even in Utah who are turning to alcohol to calm the irritability and to calm maybe the anxiety. Certainly, it's socially acceptable because every TV show you watch where there's this power woman who's a lawyer, who's a detective, or whatever, as soon as she gets home, she kicks off her four-inch heels, which she shouldn't be wearing in the first place, and pours herself an oversized glass of always red wine. And I think, "Well, that's a lot of drinking they're doing."

I don't know if that's in your practice, but some of the many women I saw, "Well, how much do you drink?" "I usually have two glasses a night." I thought, "That's 14 glasses a week." "And then how big are your glasses? Are they five ounces?" "Well, no, they're kind of more than that." I'm worried about that.

Katie: They're a whole Stanley cup.

Kirtly: Oh, god, I should talk about my mother, but I won't talk about my mother who used a beach cup. The whole Stanley cup. Yeah. "How many cups?" "Just one or two a night," and they were beach cups.

Katie: But no, I agree, Kirtly. I think the alcohol . . . there are multiple layers to this, right? So if somebody is just having a glass of wine with dinner, that might still disrupt their sleep.

So we can start there and talk a little bit about any alcohol does change your sleep patterns. So I do ask my patients who are having the combination of trouble sleeping and anxiety about their drinking habits, because it may really be a time in your life where just even a little bit of alcohol plus a little bit of hot flashes plus some things that worry you are a combination that is really going to disrupt your sleep.

If you wake up at 2:00, whether it's alcohol or a hot flash, and then you're lying awake thinking about the things that you're worrying about and having a hard time going back to sleep, that's rough for anybody.

But you're right. I think especially during the pandemic, we saw alcohol use really accelerate for a lot of people, including people in Utah. Again, midlife may be a period of time where maybe you aren't so busy with your kids in the evenings and you have a little bit more free time, and it's easy to have that second glass of wine. It does become a habit and a ritual, and I think it sneaks up on people.

And so it is important to talk about and, like you said, to really talk about, "Well, how big is that glass of wine? And how many nights a week are you having wine?"

Kirtly: Well, I mentioned wine mostly because that tends to be, for many women, the alcohol form of choice. And I just don't know that women are that aware of . . . they know that alcohol can relax them in the short term and sometimes it may help them fall asleep. But then at the critical time of night where you need to get your deep sleep, or your transition to REM sleep, people are wide awake. And then they think, "Well, I'm wide awake because I'm anxious, so I'm just going to drink more."

They don't always make that connection that what happened four hours after or six hours after their glass of wine or two glasses, that they're actually disrupting their sleep pattern because of the alcohol. It's a very interesting neurochemistry that I think a lot of people just don't click to.

Katie: That is the first step, is to start to understand that. And then what I often do is just talk to people about, "Well, how would it be to take a month off and see if you feel different?"

Kirtly: Right. Or save drinking for special occasions, or however they want to do it. I'm not judgmental as someone who drinks myself on occasion, but I clearly had to make some decisions back when I was deciding how I was going to sleep in my own menopausal transition.

It was best if I had no . . . I really had to watch my caffeine and my alcohol because I really needed to sleep when I needed to sleep, and I needed to be alert when I was going to be alert. For me, that's just how . . .

Katie: And calories. I think that's the other thing. That's the other way in. Two glasses of wine a night is 20 pounds a year.

Kirtly: Well, it's not just that. When you've had that second glass, you don't make good food choices anymore. Give me a glass of wine and all of a sudden all those crackers and cheese or that second helping of god knows what . . . It's like I don't have complete control over my appetites once I've had a little bit of wine. Oh, dear.

Katie: One other thing I talk to people about, because it's an awareness that I'm starting to have more and more, is it's easy to put all this responsibility on our patients, or ourselves, myself even, that I need to have all of this self-discipline. But socially I like to look at the engineering of it too.

I think a lot of alcohol companies are marketing their products to women more. It's an opportunity for growth. Women have their own disposable income. And you certainly see this if you just walk through the liquor store. The number of wine labels that are clearly designed to attract female buyers . . .

Kirtly: How did they know? That's how I pick my wine. I want the cutest label.

Katie: I want that pretty butterfly.

Kirtly: Or something that's funny. Our own wine stores here in Utah used to let us see the wine rating label. So mine was always . . . it has to be under $20, it has to have a cute label, and be rated in the high 80s or something. But the label was often the most important thing. They know me and I'm not even a big drinker. Oh, no.

Katie: But I think for women to rise up and say, "Hey, stop that."

Kirtly: Well, we have to rise up and say, "This something is good for me." But it's become a middle class and upper-middle class norm to just pull out the bottle of wine or something at dinnertime for many women. And it's enhanced by what you watch on TV. I don't know.

Katie: Good news, though. I think that there is a bit more of a movement to talk about this more. So I'm seeing more and more kind of reframing it a little bit, talking to people about being sober-curious.

There's a growing market for non-alcoholic beverages and a little bit more awareness of what I think we've been really talking about here, which is getting its own label of gray-area drinking. We're not saying somebody has a full-on severe substance use disorder, but maybe drinking in that gray area where it's a habit that's sneaking up on you.

So I think there is more conversation about a more nuanced way of discussing the issue and a growing body of alternatives. You're starting to see alcohol-free bars and lots of alcohol-free drinks. And so I think there is a commercial response to this as well, which is nice to have.

Kirtly: Well, the other thing I wanted to touch on during this emotional domain is I think that this is often a time of transition in our midlife at the time that our ovaries are deciding that we shouldn't make more babies, which is a really good thing. Our own ÈËÆÞÖгöÊÓƵren may be leaving, or they're not leaving soon enough. And our parents and even friends, we start to lose our friends.

So the concept of loss, what does it mean to lose people we love, either because our kids pack up and leave? And this could be a good thing or not so good thing. Or they move in with their girlfriend and their girlfriend's baby, and so what was supposed to be a quiet time for you now is not so quiet. I think this is part of what makes this a complex time in women's lives.

For me, all these things happened. I lost a parent and my son went off to school. I'm now past my midlife. I remember thinking it being a very powerful time for me to listen to my own heartbeat, but it still was connected. Those connections, you cannot just cut. When kids have left, you just can't cut the cord, and now you can't hear the signals anymore. You still either hear signals from your kids or you make up signals that you're not getting from them. It's tough.

Katie: It is. It is a challenging time. I agree with you. Right around that time that I was going through menopause, my youngest ÈËÆÞÖгöÊÓƵ went off to college and I just lost my mother. And you do feel just a little adrift.

I used to run and I would go on my running route, and I had this question I would sort of ruminate on. And I would ask myself, "Now, what's going to make this okay?" And that's been a very useful question for me at a lot of stages in my life.

But I remember really vividly running back and forth and thinking, "All right. Now what am I going to do?" And for myself, I went back and thought, "If I could have been anything I wanted to be, what would I have done?" I kind of landed on not really a career change, but I got this idea to go back to school. So at 50, I applied for a PhD to become a PhD student in anthropology.

Kirtly: I know, Katie. I was thinking, "What are you doing?" That was my thought.

Katie: But that's really how I came to it. After a long time of raising ÈËÆÞÖгöÊÓƵren, I didn't know what I was going to do with all that time that I had spent ironing uniforms and packing school lunches and going to swim meets. And so for a long time, it was just a question of, "All right. What next?" And that was the thing I asked myself. If I could have been anything, what would I have been?

Nursing, for me, was a very practical choice. But I got thinking about, "It's not too late. I could still go and study, stick my head in a completely different discipline, and it doesn't require a whole career change."

Now, granted, I have a lot of privilege. I work here at the university and I get half-price tuition and I didn't have to pack up and go to a different school. But I still think that that's not a bad framework for anybody, is to say, "All right. You've got half of your life ahead of you and you still have an opportunity to reinvent yourself one or two more times. So what would you do with that?"

Kirtly: Well, I think that particularly framing it that way, Katie, instead of saying, "I only have half my life left. I'm almost done." Half your life seems like . . . Maybe it's, "Half my life, then my life is almost over, la, la, la." But thinking, "I've got a whole other part of my life ahead of me."

I think this gets into this U-shaped curve of happiness, which is an analysis of how happy people are measuring starting in their 20s up until their 80s. And this is a worldwide assessment of men and women. It seems like happiness is at its peak years or in its 20s, and then it kind of goes down in the 30s, and it goes further into the 40s. And then by the time you get to your 50s, it starts going back up. By your 60s or 70s, you've got a lot of things figured out. Things don't worry you quite as much.

So the U-shaped curve of happiness has been documented in people all over the world, in men and women. And in fact, currently some data suggest that American people who are over 50, in their late 50s, early 60s, may be some of the happiest people in the world.

And our younger people, our 20-years, having just come through the pandemic and are trying to find a job and find a house and live financially, aren't as happy as they should be based on previous years' data.

But there is this magical turn that happens in your worries and in your happiness at about 45 to 50. It starts going up, I think.

Katie: I don't know if you've seen it. There's an interview Jodi Foster just did with one of the morning talk shows. She just apparently turned 60 recently, and she's talking about how 50 was really a hard age for her. At 50, she was a little bit at loose ends and not sure where her career was going. She just turned 60, and she's talking about how incredibly happy she is now, that something just magic had happened somewhere in that decade.

And so I think that's a lot about what you're talking about. At the peak of that transition, things seem really hard and overwhelming. Something I do tell my patients is, "It's going to get better." One day you're Jodi Foster and you wake up and you're 60 and you're like, "I am so happy."

And what she said about it was that she's not competing with her younger self anymore, that she's just enjoying what she's doing and she's no longer feeling like she's in competition with her younger self. And I liked that as well.

Kirtly: Oh, I like that a lot. And Katie, I like what you said about when you would go for a run. It's like, "What would I do to make it better?" When you're in that low part, or in the next 10 years . . . I do this what I call the bathtub test, which is, "Who do I want to become at 60?" If I'm in my lows, or if I were because I didn't ever get very low, "Who do I want to be in 10 years and how do I get there?"

So ask yourself a few questions if it seems like it's low times. Ask yourself a few questions. Who do you want to be in 10 years and how can you get there? And you don't have to get all the way there. I always wanted to be able to sing like Barbra Streisand and I will never make it. But I gave that one up and looked for other things.

But I would say, having been through the midlife transition and the menopause transition, at 60 I was very calm. I felt like I was at peace with myself and the foolish person I was when I was in my 20s and 30s, and I was a happy girl. I still am a happy girl.

Katie: Right? I think the good parts just keep getting better.

Kirtly: Yeah. Well, we hope all of you listening are in the upswing of the U-shaped curve of happiness. And if you aren't, take some time to spend with friends, reach out, and if you're really struggling, talk with your clinician because they can help.

And keep listening to the 7 Domains of Midlife. We have posted the physical domain already, and upcoming will be the social, financial, intellectual, environmental, and spiritual domains of this amazing time of life. Listen to the Kirtly and Katie Show, and we are going to help you think about this middle part of your very own life. Thanks for listening.