From the main article.....
"Result- there is insufficient evidence at present to maintain that menopause causes depression."

From the editorial, well actually most of the editorial ...
"The linking of the menopause with depression is pervasive in lay and medical discourse, despite limited supporting evidence. Historically, myths relating to menstrual taboos, as well as attitudes towards fertility and aging, have produced an image of the menopause as a time of physical and emotional decline. In the 19th century menopause was thought to cause insanity, and it was only as recently as 1980 that the diagnosis of involutional melancholia was removed from the third edition of the Diagnostic and Statistical Manual of Mental Disorders. With the development of hormone replacement therapy, treatment of menopausal women shifted from the domains of psychiatry and psychoanalysis to gynaecology and endocrinology. 

.............It has been proposed that oestrogen might cure "menopausal depression" and that it might offer an additional bonus of increased well being or quality of life for non-depressed healthy women. 

Defining the menopause as an oestrogen deficiency disease implies that the cause of depression lies in a woman's hormones. This has important implications for the way middle aged and older women's views and behaviours are perceived in society. It is also relevant to the day to day clinical practice of many doctors, since many women who seek medical help commonly present with a mixture of vasomotor and psychological symptoms. 

So, what is the evidence? Does the menopause cause depression? In this weeks BMJ , Louise  Nicol-Smith presents a systematic review of the epidemiological studies relating to this question, focusing on the issue of causality.........the review concludes that there is no substantial evidence to support the view that a natural menopause causes depression.......... 

Cross-cultural research provides examples of communities in which women have positive attitudes to the menopause and report few or no symptoms. These suggest that the psychological impact of the menopause is influenced by the social values ascribed to older women and the roles available to them, as well as cultural differences affecting lifestyle factors, such as diet and exercise. 

As for epidemiological studies........few changes were found to be attributable to the menopause other than hot flushes and night sweats. Though there was considerable variation between women in terms of well being and depression, the prevalence of depression did not increase during the menopause in four of the five studies. Moreover, women of childbearing age tend to be more prone to depression. 

In the prospective studies, psychosocial factors were found to be the main predictors of depression during the menopause. These included past depression , socioeconomic status, stressful life events such as bereavements, and negative beliefs about the menopause. The menopause seemed to have a more negative effect on women who previously believed that menopause brings a host of physical and emotional problems. Marital and employment status as well as social support can moderate the effects of stress, as at other stages of life. Those who suffered chronic arthritis or thyroid problems were more prone to continued depression. Experiencing a longer menopause ( at least 27 months ) was associated with an increased transitory risk of depression; this association seemed to be explained by increased exposure to vasomotor symptoms. 

Meanwhile, correlational studies have reached fairly clear concensus that there is no link between oestrogen concentrations and depression....... 

........Overall there is no conclusive evidence that hormone replacement therapy improves depression in women seeking help for menopausal problems over and above placebo effects. There is some evidence of a small improvement in well being in selected, healthy women, particularly when higher doses are used. Again carefully designed studies are needed to disentangle the effects of placebo, relief from vasomotor symptoms, and the possible psychoactive properties of estrogen. However, even if hormone replacement therapy increases well-being or improves mood, this would not necessarily mean that depression is caused by low levels of oestrogen. 

Taken together the above findings suggest that to attribute depression in a middle aged woman automatically to the menopause is overly simplistic and usually unjustified. The menopause has a psychological, social, and cultural, as well as a biological importance. On the biological level there is more evidence in support of prolonged and severe vasomotor symptoms causing distress than hormone levels. Nor should we forget that for most women the menopause is not a major crisis and that many feel relieved to be free from menstrual periods and the possibility of pregnancy. 

.................Finally, to attribute depression to the menopause implies a hormonal cause, ignores psychosocial factors, and may indirectly promote the negative beliefs that have been found in epidemiological studies to predict depressed mood in middle aged women." 

Myra S. Hunter 

Talk about your self fulfilling prophecies!. As I've said before, if you are well, (and sometimes even when you are not) there is no compelling reason at this time to embark on a course of hrt. 

• Over the past 30 years, at least 94 studies published in the English language have investigated the relation between menopause and depression.
• Causal and methodological criteria can be used to structure the findings and draw conclusions in a literature review.
• Menopause has so far not been shown to cause depression. 
• In addition to methodological and statistical constraints, a temporal problem related to the menopause concept hinders research in  this area.
• Theoretical work is required to integrate causal criteria and standard clinical epidemiological concepts."

The review focused on 17 studies which concluded that there was an association between menopause and depression. (So, 64 studies discount the hypothesis). 

It applied Hill's criteria to the conclusions to see whether the "most likely interpretation of an observed association is causality."   These criteria are: 
 

•  Experimental design. A strong design (randomized double blind placebo controlled yada yada yada) or weak (retrospective, cross-sectional). Since all women will become menopausal, control for the putative risk factor  (menopause) is impossible. Therefore "all studies located used a non-experimental design" 
•  Strength. Strong associations allow a safer inference of causality, as they are less likely to be the result of study bias. This plays back to the design, as the commonly applied methods of controlling for bias, randomization, controlled exposure to the agent, are unavailable. "Study design has not, therefore, added weight to the findings of any of the individual studies."
• Consistency. Observed associations made across many investigations support the notion of causality. The more consistent observation is that menopause does not cause depression (64 studies against 17). 
• Specificity. This criterion relates to a specific cause producing a specific effect. If this can be demonstrated it is strongly indicative of causality. None of the psychological effects attributed to the menopause occur exclusively in mid-life, so specificity can not be established." -
• do all menopausal women suffer osteoporosis? -
• do all menopausal women suffer cardiovascular disease? 
• If menopause and "estrogen deficiency" caused osteoporosis, and cardiovascular disease, then they would be observed universally. They are not. 
• Temporality. Cause precedes effect. There are methodological issues with the determination of menopausal status which cloud the determination of temporality. 
•  Plausibility and gradient. "use of small clinical samples and lack of replication prevent the drawing of causal conclusions from this material, at present" 

Coherence and analogy. " are understood to relate to the logical relation between the chosen subject of interest and other specialties where a causal link has already been established." Is a menopausal cause for depression compatible with existing understanding of the etiology of depression? Is estrogen an appropriate primary intervention for the woman suffering a major depressive episode? The answer is unequivocally NO. 

Mark

 Abstract: 

Beyond the repeatedly confirmed finding that women diagnosed with mood disorders greatly outnumber men lies a widely varying set of hypotheses that attempt to explain the suspected causes, incidence, symptoms, and comorbidities from various perspectives. Several complex factors, however, have impeded attempts to study why women are so vulnerable to depression. This article examines the problems associated with studying affective disorders in women and reviews the current hypothetical constructs of the etiology and pathophysiology of depression and their potential relevance to the disproportionate number of women with unipolar depression. The association of depression to biological stages of a woman's life and the differences between the biology of men and women are described, and the potential social, psychological, and environmental factors that might particularly promote the development of depression in women are discussed. [Medscape Women's Health 2(2), 1997. © 1997 Medscape, Inc. 

Vulnerability in Relation to Reproductive Transitions
Menopause. 

Despite earlier clinical beliefs that menopause was associated with increased depression, the preponderance of evidence now indicates that the climacteric is not associated with increased risk for affective episodes Incident or recurrent rates of mood disorders in fact decline in women after menopause and rise in men in later years so that gender differences in mood disorders narrow with age. Such trends are more consistent with psychiatric models that link depression to psychosocial vulnerability factors than they are with simple biological models linking estrogen deprivation to depression. Nonetheless, in the perimenopause period, defined as 1 or 2 years immediately preceding cessation of menstruation, there is a peak in dysphoric mood, disturbed sleep, and somatic complaints. Moreover, dysphoric mood is associated with a long perimenopause, but it subsides with the onset of menopause. 

The National Comorbidity Survey, in which a cohort of men between 45 and 54 years old were interviewed, also indicated that the number of 12-month recurrent depressive syndromes is higher in women than in men during the period that corresponds to women's perimenopause and menopause years. The relation of recurrent mood disorders to hormonal changes or life events at this time, however, cannot be estimated from the study. 

In studies of mood disorders in women who are undergoing reproductive transitions and hormonal changes, a tendency to equate individual depressive symptoms with a clinical depression syndrome may have the effect of multiplying the variety of etiologic subtypes under the depression rubric to make the heterogeneity seem even greater than it is. 

There has also been a tendency to examine hormonal biological variables to the relative exclusion of psychosocial variables or even of sleep deprivation, which may mediate vulnerability. The preponderance of research suggests that direct hormone/mood relationships are not to be found. 

Does anyone have any helpful hints for those times when anxiety feels really disabling? Does anyone have any suggestions to deal with the anxiety stuff?  Or any other words of wisdom, for that matter!

Have you considered talking with a shrink about your problems with anxiety and depression?  Not that you're crazy, but anxiety and depression are something they deal with all the time, and they do have drugs that may help.

If your anxiety and depression seems to be linked to your cycle, it's probably part of PMS or PMDD (Premenstrual Dysphoria Disorder).  Some of the SSRI antidepressants have been used to help with good effect.  However, they do have that nasty sexual side effect of lowering libido and orgasmic responsiveness for some people.  And folks report that where one doesn't work for them, or has intolerable side effects, others may.  It's a crap shoot, figuring out what works for an individual.

If you don't want to go the drug route - and I don't blame you if you don't!  - meditation and deep breathing exercises may help with the anxiety, or at least help you to manage it.  For meditation, one of the best books I know of is "Minding the Body, Mending the Mind" by Joan Borysenko.  She describes her odyssey with disabling stress and anxiety, and how she came to use meditation and yoga to work her way through the problem.  And she gives several meditation and relaxation techniques that are easy to use.  It's available in paperback.

Anothe book which I think is excellent for depression is called "Feeling Good" by Dr. David Burns.  Also in paperback.

Deep breathing is useful for general relaxation, and for when you just need something to help you through a particularly anxious episode.  Here's a simple technique, using belly breathing.

Lay on your back, and put your hand on your abdomen, just below your navel.  Exhale as much air as you can through your mouth.  Now slowly, breath in through your nose by lifting your abdomen (and not your chest or shoulders).  You'll know if you're doing this right because your hand will rise as you breathe in.  Exhale slowly, and repeat a few times until you feel confident that you're breathing using your abdomen, and not your chest.  You take in a lot more air when you belly breathe.

Now for the relaxation.  Exhale as much air as you can.  Slowly, on a count of six, inhale by lifting your abdomen.  Hold for a count of four.  Exhale through your mouth to a count of eight.  You can reduce the numbers if the sequence is too long for you.  Eventually you'll be able to lengthen the sequence.

Repeat several times.  Note that you do not need to be lying down to do this exercise.  I do it sitting in the car when I'm stopped at a light or in traffic, to help "center" myself.  Or in a line at the grocery store... whenever I'm feeling a bit stressed, it helps to calm me down.

Try to focus exclusively on your breath as you do the exercise.  This helps slow down the jibber-jabber of thoughts and bring your focus into the present.

I wouldn't claim that either meditation or deep breathing will cure the anxiety; from the way you describe it, it's likely coming from some whacked out body chemistry.  But the techniques at least are often helpful in lessening momentary anxiety levels.

Hope this helps.

FurPaw