Prof Jayashri Kulkarni: Mental Health and Menopause

[01:44] Sonya: I'm delighted to have you on their menopause today. I'd love to have a conversation with you around your research and findings into depression as a by-product of perimenopause and menopause.

[01:59] Prof Kulkarni: Yes. So I've been working for decades now on the whole area of hormones, go, natal hormones, and their impact on mental health in women. And there are several key areas or times in a woman's life when there are hormone changes and big fluctuations that then result in depression, anxiety, and even psychosis. So menopause is probably one of the huge hormone transitions that occurs in a woman's life. And over time, what I've been working on and researching is the relationship of depression in the perimenopause, which is the time leading into the actual change in reproductive and fertility status for women, and the causality of the hormonal fluctuations and mental health issues. So I'm not sure if your listeners are aware, but depression in the 42 to 52 year age group of women in Australia is huge. It is about four to five times more than depression in other age groups for women and for men. And I don't think it's a coincidence that, in fact, this sudden rise in depression, it has to be related to a whole range of factors, no doubt. But I think the hormone shifts because that's right in the space of perimenopause is a clearly important one. Of course, middle aged women have a lot on their plates they've got to deal with, so I wouldn't be saying it's just one thing, and nor do I want to medicalize menopause, because millions of women, of course, sail through it without any problem at all. I see, however, in my clinic and my hospital work, women who really struggle with major depressive illnesses or anxiety disorders that robs them of the quality of life that they're entitled to. And it has such big impacts on our community at large because middle aged women are often the linchpins for adolescent children raising them, for taking care of their elderly parents, for being managers in the workplace, for maintaining networks and relationships with friendships, and of course, their own intimate partnerships and so on. So there's a lot going on.

[04:28] Sonya: There is a lot going on, yeah.

[04:30] Prof Kulkarni: I think we've got to get on top of this. And there's definitely a correlation between gonadal hormones, estrogen, progesterone, testosterone, and the fluctuations of those hormones and what it does in the brain.

[04:42] Sonya: So what led you to move into this field of psychiatry, is that correct?

[04:48] Prof Kulkarni: Yes. I'm a psychiatrist, so I did medicine first. I worked in emergency medicine for a while, and then I got interested in understanding the whole person story. And I found that it was something that fascinated me. Why women? Well, I worked in a big mental health asylum, as they used to be, those big, awful, terrible hospitals out on the outskirts of town and with big walls. And I was assigned the old fashioned women's ward, which was right out the back. Horrible Dickensian kind of setting. But there I met a lot of women who had been unfortunately admitted to psychiatric hospital for years and years, and a lot of them told me their stories. In fact, I'll never forget the words that one patient said, which was, it's my hormones, doc. I was okay until I had children. And she told me her story about the last time she had a child, and the child was now twelve, and she had developed a full blown postnatal or post childbirth psychosis. That was her story. There were other women who told me their stories of how they were fine, fine, fine, and then bang, in their mid 40s, they suddenly developed full blown depressive illness or full blown psychotic illness. And I thought, look, it's not a coincidence. There's something going on here. And that set me off into thinking about the genetic hormones and then looking into animal studies, clinical studies, epidemiology studies to understand more about that. And that's what I've spent the decades doing. And I'm still disappointed that I have some colleagues overseas, but there's not like an army of researchers in this field, and nor are there buckets of gold being poured into funding this research either. So we're struggling. And the first step was to even get people to listen to the connection. It's interesting. Women themselves intuitively understand the connection between gonadal hormones and brain things like depression and anxiety. But health professionals particularly, I'm sad to say, mental health professionals don't get it. They often work in a very narrow field, which is to just look at the mental health and the mental state and not worry so much about what's going on in the body. And then you have the other side of the coin, which is in the past gynaecologists and endocrinologists, their physicians would not look at the mental health side of things. They'd look just completely at hormone or uterus and ovaries. It's almost like, hey guys, let's break down the silos, because the woman patient is a whole woman and she's got issues that she wants sorted in mind and body. So trying to think like that and look, there's some silver lining in all of this. And that is that the younger generation doctors are much more likely to expand their horizons and think a bit more about the whole person that's in front of them. So I do encourage that. But that was our first step was to try and break down silos and get each other's disciplines to look at, well, hang on, it's not just the Granada hormones effect below the waist. There's a big effect above the waist and in the brain. Really important stuff was going on. So that was first step.

[08:15] Sonya: Amazing. And then so at what point did you move into the research side of things?

[08:21] Prof Kulkarni: I moved into the research fairly quickly, and I've always been in research and clinical work side by side. And I find that very rewarding because it means that I can ask the questions in a research sense that are relevant and vital to the women patients I'm seeing, and their families will raise issues and so on. I think it keeps us grounded as researchers in a reality base. And then the things we discover in research, we can offer back fairly quickly as treatments. So. For example. In this area. The more and more and more research I did. The more obvious it became that in a certain number of women. Not all women who were approaching menopause in their mid 40s. Who suddenly developed depression or some other mental health problem. Or who had a relapse of a perfectly previously well controlled condition. That these two groups of women were now experiencing a new sort of depression. Menopausal depression. And so looking at research studies, we conducted clinical trials to understand whether we could help this condition with particularly different sorts of hormone strategies. And we have published a lot on these. But then in our clinic, we could offer that back because we weren't doing anything that was like a drug XYZ that isn't even out there. We're talking about HRT or HT as it's now called, which is hormone treatment that is widely available and we know about the side effects and so on. But it was offering it to women as a treatment for depression rather than hot flushes, which everybody associates with menopause. But hot flushes are kind of late in the piece. They're almost the last lot of symptoms. So stopping periods or having erratic periods. And hot flushes is about eight years into a process. Menopause is about 1012 years of a process.

[10:25] Sonya: Yeah. So how often do you believe that women with mental health issues, which can be attributed to perimenopause, go undiagnosed?

[10:36] Prof Kulkarni: Look, unfortunately, I think it's very, very, very common. I'd say that's the more common situation than somebody actually going, maybe it's menopause. So because I think we're still kind of siloing mental health and physical health, which is terrible, people with mental health, women with mental health issues, particularly if they got a major depressive condition, the pattern of their presentation will be that she'll sort of start to develop sadness intermittently, not all the time. And this is the other problem. It's cyclical. It doesn't just come on and stay on. There's no cyclical pattern.

[11:19] Sonya: And is that linked to the cyclical changes of the hormones?

[11:23] Prof Kulkarni: Yes, but the problem is, once it's a cyclical pattern, then she's got to contend with a few different things. One is that some bright spark will diagnose bipolar disorder, which is just wrong. And unfortunately, if she goes down that path, she'll get a lot of medications that may not hit the mark and give her a lot of side effects too. That's first problem. Second problem is sometimes her validity or whether she's really got something, gets questioned because, hang on. How come you are such a blubbering, dreadful mess today that you can't even get out of bed? And yet last week you were partying like there's no tomorrow. And there's a sort of sense of, is this real? Is this entity real, or is she putting it on for attention? Et cetera, et cetera.

[12:06] Sonya: So there's that horrible diminishing, isn't it, of what she's experiencing?

[12:11] Prof Kulkarni: And that's another side that many women talk about that they almost like they're suffering, but then they have to convince people that they're suffering, which is really not on. And then the third part of it is that it's a stuttering but worsening condition. And so the problem is that many health care practitioners will send the patient to psychiatrists or psychologists. And of course, you dig enough, you'll find stuff. So here she is talking about the ratty adolescence or the fact that her job isn't all that satisfying or that her 20 year relationship isn't as exciting as it was and so on. And then it becomes that sort of issue. That's where the problem is, et cetera, et cetera. Of course, it's helpful if she's getting supportive psychotherapy to help prop her up when she downtimes. Everyone can do with that, but it's not the answer. And then, of course, the antidepressants are used, and they're used very quickly in this age group, they're used very quickly. And unfortunately, I would estimate that there's a bit of a response to the antidepressant, but not a great response. So most women I see tell me things like, oh, I got about 30% better. And then when people sense that there's some improvement, they'll go, oh, yes, well, we just got to keep trying with.

[13:38] Sonya: A bigger dose, up the dose, or.

[13:41] Prof Kulkarni: Well I’ll add in another one, or we'll add in a mood stabilizer, we'll add in an antipsychotic and on it goes. And so you can see that this is where you ask the question about diagnosis. And I think the problem is that everyone was more comfortable with a major depressive episode or major depressive illness diagnosis. And even to say things like menopause or depression is like, what are you talking about? What do you mean menopausal depression? There's no such thing. And I've had that comment come back and back and back at me, whereas the women themselves go, oh, you're right, you're right. I haven't thought this before. There's nothing new. That's the other thing to look for. What else is going on in this woman's life that's new? Because I take the opposite view. I reckon you get to 45 and you got a pretty good handle on things by that point.

[14:34] Sonya: Very true.

[14:36] Prof Kulkarni: Pretty good at juggling this, that, and the other thing. Unless, of course, look, things can go horribly wrong. People around you can die, you can get diagnosed with some terrible disease, or you can lose your job or stuff can happen. But if stuff hasn't happened and she suddenly develops a depression, then you've got to re question the concept of is this major depressive disorder or is this the X factor, which is the hormone factor? Again, when people come to see me, I have a biased group because I'm seeing women who've already tried other stuff, and so I'm very keen for them to try as long as they are physically healthy, I'm very keen for them to try hormone strategy. And I would say eight times out of ten we get people better because it's been the X factor that's been missed all along.

[15:28] Sonya: Yeah, amazing. And so for women who and I fall into this category, who have not taken or been able to use a hormone treatment, I had a breast cancer diagnosis which has precluded me from hormone treatments. How can they be helped in these situations?

[15:47] Prof Kulkarni: So I think there's a lot of things that happen, though, and it's almost like in the validation of her observations, as in I was okay until the menopause hit, or I was okay until an artificial menopause happened, which sometimes happens with breast cancer treatment and so on. But it's even the knowledge for her to link the biological factor of the hormone fluctuations with the depression, it can sometimes be really empowering in itself because I find that many women are sort of self flagellating whipping themselves to say, what did I do wrong? What haven't I done? It's my fault. I've done this wrong, I've done that wrong. That's a horrible thing to be feeling that you're inadequate and also to have other people kind of say, yeah, you're right, you got depressed because, I don't know, you don't have enough moral fiber or resilience or something. So there's all of that as well as I think in the non response to an antidepressant, doctors get very frustrated and it's like, well, you're not trying to get better. The antidepressant is not working because you are not taking the right dose or you're mucking around with it or something. And so all of these things improve with a simple honest to goodness discussion about what have you observed, what are you like normally and what have you noticed that's gone wrong or different? And let's think about menopause in that context. There are other treatments that are useful. It's not all serotonin because that's what most of the antidepressants were working on, that chemistry. It's really much more complicated than just neurochemistry. It's neuro circuitry, it's neuro hormonal impact, it's the whole lot. So there are other treatments that are offered, but I think step one is validation, step two is revalidation and then you're working together to approach this problem. And sometimes I've had people say things like, well, if I try a soy rich diet, is that going to be helpful? Can't hurt. You might have to eat a truckload.

[17:59] Sonya: Of toast, it might be a bit sick of soy by the end of it.

[18:04] Prof Kulkarni: Again, I think we need all guns blazing to help each person and help each person differently as well. I found that in the case of the woman who cannot have hormone strategies because of whatever reasons or she doesn't want to, then you can come up with healthy lifestyle stuff that might suit. So there are some various yoga things there's. Mindfulness be careful of some of the hormone over the countess things because some of them can also be bad in terms of estrogen and so on. But look, there's lots of different things and then even thinking again about sometimes we go back and we do the early life story, we discover that in fact, this poor woman has had a really shocking run right from day dot with terribly abusive, stern, harsh, critical parenting or lack of parenting or somebody died or there was some separation, just awful stuff. And that can have an impact on brain biochemistry. And so often the women who have that kind of background are more vulnerable to a hormone induced depression. So these are the women who are more likely to get pre menstrual depression, postnatal depression and then finally perimenopausal depression. And that's important to understand as well because if you work with the woman in that kind of context, then you can offer her trauma therapy, which is really good. And there are some different trauma therapies that are available, eye movement, Desensitization and reprocessing type therapy. Or you can go down the pathway of different medications that are working on the glutamate system, which is not serotonin but different system. And we think that that's much more likely to hit the target for someone who's got a trauma background and then got depressed again of course, we combine different things, and if she's happy to have a hormone strategy, then we'll put that in there as well. But I just think it always comes back to why is this person struggling with depression or whatever it is now? What has brought her to this place? And I find that she holds the answers. And I always encourage people to give me their hypotheses and their theories as to why do you think this has happened to you, is the answer there?

[20:32] Sonya: Yeah, I love that. And it's that real approach of curiosity and leaning into our natural instincts.

[20:39] Prof Kulkarni: Yes. And I find that many women have thought it all out, and that's what we do. Yes, absolutely. Read about it, talk to friends about it, but then not uncommonly have had their ideas kind of knocked down, and so she's often hesitant to say.

[21:01] Sonya: So that leads me to a question that came to mind while you were talking, which is for a woman who perhaps isn't receiving the validation from whether it's her GP or the practitioner that she's seeing at the time, what's your advice for what her next steps are?

[21:19] Prof Kulkarni: So I think we're trying to get the word out there. And programs like this is very important because you reach a large number of women in the community. And so I think it's important for women to arm themselves with resources like this, this podcast, like other information that's out there, to be able to discuss it with their doctors, to say, Look, I think I have if it's menopause depression, I think I have menopausal depression. And I'd really like to try a new treatment option. And here's the stuff I've read or heard about that might be helpful. With hormone treatment for depression, what do you think? Most doctors, I think, would be, and we're talking primary healthcare practitioners I think most primary healthcare practitioners, if they're any good and if they've got confidence of their patient, they'd be happy to sit there and have that collaborative care go on. I think the problem comes when the doctor doesn't know the patient very well and they're rushing and they've got a room full of covert patients or whatever else is going on. That's when you get that rapid fire sort of prescription without too much else being considered. I reckon we got to educate women just like you're doing in the community, because most breakthroughs and developments in medicine have a twofold approach. One is that there's money put into research in it, and so you get the vaccines, you get the drugs, you get this and that. But then the other side of it is also community pressure. So you have an educated public who demand better, and that also is really critical. So I think it's a two pronged approach.

[23:00] Sonya: Right, well, I'm pleased to be able to feel like I'm a part of that, which is my purpose in creating this podcast, so that validation from you absolutely nailed it for me. Thank you. Now, I have heard you talk before about the correlation between grief and depression for women, particularly those that have experienced an early menopause. Would you mind sharing a little bit about that for us?

[23:24] Prof Kulkarni: Yeah. So again, the complexity of depression is a huge one. It's not just a single thing for every person, it's not a single set of symptoms, it's very broad and there's a spectrum of mild right through to completely debilitating depression with many, many causes. And what I find is the woman who has premature ovarian failure, for example, even in the mid thirty s or somewhere, and there or even a little older, but if she's caught by surprise by it all, then you have this sort of suddenly something has happened and she is hit by a loss. It's not a process, a natural process, it's not a slow process, it can be a sudden process which is sort of fertile today infertile next week, that sort of rapidity of onset which takes away her decision making about childbearing. And many times these days we have the situation where women have a belief that they've got a long fertility life ahead of them. Particularly when you talk to young women in their 20s. Well. Use is sort of about the optimism that they've always got lots of time and they're bulletproof and this is one area and so unfortunately. When it does happen that it's taken out of her control. She then has to struggle with the loss of fertility and it may be the sort of thing that leads to a grief response and I've seen that happen for women. Unfortunately. When they realize that they can't have children. And it's almost the woman who had been lukewarm about it beforehand, like it wasn't the person who was plucky from Mage 22 onwards, it's often the woman who was like yeah, sure, one day, maybe yes, maybe no going to find Mr ryan, all that sort of stuff, but then this can come as the bolt out of the blue. Then you've got to deal with picking up the pieces and a grief response. It also happens in women who have unexpectedly developed a physical condition like the cancers of various types, which affects the capacity for fertility or for ongoing if they have chemotherapy, for example, then there are procedures for egg harvesting and so on. But all of a sudden you're asking this person, who may never have worried, thought about fertility at all, to put her head into all of that and that's future planning in a big way.

[26:13] Sonya: And that's also whilst suffering with the trauma of the diagnosis.

[26:17] Prof Kulkarni: Yes, there's a hell of a lot that's asked of this person. And then if she gets the anti estrogen treatment, so very important breast cancer treatments, but they can be anti estrogen because it's an estrogen dependent tumor that then knocks down natural antidepressant estrogen has a natural antidepressant effect in the brain, it also has an antipsychotic effect, it's good for mental health and suddenly this gets removed. So in the state of all of the stuff that's hitting this poor woman, you also then have the biological X factor of losing that hormone. That is the good hormone. So a lot goes on. But again, this is about the consideration of mental health issues for women with hormone. Other issues, either natural menopause or early menopause or induced menopause because of treatment. And I think in the past everyone, I mean, of course, saving this person's life, getting rid of cancer, absolute priority number one, two and three, no doubt. But there are other things that impact on quality of life as well. And at some point all of that needs to come together.

[27:34] Sonya: And sadly, my experience through that was a considerable lack of support around mental health and preparation for what an induced menopause meant.

[27:44] Prof Kulkarni: Yes, so you see, again, this is what I'm saying, that we need to get medicine back on the rails for looking at the whole woman rather than the splintering off into very good expertise. And I wish you all the best for a very long and healthy, happy life. And again, back in my days as a medical student, which is ancient history now, but the prognosis was nowhere near as good for any of the cancers. So a tick well done to the ongoing.

[28:16] Sonya: Yes, absolutely, 100%.

[28:18] Prof Kulkarni: But let's now bring back some of the other stuff too so we can look at the whole person and have good collaborative care to find out what it is that she needs and she wants and put her right in the middle of all of this rather than the kind of okay, do this, do this.

[28:40] Sonya: I agree. I think for me, I felt very strongly that the posttreatment care is a lot of work that can be done there to support women more. The other area that if you've got a moment, I really wanted to touch on was do you see mental health issues arising more frequently for women that are managing menopause in the workplace? We touched on the crazy busy lives that women have, but for many work is a big part of that.

[29:06] Prof Kulkarni: Absolutely. Gosh, have you got 5 hours? It's a really big issue. And here's where I get into trouble because we have to recognize that part of the menopause depressive process is that women experience greater levels of anxiety and they have a different quality of the depression. This isn't the same depression as happens in younger women or in men. It's not that the person is always crying and bedridden and can't do anything and they're just kind of moral bummed with the depression sometimes. And a lot of the time the key symptoms can be anger and irritation and hostility and just grumpy old bag behavior. And that's the problem in the workplace, that she can be seen as just what the hell is wrong with her? She's just a grumpy old bag. But what's actually happening is that the challenges in the workplace, the stresses are mounting up and she's responding by being angry and hostile in an atypical way. Normally she's probably got a whole range of skills that she's built up on how to manage people and deal with people and so on, but she's feeling dreadful and it's coming out as just biting people's heads off. And we see this in the workplace and we also see it at home in terms of relationships with adolescent kids and intimate partners and so on. And unfortunately, a lot of marriages go to pot at this point and people also lose colleagues in the workplace because everyone is busy, they don't have time to stop and say, what is wrong with you? And there's no hot flushes to give it away. It's easy once the hot flushes happen. But this is all happening four to five years before the hot flushes. So again. It takes quite a bit of insight and knowledge for either her or for people who know and love her to say. You're not yourself. Something weird is going on here. And for the penny to drop that this is the beginning of the menopause process in the brain. But in the workplace. Yes. It does create this workplace tension and sometimes that plays out in horrible HR issues and so on. Where either she is charged with bullying or she is the victim of bullying or harassment or a whole range of different things can go on. There's also the issue of people who do night shift or work different hours. So nursing, for example, would be a profession where I do see a lot of the time quite senior nurses as they're going into the menopause of depression and because their sleep cycle is disturbed. And that's another brain hormone function of estrogen and progesterone to regulate sleep. So that's becoming disturbed. So she's not getting enough sleep, which is already making her irritable and hostile, and then you throw in weird rosters and night shifts and whatever else, and that just makes it all much worse. Sleep deprivation is just terrible for mood, so that's another feature of it all. In fact, in the beginning people said to me, maybe the whole menopause depression is really created because women have got hot flushes and they're not sleeping as well. And certainly we think it's a contributing factor, but it's not the whole factor because they can actually get this well before that. So sleep disturbance is the other role. And then in the workplace, of course, we do note that there are increasing challenges. Sometimes we also see part of the symptoms of menopause or depression are cognitive changes. So people describe difficulties with memory yes, word finding with concentration, and they just say things like, I just can't learn new stuff like I used to. And I know that people are. Laughing at me behind my back at work. And there's example after example of when a new computer program is introduced in the workplace and she's the manager and says, I just can't get my head around it. I don't know what's wrong with me. Am I dementing? That's a common question.

[33:34] Sonya: Yeah. I believe that there's often a fear for women, that it's actually symptoms of an early onset of dementia, and that actually I've heard stories where that's actually held women back from seeking support because they are so fearful of that diagnosis.

[33:52] Prof Kulkarni: Absolutely. And I think it's also the rapidity of the cognitive changes that can happen. So this is very classic stories. I came out of the shopping center and I could not find my car. I cannot remember where I parked it. Losing things and then worse is when the woman says, and my mother developed Alzheimer's, albeit when she was 80 something, but it still becomes this fear, as you said, and it does stop some women from getting help because they're scared that someone's going to say, no, no, you actually do have dementia. Get out of the workplace. That's it for you. There's a lot of trepidation about even that's an extreme part, but even the minor parts about being found out to not be as good. Many women have had this fraud syndrome. Even the most talented, most skilled women will often say, I only got the job because other people didn't apply or because they felt sorry for me. Oh, all sorts of rubbish. But then you add in the menopausal cognitive changes and all of a sudden this person who might be a senior manager feels like she's just lost it. She can't multitask the seven things that she used to do quite comfortably, to only do three or four things now. And that makes her feel like she's just not good enough in the workplace. So that leads to a whole bunch of actions that, depending on her personality, she can either take it inwards and become introverted and sort of disappear into herself, or she can snap more people's heads off and make out that it's their fault and so on and so on. So lots and lots go on. And it's a twelve to 15 year process. It's not small. Average is about eight years. So it's not a small process. And the more we learn about it, the better we'll all be at understanding ourselves, but understanding our female colleagues and female family members and helping, because it's not the constant sort of decline of anything. There are solutions to all of these issues, but the first step is recognizing it, and then things can be done to help her be herself and enjoy herself, too.

[36:16] Sonya: Yes. Super important, isn't it? Finding that joy in life again.

[36:20] Prof Kulkarni: Absolutely. We all deserve the right to be joyful.

[36:26] Sonya: Yeah. And I feel, particularly given everything we've been through in the last couple of years, I do feel that there has been a lot of people that have lost touch with joy in life.

[36:36] Prof Kulkarni: Yes. And so, again, we need to be mindful of the fact that if you lost joy because you're depressed, then it's a symptom of depression. You'll get it back, but you need to put it in the context that it's a symptom of depression. It's not that you have to go and make huge life changes, but understanding it is really critical.

[37:00] Sonya: Yeah, that's an important tip. So, to wrap things up today, what is the biggest piece of information that you would like to share with women listening today?

[37:12] Prof Kulkarni: So what I'd like to share is that hormones have a big impact on mental health, and it is real. So it is not just something that you're making up. It's not an excuse for bad behavior or any of the labels that we've had. It is real, but there are solutions. And it's always important, I think, for every woman to back herself. She knows what is going on. For her, I really think we call it the old fashioned women's intuition, whatever it is. But most women have got pretty good insight into their own bodies and minds. And so it's really important to back yourself. And if you think there's something going on that is unusual for you, that is really making you depressed and you think it's your hormones, then tell your doctor. And don't just keep it hidden. Back yourself all the way, because there are solutions out there and you keep going until you find the treatment that helps you and fixes the problems for you, by you.

[38:15] Sonya: Yeah, I think that's really important, that message of keeping going as well, because I do hear stories from women who find that they're not as supported by their primary healthcare as they would like to be, for all those reasons that we talked about earlier. But it is important that if you do find yourself in that place, to take another step, to continue to kind of keep knocking at that door until you do find somebody that can support you.

[38:40] Prof Kulkarni: Absolutely.

[38:41] Sonya: Professor Kulkarni, thank you so much for your time today.

[38:45] Prof Kulkarni: My pleasure. Thanks for doing this program.