The book is written by a psychiatrist and a nurse/psychotherapist who founded a women's mental health center that incorporates into their basic treatment philosophy an understanding of how hormonal influences affect our mental wellness. Aside from a few quibbles, mostly things that have to do with the fact that the book was published a few years ago now, we think it's a tremendously sound and useful resource for us all. We're going to summarize and discuss a lot of it here, but we're still just skimming the top of the varied information presented. This review does not encompass everything of value in the book; this is merely intended to help you decide whether or not and how it might be useful for you as you explore strategies for dealing with surgical menopause.
Overall, the material in the book is excellent: content-rich, physiologically sound, simple enough for a non-professional to follow but not a simplistic "pop science" sales pitch. There's real content to take away from this book.
Their premise is that estrogen and its related ovarian hormones have profound effects upon brain function. We've more or less reviewed that basic physiologic information in a previous discussion here, so we're going to assume you've already read that. Go ahead and read it now if you haven't. But beyond that relationship, Sichel and Driscoll go further into how hormonal imbalances have a lasting effect on brain function.
According to these authors, low-level and intermittent brain dysfunction induced by hormonal imbalances, stressful episodes and genetic susceptibility are often unrecognized heralds of more serious brain dysfunction, episodes of which may later be brought out by more serious hormonal imbalance. Although a lot of their material speaks to hormonal imbalances of puberty and menstruation setting the stage for pathological levels of postpartum depression or other brain dysfunctions (worsening of OCD, bipolar disorders, etc), they also acknowledge that the hormonal dip of menopause can be a similar trigger. In other words, our experiences of hormone balance (or lack thereof) earlier in life leaves us more susceptible to dysfunctional brain episodes whenever we undergo another hormonal uproar, of which menopause is clearly a significant example.
I'm going to give a lengthy quote here of content that goes into some detail on this imprinting (or as they call it, "dysregulating") process because I feel it has real applicability to our situation when we experience sudden-onset surgical menopause:
You've been held up at knifepoint and your heart raced, your mouth became dry, and your stomach churned. You may wonder how all that happened so quickly. Your response to stress is a lightning-fast yet highly complex cascade of chemical and biological events in your brain and body.
A nucleus in your old brain [that is, closer to your brain stem, the more primitive part of your brain] called the locus ceruleus is the brain's main depot for the neurotransmitter norepinephrine. Norepinephrine activates serotonin and cortisol-releasing hormone from structures in the limbic brain, and prompts the pituitary gland to release adenocorticotropic hormone (ACTH) into the bloodstream. ACTH tells the adrenal glands, which sit atop the kidneys, to secrete cortisol and adrenaline, the body's stress hormones, which in turn send your heart pumping, your stomach churning, and so on. As complicated as this may sound, amazingly the entire circuit is activated within milliseconds.
Every part of this stress circuit (what's called the hypothalamus-pituitary-adrenal circuit or HPA) is pumping to biochemically enable you to respond. You are now primed to meet the crisis.
When the robbery is over, you may be left without your wallet, but your body will remain on alert for a while. Eventually your heart rate will slow, your breathing will return to normal, and you will feel relieved. Your brain, however, will continue to stay “armed” for a few days in response to the event. You may find that you startle easily or feel a bit anxious for a time, but ultimately your body will reregulate and resume normal functioning.
The brain has intrinsic mechanisms for switching off the stress response and allowing recovery to take place. Once the original threat is gone, adrenaline and cortisol tell the pituitary and the limbic brain (in particular the hippocampus) to stop secreting ACTH and other stress hormones. When this occurs, the locus ceruleus replenishes the depleted norepinephrine, serotonin normalizes, cortisol drops, and the HPA circuit quiets. The hyperalert state settles because the brain has biochemical mechanisms to bring it back into balance. This chemical ability to “switch off” is vital. Yet in women's brains estrogen and progesterone appear to delay the ability to switch off the stress response.
Although traumatic, fortunately the robbery doesn't limit your life and you go on without further repercussions. You cope because you have some power over your destiny. The act of willingly surrendering your wallet was a key factor in surviving the attack, and that provides you with a sense of control.
But the repetition of difficult life stressors such as these can chemically “load” the brain. For instance, suppose now that you're seventeen and your best friend is killed in a car accident. The same stress reaction that occurred during the robbery cascades through your body, but this time your anxiety persists.
It's not as easy for your cortex to process this event as it did the robbery; your brain is unable to switch off your stress-hormone response. Serotonin levels become depleted, and your HPA circuit, taking on a life of its own, goes into overdrive and stimulates the overproduction of stress hormones from the adrenal gland. As a result, no matter what you do, your cortex cannot calm the primitive limbic responses as easily as it did before. You begin to have symptoms of chemical dysregulation: difficulty sleeping, loss of appetite, problems concentrating.
Four months later you are still not feeling yourself. You eat poorly and have lost fifteen pounds. Your sleep is disturbed, you are easily irritated, and you find that it is harder to get going in the morning. It looks and sounds as though you are in a major depression. Because the onset of these feelings coincides with the death of your friend, you tell yourself that in time you will feel better and your symptoms will settle on their own.
But when they do subside and your brain has finally been able to switch off the stress response, it is not without cost to you. Your brain's biology has probably changed. The nerve cells activated by the stress of your friend's death may now be sensitized by complex factors affecting their genetic coding, so that they learn to function as if stress were present all the time.
Therefore, when another traumatic event occurs, even if it is not as severe as your friend's death, your HPA circuit may become more easily disturbed because it has already “learned” how to do so. A changed biology is now part of who you are.
[several more illustrative examples cut]
The series of stressful events we have proposed has loaded, strained, and eventually changed your brain's mood pathways. Ultimately this sensitization becomes so profound that a normal female event such as the premenstrual period can easily trigger the biochemical disruption that leads to depression. The result: You bring a chemically altered brain into your adult years and are at risk for mood and anxiety problems throughout your reproductive life.
The lessons here for us are twofold. First of all, some of the response we show to the sudden onset of surgical menopause is the result of our genetic makeup plus all of our preceding life events that may have carried out this brain "training" that can set the stage for the hormonal disruptions of menopause to have a strong effect on our brain function. Because of that, they will also influence how we deal emotionally with the physiological aftermath of the stresses and hormonal changes we encounter. And secondly, being in this state of hormonally-triggered disability further establishes it in our brains and makes it harder to recover on our own, to the point where we may need more help than simply restoring hormonal balance in order to get back out of the situation.
The book spends quite a bit of time going through the various standard psychiatric diagnoses and reviews what they look like and how their presentation may be affected by hormones. The chapter is titled “What I'm feeling has a name?” and I think that's an important statement about recognition that they are making: women are encouraged by society and medical practitioners to minimize their symptoms, accept them as “just their lot in life” or “something you'll get over” and this prevents us from recognizing mood disorders as a problem and as something we can get help for. While noting that diagnosis is the job of the mental health practitioner (and we've discussed in that referenced previous post how the very disorder we're experiencing can obscure our ability to recognize that we are ill), they go on to say:
When we listen to women's accounts of their lives, we want to know whether they've experienced these symptoms because that helps us to pinpoint the onset of the disturbance. To ascertain if our patients have a special vulnerability to hormonal change, we look for:
- evidence of puberty-related depression
- evidence of premenstrual depressive symptoms
- an adverse response to oral contraceptives
- depression or anxiety while taking fertility-enhancing drugs
- signs of illness during pregnancy, including mood changes in the first few weeks
- changes in demeanor in the last few weeks of pregnancy
- problems in the delivery or the baby's health that could contribute to mood changes later
- obsessional thoughts of harming the baby
- changes in disposition before and after taking hormone-replacement therapy
We can make use of this knowledge preoperatively, when we know we are facing surgical menopause. If we have experienced these elements of possibly hormone-related problems earlier in life, there is some risk that the hormonal events of surgical meno may be more challenging to our brain stability than they would be for another woman without hormonal instability in her past. This doesn't mean that we are going to go nuts in menopause; it may mean that we will need some extra support and preparation to face the challenges that this transition places on our whole body and in particular on our brains.
We frequently have conversations on our discussion forums about post traumatic stress syndrome and resolving trauma, but this book ties up that package even more neatly:
Stress and depression are highly interrelated. In Chapter 3 we saw how traumatic life events can permanently alter the brain's delicate mood pathways. In fact, research from laboratories all over the world have found that at least half the people who suffer from depressive disturbances also have disruptions in their stress-hormone levels. This has led to the theory that depression is one way in which the brain responds to stress.
Traumatic events evoke the stress response—that complex cascade of cortisol and other hormones—in your brain and body. In face, when the emotions are powerful and prolonged, the stress response can overwhelm your brain's self-regulatory capacity, which is usually able to counter it. Cortisol levels remain high, and for reasons that we don't yet understand, they don't shut off.
Now we dislike the term (and concept) of "crashing" as our response to ovarian loss and hormone depletion. This book uses the model of an earthquake to describe a dysregulating event, and we think this concept is a great one because it better deals with the complexity of the situation over time:
An earthquake is a perfect analogy to describe what is happening in our patients' lives. Earthquakes occur when the internal pressures on a weakened subterranean fault line become overwhelmed. To relieve the intense pressure, the fault line gives way with great force and the earthquake erupts, breaking through the earth's surface and creating chaos and destruction above. When all has settled, the fault line shifts into a new position, vulnerable to the pressures of the rock adjacent to it and in a state of altered quiescence, while the cycle of pressure builds again.
Our basic brain biochemistry can be equated with the fault line beneath the earth's crust. As the surface of the earth above the fault line appears intact, so, too, do women, as they often portray themselves as feeling "fine" even if their brains are suffering from overloading and strain. Eventually the burdens of stressful life and/or hormonal events can disrupt this delicate balance of brain biochemistry (just as the pressures created by geophysical forces affect the geologic fault line) and an emotional earthquake occurs.
A significant portion of the book details clinical examples of these "earthquakes" at different significant hormonal milestones in women's lives. One of these is obviously menopause. Naturally, the authors deal primarily with natural menopause—that remains, of course, the overwhelmingly more common experience. In relating clinical stories to do with meno, much of their attention is thus devoted to recognition of menopause. And I have to say that this section and their background on HRT use in meno is one of the weakest—because it is so dated—aspects of their whole discussion. Their material predates WHI and is only at the beginning of the present period of interest and research into human-identical HRTs and route-related effects.
More seriously and misleadingly, however, they also talk about "tolerating" use of specific hormones as an on/off function. That is, you either "tolerate" the hormone or you do not. This misses what has come to seem most critical in hormone balance: it is not the hormones themselves, for which we all have demonstrated needs, but rather the amount we have in our systems, our remaining unmet needs and how a given HRT fulfills that need that determine the reactions we observe when we take a given HRT at a given dose. This distinction is much more useful for us in functional terms than simply writing off an unpleasant response as a demonstration that we cannot use that hormone. Because of this conceptual lack in this book, we found the chapters on menopause and hormonal manipulations particularly unhelpful in terms of guidance. But then, this book is not about hormonal balance; it's about brain function and how hormonal disruptions affect it.
We did find interesting and worthwhile in those chapters the authors' discussion of how it's necessary to support both brain chemistry and hormonal needs in the process of diagnosis. In particular, they try to make a point of providing for both in search of chemical stability before making any effort to reach a psychiatric diagnosis. This, we think, speaks to our concerns when we grow frustrated with caregivers who seem to feel that once we've been given an HRT prescription, any HRT prescription, any further difficulties we experience must be due to the fact that we're depressed or just not "adapting well" to the idea of our surgical menopausal state. The authors' stance is rather in contradiction to that premise, saying that you can only diagnose underlying disorders once the immediate chemical disruptions are stabilized. Do we hear a resounding "duh!"?
So how can we use this book to help us deal with our own problems in surgical meno? First of all, understanding the physiology, understanding their earthquake model and the idea that if we have had past experiences of hormonal disruption that have challenged our equilibrium (like postpartum depressions) or a family history of similar problems, we are more liable to experience a rocky time at menopause, gives us a validation and encouragement to see this as something that can be dealt with. Not only does it exist (we're not "just" crazy!), but there are ways to deal with it.
Further, if we have a surgeon or other health professional who is dealing with our hormone balance needs by handing us an SSRI and telling us to see a shrink, we have two choices. We can look for another doctor and continue trying the d-i-y approach of seeking primary hormone balance as the solution to our problems. If we are truly having an "earthquake," this may take some time, but we may be able to persevere in waiting out our brain's slow adaption and relaxation.
Or, we can choose to support our brains as well as the rest of our bodies and look for a psychiatric practitioner or therapist who is able to deal with the complex interplay of brain and hormonal chemistry and guide us through the earthquake into the search for better stability. From what we've learned in this book, we think that women who are at high risk, because of family history or their own previous experience, might well be better served by this latter approach. As in all things, however, the choice of this professional and their expertise in dealing with this sort of practice model is important: not all mental health professionals are comfortable with this or capable of working with the hormonal interplay.
So is there a lesser level of intervention for those of us who just want to bootstrap our own way through this experience?
Yes. The other significant portion of the book involves detailing the rest of their treatment plan, the plan that they use in conjunction with drugs and therapy and the one they set up as long term maintenance for those who are no longer in active treatment. They refer to it as the "NURSE" program in an acronym based on its components:
- Nourishment and Needs: refers to eating a sound diet for health, that meets but does not exceed needs. We've discussed elsewhere how our needs and metabolism change in menopause and how important changing our dietary makeup may be in preventing menopausal weight gain. The specific dietary recommendations in the book are, alas, somewhat outdated; we recommend instead the references linked to from our bookmark account with the tag "diet" for more current information. Also in this category would come the very important nutrients—zinc, magnesium, B vitamins—that are required for HRT metabolism. This can all have significant brain impact and a certain percentage of negative HRT experiences are due not to the HRT itself but to an underlying deficit of these nutrients.
- Understanding: This is the informational component, one of the cornerstones of what we're trying to do with the Survivor's Guide. We need to know what's going on in our bodies and brains in order to best care for them and to recognize what is happening with them in surgical meno. Sometimes this understanding requires a therapist's assistance to elucidate; for many of us, self-education is adequate. But we are equipping ourselves for a healthier menopause when we understand what is going on in our bodies.
- Rest and Relaxation: In this section, the authors acknowledge the importance of sleep for good health and the way that sleep and daily hormonal cycling play into acquiring good quality rest. We know insomnia in various forms can be stimulated by hormonal imbalance, and this underscores how important unraveling those imbalances to restore good sleep, not just medicating to overwhelm our insomnia, is a key to healthy rest. They also speak to the importance of various stress-reducing techniques, such as meditation, visualization, and mindfulness, in restoring proper cognitive function after it has been disrupted and to protect it from further disruption. Developing a long range plan for relaxation is an important component of their long-term prevention strategy.
- Spirituality: as used here refers not just to religion, but to
any experiences that help you to feel uplifted and joyful. Relationships, solitude, appreciation of nature, creative endeavors, music, keeping a journal or other reflective practices, and belief in God/Goddess or a higher power can all nourish the soul. - Exercise: We've discussed the importance of exercise for regaining post-op physical endurance and strength, weight control, bone health, and metabolic risks. But exercise has also been demonstrated, over and over, to have a positive effect on brain chemistry and relief of depression. It is turning out to be one of the single most important facets of healthy living.
Now if you've read along and are thinking "gee, none of that is really very radical," then you're right. As a treatment approach, it's the sort of vanilla "take care of yourself" stuff we get in different forms from a variety of sources. But, hey, it works. It really works for real physiological reasons. And it's as important for maintaining brain health in menopause as drugs like SSRIs or other antidepressants can be. Just because these are not strange and exotic measures, that does not lessen their potency. Even alone, for those who cannot or choose not to use hormones to deal with surgical menopause, they are a cornerstone of coping strategies. These are real tools and have real effects. Healthy living makes you healthier—who'd have thought?
There's obviously a great deal of information in this book. We've found it very interesting in the development of this topic from a direction different from the more purely hormonal one we usually discuss. Much of our focus has been on the disruptions of imbalanced hormones and the stress of the surgical menopausal transition and the effects these have on our brain and body, with the implicit understanding that if these hormones are brought back to a more functionally-appropriate level, other signs of this disruption will be self-correcting and alleviated by hormonal balance. But this book's focus on mental illness brings the suggestion that just making hormones "right" may not be enough to reverse a situation of illness, and that ultimate wellness may additionally require specific assistance to the brain to enhance healing.
This takes our discussions a needed step further and casts light on those situations where even rough balance seems especially slow and difficult to achieve and maintain. We've talked about stress in general, but this brings it home and provides the insight into some of the ways stress and hormones really fit into the whole picture: not only do our stressed adrenal glands have trouble managing our hormone burdens, but our brains are so dysregulated by stress that we cannot make good use of even the hormones we have. And it provides important validation and encouragement, when hormones simply are not moving the situation along well, for reaching out to another variety of approach in enhancing recovery and wellness.