Introduction
This is not so much a story about how an SMI peer advocate became a psychiatric nurse practitioner – that’s another book- but about how close menopause came to derailing that dream. I’ve been diagnosed with depression, Bipolar I (with peripartum onset), OCD and GAD and PTSD. I wasn’t aware I had PME until I was about 30, partly because my cycles were very irregular and partly because the internet was very new, and apps were relatively new (I didn’t have a smartphone until 2015).
I identify as having Broader Autism Phenotype, with all 4 of my children diagnosed with ASD (in all 3 levels). The people who know me the best think I have ADHD. But my children with Level 1 ASD have had ADHD ruled out, with their symptoms ascribed to anxiety or trauma. So I’m less certain about the ADHD.
In 2021 I had a hysterectomy to treat severe, chronic anemia but still had some PME because I still had ovaries. I didn’t think I would need to worry about menopause. My low iron had been eroding my resilience and I had twice instigated divorce proceedings from my husband of about 30 years, because I was worn out having a few special needs kids, working full time as a psych nurse and being in grad school. I hadn’t felt like I could handle marriage as well without some boundary clarifications.
In 2022, it was the start of my final semester for NP school. I started having trouble sleeping, and apparent irritable bowel syndrome didn’t seem to respond to lactose restriction or moderating fat (in case it was my gall bladder). I couldn’t stop worrying about current events. It was like I was in a fishbowl of anxiety, unable to understand why people around me weren’t paralyzed by the state of the world (mostly, climate at that time). I was subsisting on homemade oat bars that I could force myself to eat. A lifetime teetotaller, I started fantasizing about trying alcohol. I had my husband hide the prescription of opiates I had from my last root canal. I requested a hiatus from school.
I had hot flashes now and then for several years. I had thought them a nuisance when they hit 4 times a day 2020-2021, but in 2022 they started happening several times each hour. I’d had hormones labs every couple years since I was 45, but the levels were always “in range” (the ranges are ludicrously broad because they’re female hormones). But this time the labs finally came back at virtual zeros. The day I got this news, I was as relieved as the day I learned Bin Laden was dealt with. There was something measurable wrong with my body! It didn’t explain everything, and I wasn’t ready to try and go back to school. Because I’d had a hysterectomy, I was able to take estradiol and “just keep swimming”. But I wasn’t ready to resume my grad program.
I worked nights and a few months later another nurse got talking about a relative they knew who had been diagnosed with bipolar and was now pregnant. They were worried about the relative’s mental health going through birth. I talked a little about my own experience with postpartum mania in 1992, and also about a newer treatment I’d heard of for postpartum depression called allopregnanolone. It was highly effective and a naturally circulating substance. IV administration was highly effective but could cause sudden sedation, so it had to be administered in a nurse managed setting. As I researched allopregnanolone, I began to realize why my biochemical menopause had been so rough.
The people who brought allopregnanolone to the market sought an FDA approval as a treatment for MDD, but it was declined due to being too habit forming, like benzodiazepines. I suddenly saw the anxious distress of the previous autumn in a new light. The restlessness, nausea, diarrhea, irritability, cognitive distortions, and even the temperature dysregulation are symptoms we scale for alcohol withdrawal.
Menopause is a natural process, like pregnancy or menstruation, and there are hazards in medicalizing it. But the implications for the 20% of people with clinical mental disorders needs to be better understood, to prevent suicide, divorce, career disasters and addiction. Allopregnanolone is a sedative mood stabilizer, similar to agents frequently used in alcohol detox, most of which are scheduled as controlled substances. Bipolar and Schizophrenia both have increased onset in the decade of menopause.
People who don’t have mental health issues can weather menopause through what I’d call the standard of care: prioritize sleep, eat well, move more, mindfulness, and connect with loved ones. Lifestyle improvement. Supposedly, for most people, this will work. These match pretty well with psychiatric hospital discharge recommendations (in addition to taking your medication and following up with doctor/therapist). The symptoms and role changes associated with menopause make most of these more difficult.
Even where standard of care is applicable, it is important to remember that trying to implement the entire list all at once is not sustainable. Rather, each habit needs to be explored, adopted, and with repetition, ingrained. The Gordon/Burch change model reflects these stages
| Incompetent | Competent | |
| Conscious | Consciously incompetent | Consciously competent |
| Unconscious | Unconsciously incompetent | Unconsciously competent |
Neurodivergent Menopause 