# Motivation and emotion/Book/2024/Perimenopause and emotion regulation

* Multimedia presentation (3 min)

## Overview

* Case study:
* Maggie, 46, entered the perimenopausal stage eight months ago. During the past eight months, she has found that her mood often changes quickly throughout the day, and she rapidly experiences feelings of anger and irritation that are situationally disproportionate. This morning Maggie’s son, Christopher, informed her that he had misplaced a permission slip she had signed and enveloped for his year 9 excursion. Quickly, Maggie shifted from enjoying her calm morning to raising her voice at Christopher to the point that he became upset, before admonishing his reaction and banishing him to his room.
* What caused Maggie to act this way towards Christopher?
Perimenopause is a natural and inevitable condition that all biological women will experience in their lifetime. Perimenopause refers to the period before menopause (see Figure 1), during which the levels of estrogen and progesterone fluctuate, resulting in an array of other symptoms; physical, mental and emotional. Once the menstrual cycle has been absent for 12 consecutive months, women officially reach the menopause stage (Troìa et al., 2020).
As a result of fluctuating and changing hormones during the perimenopausal stage, women often experience mental health issues, persistent mood changes and emotional dysregulation. Symptoms of depression and anxiety increase during the perimenopausal period, alongside aggravated mood changes (Troìa et al., 2020), which can profoundly negatively impact emotion regulation abilities (D’Avanzato et al., 2013).
Emotion regulation, an individual's ability to effectively manage their emotions and respond to emotional experiences, is profoundly impacted by changing hormone levels and life circumstances (Gross, 2015). Most often, those who experience emotional dysregulation are unaware that their actions are disproportionate to the interactions in which they are responding, meaning that interpersonal relationships suffer as individuals struggle to control their reactions. Emotion regulation abilities are greatly impacted by changes in ovarian hormones specific to the beginning of menopause (Berent-Spillson et al., 2017).
* Focus questions:
* What is perimenopause?
* What are the theoretical underpinnings of perimenopause and emotions?
* How do fluctuating ovarian hormones throughout perimenopause influence emotion regulation throughout the brain?
* How can emotional dysregulation be managed throughout the perimenopausal period?

## Theoretical underpinnings of perimenopause and emotion regulation

Neurological and biological theories can be utilised to explain the basis of how changing hormones and brain mechanisms during the perimenopausal period influence emotion regulation and expression. Changes throughout the endocrine and central nervous system during perimenopause, alongside various vasomotor symptoms, contribute to the negative affect and emotionality experienced by women during this period (Zhang et al., 2023).

### Somatic marker hypothesis

The somatic marker hypothesis, developed by Damasio et al. (1996), states that unconscious emotion-related signals (somatic markers) are changes in the visceral (internal) state of the body that assist cognitive processes in decision-making and reactivity. According to the theory, these visceral responses are a factor within the extensive emotion response system (see Figure 2) that also includes changes within the endocrine and central nervous systems that influence the processing of environmental stimuli (Damasio, 1996). Changes in the internal state, including changes in heart rate and blood pressure, can unconsciously bias individual behaviour (Reimann & Bechara, 2010). According to the theory, the brain, specifically the prefrontal cortex, translates the sensory properties of external stimuli into changes in the internal bodily state that influence emotional reactions, affect and decision-making (Reimann & Bechara, 2010).
These changes throughout the endocrine and central nervous system can be directly related to perimenopause. Throughout the perimenopausal period, changes are caused by the fluctuating levels of estrogen and progesterone (Duralde et al., 2023). These hormone changes in the endocrine system directly influence brain activity and reactivity, whilst also causing a range of vasomotor symptoms, including hot flashes and increased heart rate (Troìa et al., 2020). According to the somatic marker hypothesis, the signals conveyed to the brain by unconscious somatic markers regarding external stimuli will be altered by the changing ovarian hormones, impacting neurological emotional responses (Reimann & Bechara, 2010).

### James-Lange theory

According to the James-Lange theory, environmental stimuli cause emotions directly related to physical changes such as heart palpitations, shortness of breath, anxiety, and changes in facial expressions (Stanojlović et al., 2021). The theory posits that emotions are manifested via complex physiological changes and altered behaviour (Stanojlović et al., 2021). Simply put, emotions occur as the neurological system perceives physical reactions to stimuli, and the individual acts according to these perceptions (see Figure 3).
Throughout the perimenopausal period, decreased estrogen levels are correlated with oxidative stress and inflammation of the vascular wall, causing a series of physiological perimenopausal symptoms that can extrapolate mental and emotional stress (Zhang et al., 2023). Related to the James-Lange theory, the vasomotor symptoms of perimenopause may result in increased sensitivity to environmental stimuli and stress, as the body is already experiencing symptoms that often trigger our fight-or-flight response (Stanojlović et al., 2021). Consequently, perimenopause influences the affective system alongside the vasomotor system, meaning that women also struggle with emotional differentiation within themselves and others, and regulation of their emotional responses (Mueller et al., 2024), which can be extrapolated by the complex physiological changes described by the James-Lange theory.

## Hormone changes, the brain and emotional dysregulation

Perimenopause is characterised by fluctuating levels of two ovarian hormones; estrogen and progesterone. The changes in these two fundamental hormones have profound influences on women during the perimenopausal stage across the brain and nervous system (see Table 1). Much of the research into the influence of ovarian hormones on brain functioning throughout perimenopause remains ambiguous (Beltz & Moser, 2019), so continuing research into this area to assess possible medical treatments in the future is vital.
Table 1. Brain regions and their influence on emotions :
| Brain region | Role in emotion | Relationship to ovarian hormones |
| Hypothalamic-pituitary-gonadal (HPG) Axis | Multilevel hormonal system in the brain. Influences mood and emotion regulation via hormone modulation. | Regulates estrogen and progesterone levels. |
| Amygdala | Part of the corticolimbal network that is responsible for learning and memory. Regulates cognitive and mood functioning. | An abundance of progesterone receptors present in the amygdala. Fluctuating estrogen levels impact amygdala regulation over mood and cognition. |
| Prefrontal cortex (PFC) | Involved in emotional and cognitive regulation. Uses emotional information in decision-making. | Contains an abundance of estrogen and progesterone receptors that react to hormone changes. Estrogen supports neuroplasticity throughout the PFC. |
| Hippocampus | Links between short-term and long-term memory. Helps to regulate cognitive and mood functioning. Vital to the stress response. | Low estrogen levels lead to decreased hippocampal activity. Progesterone aids in the hippocampal function of recognising emotions and emotional memories. |

### Hypothalamic-pituitary-gonadal axis

Fluctuating female sex hormones occur throughout the perimenopausal period, which involves changes in estrogen and progesterone levels due to differences in regulation throughout the HPG axis (Sharma et al., 2021). These fluctuating hormones modulate emotion and memory processing and regulation. The HPG axis is a multilevel hormonal system that regulates the production of estrogen and progesterone in women through multiple feedback mechanisms at the ovary, pituitary, and brain (Sharma et al., 2021). This irregularity of ovarian hormones during the perimenopausal period creates an unpredictable environment throughout the cognitive, mood and emotion regulation systems that are influenced by ovarian hormones (Albert & Newhouse, 2019).

### Neurons and neurotransmitters

Ovarian hormones are vital for maintaining brain function (see Figure 4) and the brain's response to environmental stimuli. Throughout the perimenopausal period, ovarian hormones are essential for emotional and cognitive processing (Toffoletto et al., 2014). Exogenous estrogen and progesterone can be administered to account for these fluctuating hormone levels and their effects on emotional and physical functioning throughout the menopausal transition (Zhang et al., 2023). Estrogen and progesterone possess neurotrophic effects by acting via neuron receptors. Estrogen and progesterone receptors are abundant in the brain regions that are vital for cognitive and emotion regulation, such as the PFC (Toffoletto et al., 2014).
The serotonergic neural system, which plays a significant role in mood, cognition and depression, influences most areas of the forebrain, specifically the hippocampus, amygdala and prefrontal cortex (Sundström-Poromaa et al., 2020). These three areas are abundant in ovarian hormone receptors (Catenaccio et al., 2016). Increased risk for mood dysregulation throughout the perimenopausal period can be associated with periods of low estrogen resulting from the loss of estrogen support of the serotonergic system (Zhang et al., 2023). The antidepressant effects of selective serotonin reuptake inhibitors are increased by the presence of estrogen in the brain, promoting beneficial mood effects throughout the serotonergic system (Albert & Newhouse, 2019). In general, estrogen can promote serotonin signalling and release to exert antidepressant effects (Zhang et al., 2023), emphasising the role of exogenous estrogen as a treatment for the negative emotional and mental symptoms associated with perimenopause.
The stress-exposure model of depression states that stressful life events, combined with a biological vulnerability to the disorder, results in depression (Liu & Alloy, 2010). Altered functioning throughout the brain regions that are vital to the stress response is common for those with depression (Zhang et al., 2023). Specific to perimenopause, these regions include the amygdala, hippocampus, and prefrontal cortex (Zhang et al., 2023). The changes in these regional responses can be associated with altered estrogen and progesterone levels (Catenaccio et al., 2016), and cause uncontrolled stress responses within perimenopausal women, including hyperactivity throughout the HPA axis and a hypothalamic insensitivity to feedback from cortisol, the hormone responsible for mediating the stress response (Albert & Newhouse, 2019).
Perimenopausal depression can further be associated with dysfunction of the gamma-aminobutyric acid (GABA) system and the HPA axis. The GABA neurotransmitter system works to construct specific signals to the CNS to control nerve cell hyperactivity that is associated with anxiety, stress and fear (Sundström-Poromaa et al., 2020). Progesterone increases GABA receptor functioning, making it vital to alleviate the emotional dysfunction present throughout perimenopause, with GABA receptors distributed throughout the CNS and within the amygdala, hippocampus and hypothalamus (Sundström-Poromaa et al., 2020). Exogenous hormone treatments work to mimic endogenous estrogen and progesterone, working to inhibit the HPG axis while exciting GABA receptors, producing a calmer affect that aids in emotional regulation (Sharma et al., 2021). However, research into the confusing periods of increasing progesterone and estrogen at the beginning of perimenopause remains ambiguous (Weiss et al., 2004), and further studies must be conducted to clarify specifically what occurs throughout the periods of changing hormone levels and provide possible treatment options.

### Brain regions

Estrogen supports neuroplasticity throughout the prefrontal cortex and the hippocampus (Toffoletto et al., 2014). By supporting neuroplasticity, estrogen can aid an efficient and dynamic stress response to the negative circumstances and symptoms associated with perimenopause, also working to prevent any disrupted ventral–dorsal system interactions that work to process visual information for the purpose of visual perception and movement execution (Albert & Newhouse, 2019). During a healthy stress response that is not inhibited by fluctuating ovarian hormone levels, reciprocal interactions between the amygdala, PFC and hippocampus allow for the quick evaluation of and response to stressful stimuli, but changing ovarian hormones can cause these mechanisms to become dysregulated as the amygdala no longer exerts control over these functions (Albert & Newhouse, 2019). Reduced dorsal activity due to changing estrogen levels uninhibits the amygdala, resulting in long-term irritability, anxiety and inability to control one’s emotional responses (Sharma et al., 2021).
Furthermore, maintaining function throughout the limbic system, especially the amygdala and hippocampus, helps individuals evaluate the emotional aspects of situations and prepare for the fight-or-flight response which can cause increasing anxiety within perimenopausal women who experience ongoing excitation of the amygdala via low estrogen levels (Sundström-Poromaa et al., 2020). These periods of increased stress sensitivity present throughout the perimenopausal period caused by ovarian hormone changes increase mood and emotion dysregulation susceptibility in these women (Albert & Newhouse, 2019).
However, research into the distinct influence of fluctuating estrogen levels on hippocampal functioning is unclear. During low estrogen phases throughout the perimenopausal period, women demonstrate increased negative mood responses and less hippocampal activity due to psychosocial stress, which results in impaired long-term memory formation and memory retrieval that in turn influences emotional responses (Albert & Newhouse, 2019). Yet, increased concentrations of estrogen in the hippocampus is associated with decreased positive affect mediated by hippocampus volume fluctuations (Albert & Newhouse, 2019). The changes in estrogen receptor density due to increased levels that can occur at the onset of perimenopause alters the otherwise stable hippocampal functioning during estrogen fluctuations (Toffoletto et al., 2014), with the deficit in dynamic response ability of the hippocampus associated with increased vulnerability to mood and anxiety disorders in perimenopausal women (Albert & Newhouse, 2019). Explicit distinctions between the influence of decreasing and increasing estrogen levels throughout the hippocampus, alongside research into stable treatments for these differing estrogen levels, is an area of further focus (Beltz & Moser, 2019). The role of the hippocampus and how it is influenced during perimenopause by other brain regions must be clarified in future research for optimal treatment.
Furthermore, high concentrations of progesterone are also present in the brain during the onset of perimenopause (see Figure 5). High volumes of progesterone receptors are present in the amygdala and hippocampus, which are vital for cognitive functioning and emotional processing (Toffoletto et al., 2014). Progesterone influences emotion processing within the brain, especially recognising emotions and emotional memories, both of which are roles within the hippocampus (Sundström-Poromaa et al., 2020). Similarly, when progesterone levels are high during perimenopause, this causes increased amygdala responses to emotional stimuli and events, meaning that individuals respond quickly when negative stimuli are presented (Sharma et al., 2021). Emotion recognition accuracy and emotional processing abilities, such as the evaluation of salient stimuli and corresponding arousal levels, appear poorer during phases of high progesterone during the perimenopausal period, specific to this comprehension of negative emotional stimuli in the amygdala (Catenaccio et al., 2016).
* Case Study:
* Figure 6. Blood test.
* Maggie’s awareness of her behaviour and perimenopausal symptoms increases as she reflects on the strain her family is currently under due to her outbursts. Alongside hot flashes and insomnia, Maggie experiences brain fog, difficulty remembering appointments and information at work, and increased anxiety about work deadlines. She is also stressed about going to the doctors for more tests and possible medications without getting any answers as to why her physical and mental health continues to decline.
* After being dismissed once again by her GP about further testing, Maggie decides to reach out to a menopause specialist, as she feels as though her physical and emotional symptoms are becoming uncontrollable and detrimental to her wellbeing.
* The specialist sends Maggie to receive blood tests (see Figure 6) to determine her estrogen and progesterone levels, and complete a variety of cognitive tests to examine her cognitive brain functioning.
* What will the tests discover has changed in Maggie’s brain and ovarian hormones?
Test yourself!
1
Which hormone fluctuates throughout perimenopause?
Estrogen
Testosterone
Cortisol
2
Which brain system is responsible for regulating ovarian hormones?
Limbic system
HPG axis
Central nervous system
3
In which two areas are progesterone receptors most abundant?
Prefrontal cortex and parietal cortex.
Amygdala and hippocampus.
Central nervous system and automatic nervous system.
4
How does the amygdala respond to lowered estrogen levels during perimenopause?
The amygdala is inhibited, leading to increased anxiety and stress.
The amygdala experiences increased excitation, leading to ongoing stress responses and high levels of anxiety.
Estrogen does not influence activity throughout the amygdala. :

## Emotion regulation strategies

Psychosocial interventions seek to address behavioural, cognitive and emotional components that influence the perimenopausal experience to reduce mental and physical stress (Toral et al., 2014). Psychosocial interventions incorporate several components as a more holistic approach, working to improve menopausal symptoms, increase intervention awareness, and enhance healthy behaviours throughout the menopausal transition (Toral et al., 2014).

### Psychological and health education

Education involves providing information to women throughout the menopausal transition via discussions with health professionals, workshops and providing specific educational materials. This includes information and guidance for behavioural changes and self-regulation support to limit the gap between knowledge and behaviour, such as the self-management of symptoms, goal setting and planning. Some approaches also included training in skills of emotional self-regulation and relaxation for stress management.

### Cognitive behavioural therapy (CBT)

CBT interventions are a psychological intervention option for improving well-being throughout the menopausal transition. CBT interventions address the management of vasomotor and psychological menopause symptoms, and can include psychoeducation, counselling, mindfulness training, problem-solving, coping skills and cognitive restructuring. It is proven that these interventions effectively manage and reduce menopausal symptoms.
* Case Study:
* Figure 7. Cognitive behaviour therapy involves ongoing discussions with a psychotherapist, and can include working to build emotion regulation skills.
* The results of the cognitive and blood tests show that fluctuating estrogen and progesterone levels are significantly influencing Maggie’s brain functioning and emotion regulation abilities.
* The menopausal specialist utilises psychoeducation to inform Maggie of the different treatment options available, and their positive and negative effects. Informed of her choices, Maggie and the specialist agree that exogenous estrogen and progesterone tablets are the most effective treatment options, alongside CBT (see Figure 7) to aid Maggie in restrengthening her emotion regulation abilities and mood.
* After a few weeks of hormone replacement and therapy, Maggie already experiences an increased quality of life, as she feels less stressed, anxious and on edge, feels a renewed sense of emotional clarity, and no longer has issues with memory recall in her job and daily life. Maggie feels that the ongoing and detailed discussions she continues to engage in with the menopause specialist have allowed her to choose the best treatment option.

## Conclusion

Changes in emotion regulation abilities at the onset of perimenopause are due to changes in ovarian hormones and brain functioning specific to emotion, cognition and mood. These changes in emotion regulation and mood can be explained by utilising the somatic marker hypothesis and the James-Lange theory of emotion. Estrogen and progesterone levels fluctuate at the onset of perimenopause and as women move throughout the menopause transition due to changes in the functioning of the hypothalamic-pituitary-gonadal (HPG) axis (Sharma et al., 2021). Changing ovarian hormone levels negatively impact brain regions that are vital to emotion regulation and mood changes, specifically the amygdala, hippocampus and prefrontal cortex (Albert & Newhouse, 2019). The serotonin and GABA hormone systems are also influenced by fluctuating ovarian hormones, influencing the vulnerability of perimenopausal women to depression, acute stress and anxiety (Sundström-Poromaa et al., 2020).
Evidently, more research must be done to distinguish the individual roles of different brain regions on emotion regulation during perimenopause, and how changing estrogen and progesterone levels influence these brain regions. Currently, findings of this kind are unclear, as the majority of research examines the brain as a whole during ovarian hormone fluctuation (Sharma et al., 2021), so it is difficult to distinguish specific influences from each brain region or any mediating effects present. For safe and reliable medical treatments to be developed and used alongside psychological treatments, menopause must continue to be a prominent topic of discussion for organisations and governments, which should also work to continue the destigmatisation of this inevitable period of women’s lives.