The Female Brain (22 page)

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A woman’s hormones have been changing for several years before her day of menopause arrives. Starting at about age forty-three, the female brain becomes less sensitive to estrogen, touching off a cascade of symptoms that can vary from month to month and year to year, ranging from hot flashes and joint pain to anxiety and depression. Scientists now believe that menopause is triggered by this change in estrogen sensitivity in the brain itself. Sex drive can change radically, too. The level of estrogen drops, and so does that of testosterone—the rocket fuel for sex drive. The stability of the female brain’s reality, in fact, can be an almost daily uncertainty by age forty-seven or forty-eight. The twenty-four months before menopause, while the ovaries make erratic amounts of estrogen before stopping production of the hormone altogether, can be a rocky ride for some women.

That’s how Sylvia felt at age forty-seven, when she called my clinic for an appointment—the first time in her life she had seen a psychiatrist. It was the year before her last child left for college, and she had constant mood symptoms—including irritability, with emotional outbursts and a lack of joy or hope—that had started to distress her. “Perimenopause is like adolescence—without the fun,” she said one day. It’s true: your brain is at the mercy of changing hormones, as it was in puberty, with all the nerve-jangling psychological stress responsivity, worries about appearance, and over-the-top emotional responses. Sylvia would be fine one minute, but just the wrong comment from Robert could send her slamming doors throughout the house and taking refuge in the garage for an hour-long sob fest. She couldn’t take it anymore and wanted me to prescribe something to treat her symptoms. The other issues with Robert would have to wait. So I gave her estrogen and an antidepressant. In two weeks she was amazed at how much better she felt. Her brain needed the neurochemical support.

For a lucky 15 percent of women, the perimenopause—the two to nine years before menopause—is a breeze, but for about 30 percent it can cause major discomfort, and 50 to 60 percent of women experience some perimenopausal symptoms at least some of the time. Unfortunately, there’s no way to know how you’ll react until you get there.

There are some clear signs, however, when you’ve crossed the threshold. Your first hot flash, for one thing, is a signal that your brain’s starting to experience estrogen withdrawal. Your hypothalamus, in response to decreased estrogen, has changed its heat-regulating cells, making you feel suddenly, blazingly hot even at normal temperatures. Another sign of perimenopause is the shortening of your menstrual cycle by a day or two, even before you’ve experienced your first hot flash. The brain’s response to glucose changes dramatically, too, giving you energy surges and drops and cravings for sweets and carbs. This estrogen withdrawal affects the pituitary, curtailing the menstrual cycle and making the timing of ovulation and fertility unreliable. So be careful—many women end up with a surprise “change-of-life” baby thanks to the breakdown in the predictability of their ovulation.

I started the Women’s Mood and Hormone Clinic long before I was in perimenopause or menopause, so all I personally had experienced was moderately bad PMS and postpartum hypothyroidism. But when I was in my mid-forties, I began to have extremely bad PMS, with high irritability and big mood drops. At first I thought it was the stress of my job and having primary responsibility for my son. No doubt those realities played into my perimenopausal syndrome, but I resisted taking hormones for several years, thinking, Oh, this isn’t the same thing I see in my patients every day. Boy was I wrong. By the age of forty-seven, I was in full-blown perimenopause. I couldn’t sleep well, woke up hot, and often had to change my nightgown. In the morning I felt like hell: tired, irritable, and ready to cry over anything. Two weeks after starting estrogen and an antidepressant, I miraculously felt like my old self again.

Since estrogen also affects the brain’s levels of serotonin, dopamine, norepinephrine, and acetylcholine—neurotransmitters that control mood and memory—it’s no surprise that big changes in estrogen level can influence a wide variety of brain functions. This is where antidepressants or SSRIs can help, because they prop up these neurotransmitters in the brain. Studies show that perimenopausal women complain of more symptoms of all kinds—from depressed mood and sleeping problems to memory lapses and irritability—to their doctors than do women who have already passed through menopause. Interest, or the lack of it, in sex can be an issue as well. Along with the estrogen drop, testosterone—the fuel for love—can plummet at this time too.

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Marilyn and her husband, Steve, came to see me when Steve was at his wit’s end from being rejected sexually by her. “She won’t let me touch her anymore,” he said. Marilyn told me, “I used to like sex a lot and would like to have that feeling again, but every time he touches me, or gets that look in his eye, it’s…it’s…just irritating. It’s not that I don’t love him. I do.” Husbands can feel dumbfounded—a man’s hormones haven’t abruptly changed—even though they will decrease, and gradually he, too, will have fewer sexual urges. But his brain will never go through the precipitous hormone decline a woman’s brain has had to endure.

It was a good thing they came in, since this was a biological problem that was quickly becoming a marital problem. Many women do experience a drop in libido, but I suspected Marilyn’s perimenopausal situation was a little more extreme than most. I measured her testosterone and found that it was barely present. Could this be the cause of her rejection of Steve? She decided to find out by trying testosterone, so I prescribed the patch, and she slapped it on that very day.

Although sexual response varies a great deal during these years of erratic hormones, 50 percent of women age forty-two to fifty-two lose their interest in sex, are harder to arouse, and find their orgasms are much less frequent and intense. By the age of menopause, women have also lost up to 60 percent of the testosterone they had at age twenty. But this can be replaced by many forms of testosterone supplements—such as patches, pills, and gels—that are now available.

When I greeted Marilyn and Steve in the waiting room two weeks later, Steve gave me two thumbs up. Marilyn said that within a week she began to feel less annoyed at his sexual advances, and during the second week, she even felt like initiating sex herself but didn’t. Her brain circuits for sexual desire had been reignited by a little hormonal rocket fuel. Use it or lose it goes for everything, memory and sex included. The brain below the waist will shrivel up if it isn’t used.

Not all perimenopausal or postmenopausal women lose their testosterone or their sexual interest. In fact, “postmenopausal zest” is a phrase coined by the anthropologist Margaret Mead. It is a time when we no longer have to be concerned with birth control, PMS, painful cramps, or other monthly gynecological inconveniences. It is a stage of life that is free from many encumbrances and full of wonderful possibilities. We are still young enough to live life to its fullest and enjoy all the good things nature has provided us. Many women experience a renewed zest for life, even rejuvenated sexual desire, and look for exhilarating adventures or new beginnings. It is like starting life all over with a better set of rules. For those who don’t have the zest, the testosterone patch may ignite it.

By the time Sylvia decided to see me again about divorcing Robert—after he hadn’t come to visit her much in the hospital—she had passed through the last throes of perimenopause and stopped taking the estrogen and antidepressant. It was then that Sylvia explained to me it felt as if a haze had lifted in her brain once her menstrual cycle had stopped. She had always suffered terribly from PMS, and now that that was over, it was as if her vision had become clearer—about what she wanted to do with her life, and what she didn’t want to do any longer. She told Robert that although she still respected him, she had grown tired of demands that she continue to tend his needs on his timetable and keep up their large home. The monthly priming of her brain circuits by surging estrogen and oxytocin—to assure that she would tend to the needs of others—was gone. Of course she still had that blistering love for her children, but she didn’t have their physical presence and their oxytocin-stimulating hugs or her estrogen pulses to trigger her caretaking circuits and behaviors anymore. Of course she could still perform these duties, but she no longer felt driven to. She turned to Robert and said, “You’re a grown-up and I’m finished raising the kids. Now it’s my turn to have a life.”

When her kids came home during a break from college, Sylvia reported that she really enjoyed seeing them and catching up on their lives but was annoyed that they still expected her to pick up after them, cook their meals, and do their laundry. Her kids even teased her about how she would throw their laundry in the washer and dryer but wouldn’t match their socks anymore. She had laughed, too, but for the first time in her life, she said, she blasted back a reply: “Do your own damn laundry, it’s about time you grew up!”

The mommy brain was beginning to unplug. When a woman has launched all her children, her ancient mommy wiring comes loose and she is allowed to pull a few of the connections to the child-tracking device out of her brain. When the umbilical cord is cut as the children leave home, the mommy brain circuits are finally free to be applied to new ambitions, new thoughts, new ideas. Many women, however, may feel desperately sad and disoriented when their children first leave home. These circuits, which evolved for millions of years in our foremothers, fueled by estrogen and reinforced by oxytocin and dopamine, are now set free.

This time of life for some women is not so rancorous as it was for Sylvia. My patient Lynn had a deep and loving marriage to Don for over thirty years by the time their two kids were on their own at college. Lynn and Don started to travel to the places they had always wanted to go. They felt a sense of satisfaction at having raised two wonderful and accomplished children. Lynn had enjoyed being a mother but found that after a few months of heart tugs when they went off to college, she enjoyed not having to deal with the morning routine of getting the kids out the door. She was a successful—and well-liked—administrator at the university. Don was an engineer in private industry. The more time they spent alone, the more their relationship blossomed. They brought years of mutual love and trust to help them through this life transition and set up the new rules for the road ahead.

Sylvia’s midlife transition was not nearly so peaceful. By our next session, she had decided to go back to grad school and begin working in a mental health clinic two times a week. Her kids were a little unsettled by her new interests. The youngest was moving on and getting settled into life at college. She didn’t need her mother as much as she used to, but still, she was surprised and a little hurt when she talked to Sylvia on the phone and all her mother wanted to tell her was about her own new projects and plans for going back to school herself. Sylvia told me that she almost found it shocking that she was no longer anxiously asking her daughter questions about her life. She was amazed at her slightly detached response.

What’s happening in her brain? It isn’t just that the estrogen is gone—the physical sensations of tending and touching the children are also gone. Those sensations, along with estrogen, help to reinforce the tending circuits and turn up oxytocin in the brain. This process begins for most mothers during their children’s teen years, when they resist being hugged, kissed, or touched. So by the time they leave the nest, mothers have grown accustomed to less up close and personal physical tending. An experiment on mothering behavior in rats found that physical contact is required to maintain the female brain circuits for active maternal behavior. Scientists numbed the chest, abdomen, and nipple area on the rats. The mothers could see, smell, and hear their pups but could not feel them squirming around. The result: mothering and bonding behaviors were severely impaired. The mothers didn’t fetch, lick, and nurse their pups the way a normal rat mom would. Even though their brain circuits were organized and primed hormonally for mothering and caretaking behaviors, without the feedback of touch sensation, the mother rats’ brain connections for nurturing behavior did not develop, and many of the pups died as a result.

Human mothers also use this physical feedback to activate and maintain nurturing and caretaking brain circuits. The normal contact of living in the same house provides enough sensation to maintain a woman’s tending and caretaking behaviors toward her kids—even grown-up kids. Once the kids leave the house, however, that’s another story. If a mother is menopausal at the same time, the hormones that built, primed, and maintained those brain circuits are also gone.

This change doesn’t mean that the tending brain circuits are gone forever. Four out of five women over fifty say having a job where they help others is important to them. Though the initial impulse for many menopausal women seems to be doing something for themselves for once, the renewal that follows often draws them back toward helping others. The caregiving circuits can easily be renewed. If an over-fifty-year-old woman becomes the mother of a new baby, the daily physical contact will cause those circuits to reemerge in her brain—as one of my female colleagues could tell you after she adopted a Chinese baby girl when she was fifty-five years old. So once the circuits are there, they can be reignited. It isn’t over until it’s over as far as the maternal female brain is concerned.

For Sylvia, though, this was a golden time. In her reality, she was free at last to follow her own pied piper. She had taken on her own projects. Through her new courses, she had become convinced that behavioral problems in teens have their roots in early education, and she became passionate about improving how parents and teachers treat preschoolers. As part of getting her master’s in social work, she became involved in training preschool teachers in the local school system. She told me that she had also returned to services at the church where she grew up and was building a studio in her garage so that she could go back to painting—an activity she had given up when she married Robert. At one of our sessions, she was almost in tears over how happy her new life was making her. She felt she was making a difference in the world. This was in direct contrast to the increasingly heated arguments that began the minute Robert walked in the door every night.