Mental Health Concerns and Eating Disorders During Perimenopause

What is Perimenopause?

Perimenopause is the life stage when a woman’s body transitions toward menopause (the end of her reproductive years, when the body no longer produces eggs). Perimenopause typically begins sometime in a woman’s 40’s, but there can be significant variance with some women noting changes in their 30’s, and some not until their 50’s.

The perimenopause period usually lasts between 5-10 years, and in Australia the average age for reaching menopause is 51 years.

Menopause is most often a natural life event, but it can also be triggered by gynaecological surgeries or the use of certain medications (including some treatments for cancer). Perimenopause can be experienced by all people assigned female at birth (AFAB) who sill have their ovaries, including trans-men.

Why is it important that we know about Perimenopause?

Perimenopause can bring a variety of physical and emotional changes which significantly impact on wellbeing and quality of life. These changes vary in severity from person to person, and across the perimenopausal period. There’s a lot that can be done to support women during perimenopause, and it’s important that everyone is aware of the symptoms associated with this time, considering how they can support women during the transition. Some of the compounding factors which can exacerbate the experience of perimenopause are isolation, misinformation, judgement, and a lack of care or support.

There are numerous mental health concerns which women transitioning through menopause may experience, along with increasing risk of cardiovascular disease and reduced bone density. Women at midlife also have significantly increased risks of mental health concerns such as depression and anxiety, and an increased risk for the development or re-occurrence of an eating disorder.

Common symptoms of Perimenopause

According to a 2023 study conducted by the Jean Hailes Foundation for Women’s Health, approximately 20% of women experience no symptoms of perimenopause at all. For those who do experience symptoms, these can be triggered by fluctuating hormone levels, which often coincide with major life changes and stressors associated with midlife. The range of symptoms which may be attributed to perimenopause can include, but are not limited to, those below.

Some possible physical symptoms of perimenopause:

• Irregular or missed periods, or changes in menstrual flow

• Changes in ovulation patterns

• Hot flushes and night sweats

• Sleep disturbance

• Fatigue and headaches

• Muscle and joint aches

• Vaginal dryness and breast tenderness

• Bladder weakness and more frequent urge to urinate

• Skin dryness and sensitivity

• Loss of libido or reduced sexual pleasure

• Altered digestive patterns and tolerance of foods

• Changes in body shape, size and composition

Some possible mental and emotional symptoms of perimenopause:

• Feeling anxious or irritable

• Low mood or mood swings

• Forgetfulness or ‘brain fog’, difficulty concentrating

• Difficulty coping with life events

• Challenges adjusting to your changing body

Perimenopause and Mental Health

The emotional challenges of perimenopause should not be underestimated. Hormonal fluctuations associated with this life phase are linked to an increased risk of anxiety and depression, even for those without a prior history of mental health issues.

Research has found an increase in suicidal thoughts for women at midlife, and completed suicide rates for women in Australia are highest in the perimenopause period.

Physical symptoms like night sweats, brain fog and fatigue can exacerbate mood disturbances. Additionally, perimenopause often coincides with major life changes such as retirement, family and relationship changes, increased caregiving responsibilities, and personal loss, which can all contribute to increased stress.

The changing relationship with the body during menopause can also present a significant change for many women. There may also be a period of adjustment as women come to terms with no longer experiencing monthly reproductive cycles, which can impact on identity and the experience of femininity.

Body size and shape changes during Perimenopause

Perimenopause often brings significant changes in body weight, shape and composition. While hormonal changes contribute to these shifts, other factors such as lifestyle changes also have an impact. Women transitioning through menopause may also notice changes in their appetite and digestive patterns. The aging process, which naturally decreases lean muscle tissue, can make it more challenging to maintain muscle mass and manage weight. Additionally, weight cycling, or repeated dieting, can lead to further muscle loss and fat gain over time.

All of these factors can add more stress for women in perimenopause, especially when faced with diet culture messaging about body ideals and fear of weight gain.

A balanced perspective on understanding and accepting the naturally occurring body changes, while also focusing on nutrition and activity levels for optimal wellbeing is important, particularly to avoid extreme or all-or-nothing responses to the changing body.

Eating Disorders and Perimenopause

Eating Disorders can be experienced by people of all ages and all genders. Traditionally thought of as conditions impacting young women, we now know that the rates of eating disorders being experienced by older women are increasing, and are a significant concern at midlife. These mid life eating disorders can be triggered by the changes of perimenopause, and may be either a first presentation at midlife, or a re-occurrence of a condition which had been experienced earlier in life.

According to the Butterfly Foundations ‘Paying the Price’ report (2024), almost one in four people experiencing an eating disorder in Australia each year are aged between 40-59. When sub-threshold eating concerns are included, 15% of perimenopausal women report at least some elements of disordered eating.

Major hormonal shifts experienced by women during perimenopause, like those experienced during puberty, pregnancy and postpartum periods, combine with pressures on women to meet cultural ideals of thinness and ‘anti-ageing’ to create a high risk period for the development of an eating disorder. Significant life events and stressors such as increased caregiving responsibilities or significant lifestyle changes can also trigger challenging eating behaviours and body image dissatisfaction in midlife.

Eating disorders during perimenopause are often overlooked by health professionals, who may not be aware of the prevalence of these conditions for women at midlife.

This is particularly notable when the full range of eating disorder presentations is considered, including Anorexia Nervosa, Bulimia Nervosa, Binge Eating Disorder, and Other Specified Feeding and Eating Disorders. Midlife eating disorders can have complex and serious health consequences, as the body is more vulnerable to complications such as digestive issues, osteoporosis, and dental problems, and fluctuating eating patterns can also exacerbate many of the symptoms of perimenopause.

“Drawing on a summary of evidence by Samuels, Maine & Tantillo (2019), factors which contribute to body dissatisfaction and eating disorder prevalence in midlife include:

• Stress and anxiety in relation to the physiological changes of ageing, which can contribute to feelings of loss of control in the context of a culture that valorises youthfulness

• The impact of weight suppression and disordered eating over many decades of life

• The lack of older women role models amidst ageist social norms which frame ageing as something to defy and combat with diet, exercise and medication regimes

• The ongoing impact of diet culture, where disordered eating is framed as normal behaviour from a young age

• High levels of body dissatisfaction among women aged 50 and over

• Experiences of shame, stigma and isolation, given that eating disorders are stereotyped as illnesses affecting young people, and health professionals may perceive older people as ‘too old to have an eating disorder’.”

(From The Butterfly Foundation: ‘Eating Disorders and Body Dissatisfaction During Menopause’.)

Seeking help during Perimenopause

The hormonal and life changes associated with perimenopause can be challenging, with the difficulties exacerbated for people who feel isolated and unsupported during this time. If you or someone you know is struggling with the symptoms of perimenopause, or may be experiencing body dissatisfaction or eating disorder symptoms during midlife, the team at Mind Body Well can offer support and guidance to help navigate this phase. We also recommend the links below for further information.

• Australasian Menopause Society

• Jean Hailes Foundation for Women’s Health

• Perimenopause Symptom Checker

• Eating Disorders Victoria free online course - Menopause and Eating Disorders

• Butterfly Foundation - ‘Paying the Price for Eating Disorders’

Our Director Janet Lowndes reflections after attending the Asia Pacific Conference on Women’s Mental Health in October, 2024. (General information only, please consult your health professionals for individualised medical or psychological advice).

Body Image and Eating Disorders Awareness Week 2024

September 2-8, 2024 is Body Image and Eating Disorders Awareness Week

Body Image and Eating Disorders Awareness Week (BIEDAW) is an annual health promotion campaign raising awareness about body image concerns and eating disorders. This year the focus is on communication - assisting people to consider the impact of what they say about bodies - both their own and others.

The following statements from The Butterfly Foundation provide some helpful alternatives to diet culture talk.

Head over to The Butterfly Foundation website to see more information and helpful resources including a very useful script to help you advocate for yourself when visiting health professionals, including Doctors.

Exploring Endometriosis and the relationship with food and body image

In the realm of women’s health, there has long been an understanding of the impact of conditions such as Polycystic Ovary Syndrome (PCOS) on women’s mental health. More recently there is also growing awareness of the impact of Endometriosis symptoms on body image and eating concerns.

Endometriosis is a chronic condition where cells similar to the lining of the uterus grow outside the uterus, causing inflammation in areas such as the abdomen, and in some cases quite debilitating pain. This pain, along with other symptoms like bloating and digestive issues, can result in people feeling discomfort and disconnection from their bodies.

Everyday activities can become challenging as people seek to cope with chronic pain, deal with bloating and discomfort, and navigate unpredictable digestive patterns. These uncertainties can significantly impact on how people perceive and relate to their bodies, creating vulnerability to seek out ways to feel better and cope with difficult sensations and emotions.

Research into the psychological impact of endometriosis also reveals possible impacts on body image and self-esteem, with some people feeling ‘broken and inadequate’, or struggling with the sense that their bodies are outside their control.

Of course there is an abundance of dietary information available which offers strategies to alleviate endometriosis symptoms. Unfortunately this information is often misguided and not scientifically based, encouraging people to adopt restrictive dietary patterns which can exacerbate the conflict with and confusion about their bodies, contributing to further body image distress and eating concerns.

Additionally, cultural messaging regarding body image, physical activity, and dietary choices can add pressure and contribute to this body confusion, especially when compounded by challenges from hormonal therapies, difficulties with sexual arousal and intimacy, recurrent surgeries, or fertility concerns.

Research from 2021 explored why some people with endometriosis experience higher levels of emotional distress. The findings pointed to negative body image and self-criticism as major factors contributing to psychological distress. These self-critical patterns were described by one person as ‘a vicious cycle of feeling like one's body is constantly falling short’, leading to increased feelings of failure and self-criticism.

We do however know that improving self-esteem and emotional coping strategies can contribute to improved psychological outcomes for people with endometriosis. Emphasising body acceptance and reducing self-criticism are also powerful tools in coping with any chronic illness, and this is especially so for women’s health issues and menstrual concerns.

Endometriosis and Eating Concerns

Currently there is little research on the relationship between endometriosis and eating concerns or eating disorders. Research does however show that people with endometriosis regularly make dietary changes in an effort to assist with pain management and gastrointestinal issues.

Turning to clinical and lived experience, health professionals working with women and AFAB (assigned female at birth) people with endometriosis often describe the desire to control their eating behaviours in an effort to control their body, contributing to complex relationships with eating and body image.

What Can Help?

1.     Prioritise a Healthy Relationship with Food and Body Image: While dietary changes may help manage endometriosis symptoms for some, it's important to prioritise overall health and well-being and to avoid restrictive or highly controlled eating behaviours

2.     Seek Support from Health Professionals: Consult with healthcare professionals who understand both endometriosis and eating concerns – especially if you’re considering dietary changes, it’s always best to speak to a qualified Dietitian for professional nutritional advice

3.     Emphasise Body Acceptance: Work on improving your relationship with your body and developing body acceptance to enhance overall well-being, irrespective of any physical challenges. Focus on taking care of and nurturing your body, prioritising it’s needs

4.     Develop Self-Compassion: Chronic health conditions are complex and challenging to navigate. Self-compassion involves the ability to be kind to yourself in response to health concerns, focusing on changing the relationship you have with your body, even in response to things which are outside your control. Mental health professionals can assist with strategies to enhance your self-compassion.

Navigating Social Media to Promote Positive Body Image

In our digitally driven world, social media has become an integral part of our daily lives. From connecting with friends to staying updated on the latest news, it's a tool which has immense influence on our lives. Alongside the convenience and benefits, social media also presents a number of challenges, particularly in relation to body image.

The prevalence of unrealistic beauty standards portrayed on social media can have a big impact on how we perceive ourselves. Repeated exposure to these perfected images can cause us to feel inadequate, and may contribute to body dissatisfaction.

Social media can also be a great tool to assist in promoting positive body image, fostering self-acceptance and encouraging inclusivity. The key factor is how we choose to engage with social media. Here are some tips on how to use social media in a way which promotes positive body image and can protects us from dissatisfaction or potentially disordered eating behaviours.

1. Check in with Your Feelings

Notice how you feel during and after being on social media. If certain pages, accounts or images leave you feeling negative about yourself or trigger comparison, consider whether following them is beneficial to your well-being. Your mental health should always be the priority.

2. Curate Your Feed

Follow accounts and people who promote body diversity and inclusivity, and unfollow those which perpetuate harmful beauty standards. Exposure to a broad variety of body types, shapes, ages, genders, and ethnicities can reshape your perception and foster inclusivity.

3. Remember: It's Not Reality

Keep in mind that what you see on social media is often a curated portrayal of someone's life… the highlights reel. Remember also that images may be edited, filtered or enhanced, so what you’re seeing may be not be real. Remind yourself of this when comparing your life to others. Share authentic moments from your own life to contribute to a more genuine online community.

4. Combat Comparison

As the saying goes, ‘Comparison is the thief of joy’, and this is especially so on social media. Remember that you’re comparing yourself to the best possible version of another persons life, and if you begin to slip into critical self-talk, it’s probably time to move away from social media for a while to do something which focuses on your own life, your own opportunities and achievements.

5. Prioritise Health and Well-being

Move your focus away from appearance, to instead pay attention to your overall health and well-being (which is much broader than just the things we’re able to photograph and share on the socials). Embrace discussions about what makes you feel good physically, mentally, and emotionally.

Social media can either perpetuate harmful beauty standards or serve as a platform for promoting positive body image and inclusivity. By curating our feeds, being aware of our emotional responses, and fostering empowering content, we can contribute to a healthier and more accepting online community.

Navigating Diet Talk and Body Image Concerns During the Holiday Season

The holiday season is a time for celebration and relaxation. It's a time to gather with people we care about, and hopefully also a time for some rest. However this can also be a time when diet culture ramps up, creating pressure in the warmer weather to focus on our ‘bikini body’, attending events which are usually centered around food and eating, and the impending wellness focus of New Year's resolutions – all of which can make the holiday period a minefield of diet talk and body image distress.

In this article, we'll explore strategies to help you navigate the challenges of diet talk and body image concerns during the holidays. Different factors such as your environment, relationships, personal history, and comfort levels can influence which strategies are most effective for you – so think about how you can personalise this information for your own circumstances.

Setting Boundaries

Where possible it can be helpful to set some boundaries prior to an event. Depending on your relationship with the people involved and your comfort level, it might be possible to let people know how they can support you – maybe you could communicate these boundaries in person or via text. Some examples could include:

• ‘I'd appreciate it if we don't talk about 'good' vs. 'bad' foods’

• ‘It would be really helpful if we could avoid any discussions of weight during the holidays’

• ‘I really want to have fun with you over New Years, which will be a lot easier for me if we don’t talk about diets’

• ‘It’s important for my recovery that we don’t talk about ‘working off’ Christmas dinner’

Responding to Body or Diet Talk

Despite setting boundaries, it’s possible that instances of unhelpful diet or body talk could still arise. In these situations, it can be helpful to have some practiced strategies for responding. Here are some ideas:

• Remove yourself: Remember it's okay to leave the conversation or the situation. Excuse yourself for a bathroom break or step outside for some fresh air

• Redirect the conversation: Change the topic to something more neutral or comfortable to steer the conversation away from diet talk

• Express discomfort: Be honest about your feelings, eg. ‘I'm not comfortable with this conversation’

• Question the body talk: Gently question the person engaging in body talk, eg. ‘I've noticed you make a lot of comments about good and bad foods. For me, this contributed to a really unhealthy relationship with food’

• Plant Seeds: eg. ‘I've found it helpful to learn more about my relationship with my body, if you're interested, I can send you some podcast or book recommendations’

• Direct Response: In some cases, you may need to be more direct and assertive, eg. ‘I'm not engaging in diet talk’

Focus on What You Can Control

Despite our best attempts, we have limited control over other people’s body and diet talk, and we may not always feel comfortable or have the capacity to challenge them. In these situations, focus on what you can control:

• Remind yourself of your personal journey: Tell yourself that you’re on the path to recovery and that it's important to prioritise your wellbeing

• Practice empathy: If it feels safe, try to empathise with those around you who might be caught up in diet culture, and be dealing with their own food and body image concerns

• Focus on positives: Concentrate on positive aspects of yourself, list three things you're proud of accomplishing

• Consider the source: Reflect on the source of comments and ask yourself whether it's helpful to place much value on their perspective

• Use mindfulness techniques: To let go of unhelpful thoughts, such as mentally saying, ‘I'm having the thought that...’

• Practice self-compassion: Engage in self-compassionate thoughts and soothing activities after challenging interactions

Ultimately, prioritise your wellbeing, and before you know it the holidays will have passed – hopefully without too much stress or challenge along the way. Be sure to schedule in some of your favourite activities, and spend time with the people who you know are good for your spirits.