Perimenopause and Mental Health: Mood Changes, Anxiety, and Treatment
As you enter perimenopause, you might expect symptoms like night sweats, hot flashes, and irregular periods. What you might not expect is to feel like a completely different person.[1]
Perimenopause mental health symptoms, such as brain fog, mood swings, emotional rawness, and anxiety, can catch you off guard.[2] Making this more difficult is that many of these symptoms are still rarely discussed openly, meaning many women go through this alone, wondering what’s happening to them.
But it’s important to understand that nothing is wrong with you. Your brain and hormones are closely connected, and during perimenopause, that connection is under strain. To help support you through this new stage of life, here’s what you need to know.
The Emotional Symptoms of Perimenopause Are More Than Just Hormones
Feeling emotional unsteadiness, the sense of not recognizing yourself, and the anxiety and depression that often come with perimenopause can all be difficult on their own.[2] But together, they can make this phase of your life really challenging. Understanding these symptoms is the first step in coming to terms with what’s happening and what you can do about it.
What Mood Changes During Menopause Actually Look Like
Perimenopause usually lasts around 3-4 years before your final menstrual period, but its effects on your mood often begin earlier and last longer. The length of time it affects how you feel, and the intensity with which it changes your mood, can catch you completely off guard.[3]
The unpredictable nature of perimenopausal mood symptoms (which, unlike PMS and Premenstrual Dysphoric Disorder, do not follow a cyclical pattern matching your menstrual cycle) can make you feel like you have little or no control over your emotions. This alone is one of the most distressing parts of perimenopause.[3] Understanding hormonal changes and mood swings in women during this transition can help reduce some of that distress.
Perimenopausal Mood Instability
Perimenopausal mood instability is extremely common, with about 40 percent of women experiencing it.[4]
Common symptoms include the following:[4]
- Low energy
- Tearfulness
- Irritability
- Difficulty concentrating
- A sense of not recognizing yourself
- Feeling emotionally raw
Unfortunately, many women (and practitioners, too) dismiss these symptoms as a function of aging, stress, or being tired. These symptoms are real, though, and deserve care and attention, not a quick label or dismissal.
The emotional symptoms menopause generates also include anxiety. Muscle tension, heart palpitations, difficulty sleeping, and persistent worry are common. Panic attacks may also occur. But since panic attacks and hot flashes both involve a surge of heat, sweating, and a racing heart, distinguishing between the two can be difficult.[4],[5]
Perimenopause mental health symptoms also include brain fog. The cognitive and emotional symptoms of brain fog, such as trouble finding words, difficulty concentrating, and short-term memory lapses, are especially frightening. You may even experience these symptoms and wonder if you’re developing dementia.[1] On top of all that are the physical symptoms of perimenopause, which can have a much deeper connection to your mental health than you might realize.
Hot Flashes and Mental Health
Perhaps the best-known symptom of perimenopause is hot flashes, which makes sense given how common they are: studies indicate that around 80 percent of women have hot flashes during menopause.[3] They aren’t just a rush of heat, either. Instead, hot flashes can have wide-ranging impacts on your behavior.
If you’ve experienced hot flashes, you know how unpredictable they are. That unpredictability can cause intense anxiety waiting for the next one to occur. But some research indicates that anxiety precedes hot flashes rather than being a result of them. This indicates that hot flashes and anxiety have a two-way relationship that feeds into a cycle of physical and psychological symptoms that can be hard to break without appropriate mental health treatment.[6]
Hot flashes can sometimes result in social withdrawal, as some women start avoiding going out in public for fear of hot flashes being noticed. Becoming withdrawn only deepens the issue, though, with increased feelings of isolation, loneliness, and depression.[7]
Hot flashes and night sweats make sleep difficult, too. Poor sleep affects all kinds of things, from your capacity for patience to your ability to regulate emotions to your stress response. The effects go deeper still: Not getting enough sleep is also linked to anxiety, depression, risk-taking behavior, and even suicidal thoughts.[4]
Since sleep problems are among the most common symptoms of menopause (it affects up to 60 percent of perimenopausal and postmenopausal women), addressing sleep disruption is one of the top priorities of effective treatment.[6]
Why This Happens: The Science of Estrogen Decline and Mood
So why do these changes and symptoms occur? The short answer is that it’s a mix of factors, such as biology, psychology, and life experiences.[2] Learning how these factors interact with one another can make what you’re experiencing less confusing and less frightening.
Estrogen Decline and Mood Changes
The biggest biological reason why perimenopause has such wide-ranging effects is a decline in estrogen. Contrary to popular belief, estrogen isn’t just a reproductive hormone; it’s also involved in regulating several neurotransmitters, like dopamine, serotonin, GABA, and norepinephrine. As estrogen levels go up and down and eventually decline, these neurotransmitters become destabilized, and mood instability results.[6]
To go a little further, estrogen receptors are found in the hippocampus and prefrontal cortex. These regions are responsible for memory, emotional processing, and decision-making, which helps explain why you might have memory lapses, brain fog, difficulty finding words, and mood changes.[1]
Furthermore, estrogen decline causes your body’s stress response system, the hypothalamic-pituitary-adrenal (HPA) axis, to become more reactive. This causes increased levels of cortisol in your body and a state of chronic low-grade stress. In other words, as perimenopause begins, your body becomes more sensitive to stress, making daily tasks seem harder to manage than before.[6]
Estrogen isn’t the only hormone involved, either. Progesterone is a factor as well. This hormone is highly involved in emotional regulation and has a natural calming effect. The problem is that, like estrogen, it declines with age, meaning you lose a built-in buffer against sleep difficulties and anxiety.[6],[8]
Who Is Most Vulnerable
Every woman’s experience is different. However, research shows that certain factors greatly increase your risk of severe perimenopausal symptoms:
- A history of depression, postpartum depression, or PMDD is linked to increased sensitivity to hormonal fluctuations.[9]
- Early onset of menopause or surgical menopause is associated with an increased risk for depression and anxiety.[6]
- Experiencing two or more life stressors simultaneously, such as work pressure, caring for aging parents, and issues of aging, can increase the likelihood of perimenopausal depression by five times.[10]
- Smoking, low social support, lower educational attainment, and financial strain are all associated with increased rates of depressive symptoms.[10]
- Pre-existing mental health conditions like bipolar disorder and schizophrenia compound the risk of severe perimenopausal mood changes.[8]
- Cultural and social factors, such as how your community views aging and menopause, also matter.[6]
Getting a Diagnosis (and Why Perimenopause Mental Health Issues are Often Misdiagnosed)
Getting a diagnosis for perimenopause can be challenging, given the overlapping nature of its symptoms with common mental health issues like depression and anxiety, as well as common conditions like thyroid dysfunction.[3]
Part of the problem is that only 20 percent of OB/GYN residents get formal training in menopause care. Furthermore, there are only about 1,800 certified menopause specialists in the world, highlighting the lack of expertise in this field. When the system that’s supposed to provide care isn’t adequately prepared to do so, it makes your experience that much more difficult to deal with.[3]
There is hope, though. Two screening tools (the PHQ-9 and GAD-7) make visits to your OB/GYN much more productive in terms of identifying depression and anxiety, respectively. These tests can be easily incorporated into your routine visits, and their results can help your healthcare provider determine whether you need mental health support.[6]
Moreover, perhaps the most empowering thing you can do is be open and honest with your OB/GYN about your experience. Outlining not just your physical symptoms, but also your emotional ones, gives your doctor a more complete picture of what’s happening. This, in turn, can lead to deeper conversations about your mood changes and pave the way for appropriate treatment.[4] However, obtaining mental health support during menopause may mean bringing up these symptoms yourself, since not all providers will ask.
Treatment for Perimenopause Depression and Anxiety
The appropriate treatment for your perimenopausal depression and anxiety depends on your unique situation. The good news is that many effective, research-based treatments are available and can provide you with meaningful relief.
Hormone Therapy for Depression and Mood Symptoms
A popular treatment is menopausal hormone therapy (MHT). It’s effective for women without any serious medical issues, like cardiovascular conditions, breast cancer, or blood clots. In clinical trials, MHT had a nearly 70 percent remission rate among women treated with an estradiol patch.[6]
The key with MHT is timing: It’s most effective to address estrogen decline mood changes when started during perimenopause. It’s also effective when started within 10 years of your last menstrual period.[3] One issue to note is that there were some fears about MHT’s safety in the past. However, researchers have since clarified that those risks applied mostly to women who began hormone therapy long after menopause. It is now one of the most well-studied forms of hormone imbalance treatment for women experiencing mood symptoms during the menopausal transition.[1],[3]
Antidepressants and Psychiatric Medications
Another treatment for perimenopause depression is antidepressants. Typically, antidepressants are prescribed when MHT is either not appropriate for you or not sufficient to address your symptoms. SSRIs (serotonin-specific reuptake inhibitors) help regulate serotonin in your brain to address your mood-related symptoms.[2],[6]
Popular options include:[2],[9]
Sertraline (Zoloft) for depression and anxiety
Escitalopram (Lexapro) for anxiety
Fluoxetine (Prozac) for depression
Paroxetine (Paxil) for mood symptoms and physical symptoms, like hot flashes
Serotonin-norepinephrine reuptake inhibitors (SNRIs) are also effective for depression and perimenopause anxiety treatment. Your doctor might prescribe any of the following:[6],[8],[9]
Venlafaxine (Effexor) for depression, anxiety, and relief from hot flashes and night sweats
Duloxetine (Cymbalta) for depression, anxiety, sleep disturbances, and pain
Desvenlafaxine (Pristiq) for depression
Finding the right medication involves some trial and adjustment. The more openly you communicate with your doctor about how you feel, the easier it is to determine the right fit.
Therapy, Lifestyle, and Non-Drug Approaches
Of course, therapy for menopause anxiety, depression, and other mood changes can be highly effective, especially when paired with appropriate medication. In particular, cognitive-behavioral therapy is effective for treating anxiety, depression, insomnia, and even hot flashes. In some cases, it takes just 4-6 sessions to show improvement.[6],[11] None of these approaches requires a doctor’s visit or a prescription, either; just a commitment to showing up for yourself during one of the most demanding transitions of your life.
Building Your Support System with Mission Connection
The mood changes, emotional upheaval, anxiety, and other symptoms you’re experiencing as part of perimenopause aren’t permanent. The key is equipping yourself with information and building your support system so you can navigate this season of your life effectively.
Reading this article is a good place to start. Now it’s time to take additional active steps. Advocate for yourself. Seek integrated treatment that addresses your whole experience. Focus on lifestyle changes that will help ease some of your symptoms. Each of these steps will generate positive results; working on them simultaneously will be even more effective.
Perhaps the most important thing to remember is that help is available. At Mission Connection, we understand that mental health during this time of your life can be incredibly complex. We also understand that individualized, comprehensive care is the best treatment. Whether you’re looking for a therapist, psychiatric support, or just a compassionate place to start the conversation, we’re here to help you find your footing. Reaching out isn’t a sign that something is wrong with you; it’s a sign you’re paying attention to yourself, and that matters.
