Anxious? Depressed? It might be perimenopause

Menopause is no longer a word that need not be uttered out loud. Gen X is the first generation of women to, as they’ve aged into midlife, speak more openly about the challenges that come with the menopause transition and demand solutions. Even its more, shall we say, high-profile members (see Halle Berry, Drew Barrymore, Naomi Watts) have no problem sharing about their hot flushes and vaginal dryness and night sweats. But it’s not just your body that can take a hit. Your brain can too.

Perimenopause, the phase leading up to menopause, begins when menstrual cycle lengths start to vary by seven or more days and ends 12 months after the last period. This stage can stretch up to a decade — and it’s increasingly being linked to mental health shifts.

“Changes in mood are really a perimenopause phenomenon,” says Pauline Maki, Ph.D., professor of psychiatry, psychology, and obstetrics & gynecology at the University of Illinois Chicago. Research shows women in perimenopause are 40% more likely to experience depression than their premenopausal counterparts.

Hormonal fluctuations play a major role. Lisa Mosconi, Ph.D., neuroscientist and author of The Menopause Brain, writes that estrogen supports the production of mood-regulating neurotransmitters like serotonin, dopamine, and GABA. Estrogen also influences the HPA axis, which helps manage our stress response.

But, Maki clarifies, mood changes aren’t simply about hormone loss. “It’s not the loss, it’s the variability,” she says. These swings — estrogen surging one day and plummeting the next — can trigger depression, especially under stress. “Greater estradiol irregularity can predict the development of perimenopausal depression.”

Brain imaging backs this up. Judith Joseph, M.D., board-certified psychiatrist and author of High Functioning, points to studies that have looked at brain imaging which shows decreasing gray matter (which matters because that’s where the body of the neurons or brain cells exist) and that using menopause hormone therapy (MHT) — more commonly known as hormone replacement therapy (HRT) — may have neuroprotective benefits.

“One study shows the brain starts to upregulate estrogen receptors — like making more nets to catch more estrogen,” says Joseph. “That brain fog or sadness isn’t just in [your] head; it’s a symptom of what’s going on in [your] head.”

Women may feel anxiety, depression, rage, mood swings — the full spectrum of emotional states. Joseph shares that many of her patients in perimenopause report an onset of sadness, moodiness, and irritability. But because it’s not as severe or persistent as major depressive disorder (clinical depression), oftentimes these symptoms can go unnoticed by others.

“Women will not quite feel like themselves — a little low, more edgy, like their patience is shot. [There’s] a bit more anxiety, lack of motivation, like they have PMS all the time. But because they continue to function pretty close to where they were, nobody else might notice it,” says Hadine Joffe, MD, a professor of psychiatry at Brigham & Women’s Hospital.

Cognitive symptoms like forgetfulness and brain fog are also common. For some, it’s so disruptive they suspect ADHD. But as Joseph explains, “If you have no childhood history of ADHD and suddenly have symptoms of forgetfulness and poor organisation in midlife, this is likely perimenopause or menopause brain fog.”

Learn more about menopausal brain fog

Midlife comes with its own challenges — careers, caregiving, changing relationships — which take its own emotional toll. Add in physical shifts like weight gain, libido loss, and poor sleep, and the result is a perfect storm for mental strain.

Women with a history of mood disorders may be more at risk. And the majority of women who’ve experienced clinical depression earlier in life will have a recurrence, says Maki.

One of the most important ways to prepare for the potential perimenopausal mood shifts is to first acknowledge their existence. Many women are used to prioritising others’ needs and hiding their own struggles. Support from friends and healthcare providers is essential.

Joffe says that MHT is one option for women contending with flushes and situational depression, adding that hormone therapy is often combined with SSRIs and cognitive behavioural therapy. If it doesn’t help, though, she says not to hesitate to go back to your provider: “I always tell people don’t take a long time to go back and say it’s not working.”

Setting expectations can help. Joseph encourages women to prepare for perimenopause starting in their late 30s, or earlier for Black women, who tend to experience it sooner and more intensely. Regular movement, balanced nutrition, strong social ties, and quality sleep all help buffer symptoms.

And while preparation is good, panicking about it all isn’t. “The majority of women do not get a major mood problem,” says Joffe. A reason to feel less fearful — and more free — in the lead-up to this next stage.

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