Perimenopause and Menopause and Your Mental Health: What You Need to Know

If you’re one of the millions of middle-aged women around the ages of 44-56 who identify as being in perimenopause or menopause, you’re at a heightened risk for anxiety and depression. According to Raglan et al. (2020), over 40% of perimenopausal women experience depressive symptoms, with rates of depression up to four times higher than before this life stage. While anxiety during perimenopause has not been extensively studied, research indicates that women who previously had low anxiety may develop high anxiety during perimenopause. Women with pre-existing mental health conditions often find that symptoms worsen during this transition, which can last anywhere from 2 to 7 years or longer (National Institute on Aging).

Despite its impact, discussions about the connection between perimenopause, menopause, and mental health remain limited. Does your therapist understand how these changes affect your mood, self-perception and overall well-being? Do you?

Beyond Hot Flashes: Physical Symptoms That Impact Mental Health

The hormonal fluctuations during perimenopause and menopause can lead to a variety of physical symptoms, often beyond the well-known hot flashes and night sweats. Vasomotor symptoms (VSM) such as migraines, heart palpitations, dizziness, brain fog, sleep disturbances, and fatigue affect 80% of women and can last an average of 10 years (Society for Women’s Health Research).

Additionally, genitourinary symptoms (GSM), including vaginal dryness, vulvovaginal atrophy, urinary incontinence, painful intercourse, and low libido, impact 50-70% of women in this stage of life (Society for Women’s Health Research).

Other common physical symptoms include:

• Joint pain and body aches
• Breast tenderness and sensitivity
• Hair thinning and brittle nails
• Low bone density and increased fracture risk
• Unexplained weight gain, particularly around the abdomen
• Heavy, irregular, or prolonged periods

These symptoms don’t just cause discomfort; they can significantly affect mood, body image, and overall outlook on life.

How Life Transitions During Menopause Affect Mental Health

Beyond hormonal shifts, perimenopause and menopause coincide with significant life transitions that can contribute to stress, anxiety, and depression. These include

• Parenting children and teenagers
• Supporting aging parents
• Navigating career changes or retirement
• Relationship challenges that may have built up over time
• Children leaving home (empty nest syndrome)
• Coping with grief and loss
• Managing health issues and diagnoses

According to the Society for Women’s Health Research, two out of five women have considered changing jobs—or have done so—due to their perimenopause and menopause symptoms. The combination of biological and external stressors can make this stage of life uniquely challenging for mental well-being.

Recognizing Anxiety and Depression in Perimenopause and Menopause

During perimenopause and menopause, symptoms of anxiety and/or depression can arise suddenly or gradually worsen over time. Estrogen plays a key role in mood regulation by supporting neurotransmitters. As estrogen declines, so does mood stability, increasing the risk of emotional distress. Additional factors that contribute to anxiety and depression include:

• Sleep disturbances (waking up at 3 AM and struggling to fall back asleep),
• Changes in body image and self esteem
• Fertility loss and emotional adjustment
• The stress of managing physical symptoms while maintaining daily responsibilities

It’s important to note that depression during menopause may present differently than at other life stages. Instead of persistent sadness, symptoms may include nervousness, mood swings, irritability, and anger (Raglan et al., 2020).

Additionally, heart palpitations—a common perimenopausal symptom—can feel similar to anxiety, making it crucial to consult a healthcare provider for proper evaluation.

Best Strategies for Managing Mental Health in Menopause

Because perimenopause and menopause involve complex hormonal and psychological changes, a multidisciplinary approach is often the most effective for managing mental health. Seeking care from a knowledgeable medical professional and a therapist with menopause expertise can make a significant difference.

Resources such as The Menopause Society’s Certified Menopause Practitioners (NCMP) clinician database is great reference as is the crowd-sourced clinicians list on Dr. Mary Claire Havers ‘Pause life website, offering guidance in finding experienced healthcare providers. Your doctor can assess whether treatments like hormone replacement therapy (HRT), lifestyle changes, natural remedies, or psychotropic medications may be helpful.

Additionally, therapy can be instrumental in improving emotional resilience, self-compassion, and overall well-being. A study by Suss et al. (2020) found that women who practice emotional regulation, mindfulness, and self-care during menopause experience better mental health outcomes. A psychotherapist can help you with all of these areas. Your therapist can also help you manage or resolve mental health symptoms, increase mindfulness, alleviate stress, improve your relationships, and restore a sense of wellbeing. They can support you in any changes that you need to or want to make.

Psychotherapy can be a stand-alone treatment during perimenopause/menopause or co-occur with medical interventions. You want to work with a psychotherapist that you trust and feel safe and comfortable with and who has an understanding of the biopsychosocial elements of the menopausal transition. Tell your therapist what you are experiencing and how it is impacting your life.

If GSM symptoms are impacting your relationship and sex life and causing you stress or anxiety, let us know. If hot flashes are making it hard to attend work meetings because you are afraid of sweating through your clothes, if you are irritable because you aren’t sleeping, let us know. We are trained to create a safe, non-judgmental space to talk about these subjects and to help you with them. And you don’t need to worry that something might be too embarrassing to bring up–therapists hear it all. A subject that might feel embarrassing or shameful to you is quite normal for us.

The Most Effective Therapy Options for Menopause-Related Mental Health Challenges

While research on specific therapy modalities for menopause is still emerging, the strength of the therapeutic relationship is the most critical factor in successful treatment. Finding a therapist you trust and feel comfortable with is key.

Some evidence-based therapy approaches that may be beneficial include:

• Emotionally Focused Individual Therapy (EFIT) and Accelerated Experiential Dynamic Psychotherapy (AEDP): These attachment-based therapies focus on emotional regulation and deep healing.
• Emotionally Focused Couples Therapy (EFCT also known as EFT): Helps couples navigate relationship changes brought on by menopause-related shifts.
• Cognitive Behavioral Therapy (CBT): Studies suggest CBT can help manage menopause-related anxiety, depression, and even physical symptoms like hot flashes by restructuring negative thought patterns.
• Cognitive Behavioral Therapy for Insomnia (CBT-I): Proven to be more effective than sleep hygiene education alone for managing menopause-related sleep disturbances (Drake et al., 2019).

While many therapists use multiple modalities, the most important factor is working with a professional who understands the biopsychosocial aspects of the menopausal transition.

Thriving Through Menopause: How to Prioritize Your Mental Well-Being

Perimenopause and menopause are transformative life stages that bring significant biological, psychological, and social changes. Women face an increased risk of anxiety and depression during this time, underscoring the importance of mental health care. Your body and mind are deeply connected—when your body undergoes significant changes, your emotions and thoughts do too.

Seeking support from a knowledgeable therapist can help you navigate these changes with greater resilience. Whether through psychotherapy, medical interventions, or lifestyle adjustments, prioritizing mental health during menopause is a powerful investment in your overall well-being.

You are not alone in this journey, and with the right support, you can emerge from menopause with strength, clarity, and renewed confidence.  

Resources

Bromberger, J.T, Kravitz, H.M., Chang, Y, Randolph, J.F. Jr, Avis, N.E., Gold, E.B, Matthews, K. A. (2013). Does risk for anxiety increase during the menopausal transition? Study of women’s health across the nation. Menopause. 20(5):488-95. doi: 10.1097/GME.0b013e3182730599. PMID: 23615639; PMCID: PMC3641149.

https://pmc.ncbi.nlm.nih.gov/articles/PMC3641149

Drake, C. L., Kalmbach, D. A., Arnedt, J. T., Cheng, P., Tonnu, C. V., Cuamatzi-Castelan, A., & Fellman-Couture, C. (2019). Treating chronic insomnia in postmenopausal women: a randomized clinical trial comparing cognitive-behavioral therapy for insomnia, sleep restriction therapy, and sleep hygiene education. Sleep (New York, N.Y.), 42(2), 1-. https://doi.org/10.1093/sleep/zsy217

Raglan, G. B., Schulkin, J., & Micks, E. (2020). Depression during perimenopause: the role of the obstetrician-gynecologist. Archives of Women’s Mental Health, 23(1), 1–10. https://doi.org/10.1007/s00737-019-0950-6

Süss, H., Willi, J., Grub, J., & Ehlert, U. (2021). Psychosocial factors promoting resilience during the menopausal transition. Archives of Women’s Mental Health, 24(2), 231–241. https://doi.org/10.1007/s00737-020-01055-7