5 Common Perimenopause Symptoms That Can Affect Your Mental Health – and What to Do About Them
How did I not know this?
It seems like recently there has been a flood of information related to the midlife transition and hormones and I say, it’s about time! I’m sad (and a little pissed) to admit that in all the years I spent getting my education as a psychologist, working with women, often in medical settings, and being a woman myself, I learned almost nothing about menopause and I’m not even sure I had ever heard the word “perimenopause” before. Sadly, from what I’m hearing from other women, I wasn’t the only one.
Who knew that symptoms related to menopause could start years before one’s final menstrual period? (I didn’t!)
When I was in my late 40s, I remember feeling annoyed that all of a sudden, I seemed to have developed these “love handles” above my hips right where the top of my pants sat. I didn’t think I’d been eating that much, but there they were. So, I did more cardio, cut calories, and guess what—nothing happened. I had no idea that this was likely related to perimenopause for me. I was also moody and even after years of mindfulness practice I was suddenly way more reactive. Like, 13 again reactive. How could I have made it through so many years of education and exposure to the medical field and women’s health issues and still not have a clue about perimenopause?
Maybe because no one talked about it. So seeing all the information that is available now—on YouTube, social media, in books, on websites—should be great, right? But sometimes it’s hard to know what to do with all that information, not to mention sorting out what is real and what is just bull.
As a psychologist and a woman in midlife who works with other women in midlife, I have made it one of my missions to learn more about the impact of hormones on women through the midlife transition, especially as it may relate to mental wellness. And to talk about it.
Perimenopause can affect much more than your menstrual cycle. Common symptoms include hot flashes, sleep problems, mood changes, anxiety, brain fog, changes in sexual functioning, and more. These symptoms can overlap with depression, anxiety and other health conditions, so it’s important to consider both hormonal and psychological factors.
In this article, we’ll look at five common symptoms and practical options for getting help.
What is perimenopause?
Perimenopause, the transition period leading up to the final menstrual period, typically begins for most women in their mid to late 40s, although timing can vary quite a bit from woman to woman. According to the Office of Women’s Health, during this period, which can last between 2 and 8 years before menopause, hormone levels start to fluctuate and eventually decline. These hormonal fluctuations may lead to symptoms such as hot flashes, problems sleeping and mood changes as well as changes in menstrual periods (Silver, N.E.).
Hot flashes and night sweats
Out of nowhere, you suddenly feel like you’re roasting, you break out into a sweat, and the clothing that was perfectly fine 20 seconds ago is suddenly stifling. Or how about this – you’re asleep and suddenly you wake up because you’re drenched in sweat, your PJs, the sheets, everything is wet and you can’t throw off the covers fast enough?
If you have experienced some version of either that seemed to have nothing to do with the temperature of the room, you have likely experienced a hot flash or night sweat. You’re in good company since it’s estimated that up to 80% of women experience them! (El Khoudary, et al., 2019; Horst, Cirino & Adams, 2025) Hot flashes and night sweats, also called vasomotor symptoms, may be some of the symptoms most commonly associated with perimenopause. And they can really mess with your life, disrupting sleep, which may already be a struggle, and interrupting your day. They may lead you to feel self-conscious, embarrassed, and doubting your ability to handle things.
If you have been struggling with these symptoms, you can talk to your ob/gyn or primary care doctor about pharmacological options including Hormone Therapy (HT). Horst and her colleagues (2025) also note that research has shown that other pharmacological options can be effective in treating these symptoms.
If your doctor is not open to talking with you about all your options and having an open discussion of potential pros and cons for you, consider seeing another doctor. The Menopause Society has a directory of healthcare providers who have indicated interest in providing healthcare to women in perimenopause and beyond, including healthcare providers who have obtained certification in this area, found here.
If you are not a good candidate for these treatments due to health risks, side effects or personal choice, or if you are interested in additional non-medical treatment options, there are different psychotherapy approaches that can be helpful. For example, hypnotherapy specifically for vasomotor symptoms has been shown to decrease the intensity of these symptoms significantly. And therapies like Cognitive Behavioral Therapy can help to decrease how much these symptoms interfere with your life. Additionally, there is an app called Evia that provides a 5-week hypnotherapy program for hot flashes delivered digitally. The app is not free but it does have a free trial period.
Mood changes, irritability and depression
Have you noticed feeling like you are on an emotional roller coaster, not feeling like yourself, feeling moody, irritable and reactive? This is also a common experience for women going through perimenopause. In a review of research related to menopause and mental health, Horst and her colleagues (2025) reported that 45-68% of women may experience depressive symptoms and factors like a history of Major Depressive Disorder, early childhood adversity and high levels of stress in the present can increase the severity.
Even though stress and other factors can increase the intensity of these mood symptoms in perimenopause, it is important to consider that hormonal changes can also directly influence mood. In her book, The Menopause Brain, neuroscientist Dr. Lisa Mosconi describes the many roles that estrogen plays in brain function beyond reproduction (Mosconi, 2020). One effect is estrogen’s involvement in the support of neurotransmitters in the brain which affect mood. When estrogen levels start to fluctuate and then decline, the impact on these neurotransmitters can cause our mood to suffer.
And depression has a way of “feeding itself.” If you’re feeling irritable and moody, that can lead to interpersonal conflict, which may make you feel more irritable and moody and make you just want to be alone and avoid people. Then you may feel more isolated and guilty about your reactions which can lead to beating yourself up mentally which can make you feel worse about yourself.
This and low motivation and tiredness can make it harder to get out of bed and go about your day, which can make you feel even worse and keep you from doing activities that might make you feel better, and the cycle can go on and on. It can get so bad that a woman may consider suicide. Studies have suggested a relationship between an increase in suicide risk and the menopause transition, although the relationship is complex (Hendricks, et al., 2025).
Important note about thoughts of suicide
If you are having thoughts of suicide, it is important to get support as soon as possible. You can call the Suicide Crisis Line at 988 or chat with them here. If you are thinking of harming yourself, this is an emergency and you can also go to the emergency department of the nearest hospital 24/7 or you can call your local emergency number (911 in many areas of the United States). If you are having suicidal thoughts, medications, therapy and/or other forms of support can help!
Anxiety
Between the physical changes, the emotional roller coaster, not feeling like yourself, maybe dealing with developmental issues such as kids leaving home, caring for aging parents, and even questioning whether the life you worked so hard to build is even a good fit anymore, and all of this stacked on the “regular” stress that you have likely already been dealing with for years (e.g., taking care of all the beings and things that need to be taken care of), you may find yourself feeling more tense, stressed, anxious, nervous and fearful.
And just when you are experiencing increased stress and need all the coping power you can get, all the things I’ve been talking about plus other possible changes (see list below) may be cutting into your ability to cope and manage stress.
Although anxiety during perimenopause has not been studied as much as depression and some other symptoms, it is often described as a common and bothersome symptom and research suggests that the worse the menopause transition symptoms, the worse the anxiety (Horst, Cirino & Adams, 2025). Anxiety can show up as irritability, feeling wound up and on edge, nervousness, feeling tense, feeling fearful, pounding or racing heart, feeling overwhelmed and less able to cope, worry, panic attacks, and internal unease and jumpiness.
Anxiety can cause you to feel physically distressed, worried, panicky, and overwhelmed and it can shake your confidence, cause you to overthink, torture yourself with “what ifs,” and all of this can lead to avoidance. But just like depression can “feed itself,” anxiety has its own vicious cycles. For example, avoidance may bring temporary relief but can lead to more anxiety in the long run as things stack up, you feel more overwhelmed, your confidence in your ability to handle things dwindles, your anxiety and worry grow, you feel more overwhelmed and try harder to avoid, and so on.
Psychotherapy can be very effective in treating mood and anxiety symptoms including during the menopause transition. These therapies can be tailored to specifically address beliefs that may be especially relevant during midlife including beliefs about aging, body image, loss of old roles, and so on.
Sleep problems
Have you noticed waking up a lot during the night, maybe because of night sweats, aches and pains, having to use the bathroom? If so, you are experiencing some common sleep problems reported by women in perimenopause. You may have also found yourself feeling tired but then lying awake with your mind racing or tossing and turning when you try to go to sleep, or waking up too early and then not being able to go back to sleep.
It has been estimated that as many as 39-60% of women going through the menopause transition experience sleep problems (Horst, Cirino and Adams, 2025). And if you can’t get enough good quality sleep, it can make everything feel worse the next day!
If your sleep is often interrupted by night sweats, some of the options listed above under #1 may be a good starting place. There are also medication options that might help with problems sleeping so talk to your primary care doctor or ob/gyn. Additionally, there is evidence to support that therapy approaches such as Cognitive Behavioral Therapy for Insomnia (CBT-I) can help.
Lifestyle changes like regular exercise can also help, although exercising too close to bedtime might get you too wound up to sleep so it might be helpful to have plenty of wind-down time before bed. Developing a wind-down routine can be an important component of therapy to improve sleep.
While we are talking about sleep, a possible factor that can affect sleep during this time is obstructive sleep apnea, a sleep disorder which interferes with or even temporarily stops breathing during sleep. Although classic symptoms of sleep apnea include loud snoring or gasping for air while sleeping, in women, these symptoms may not be present so women should pay especially close attention to chronic sleepiness during the day, problems with mood and concentration, and repeated nighttime awakenings (Haver, 2024).
Sleep apnea can have serious negative consequences, so if you are experiencing any of these symptoms, consult with your doctor for a possible referral for a sleep study and to learn more about treatment options.
Sexual and genitourinary symptoms
Speaking of problems in mood, the menopause transition can contribute to not being “in the mood”. This can result from hormonally-influenced physical problems related to the menopause transition, lower desire due to changing hormones, and thoughts that can create self-doubt and just not make you feel great about yourself.
Let’s set the scene…you may be feeling kind of down, maybe you’ve noticed some changes in your body that are making you feel self-conscious, you may be having some negative thoughts related to getting older, you may be feeling irritable, including at your partner, you may feel physically uncomfortable from hot flashes, you may just feel exhausted from not sleeping... not ideal for romance. And hormonal changes can directly contribute to low libido and symptoms that affect the functioning of the genitals, bladder and urinary tract, called genitourinary symptoms (Menopause Society, 2025).
Genitourinary symptoms caused by decreasing estrogen levels can contribute to pain and discomfort during sex because of vaginal dryness and thinning and loss of elasticity in vaginal tissue.
The bladder and urinary tract can be affected which can lead to the sensation of needing to urinate often. These hormonal changes can even lead to more frequent urinary tract infections (UTIs). If you are experiencing any of these symptoms, please let your doctor know since there are many treatment options available. The Menopause Society lists a number of options that can help.
Even if you have no interest in a sexual relationship and do not consider sex a priority, there are treatments that can improve general comfort and well-being and prevent UTIs which can cause serious problems, especially as we age. While many of the problems associated with the menopause transition do tend to stabilize over time, estrogen levels continue to fall and so these particular symptoms are not ones that will improve without treatment.
Many women may also experience pelvic floor conditions such as pelvic organ prolapse that can contribute to discomfort and self-consciousness. Pelvic organ prolapse occurs when muscles and connective tissues in the pelvic floor weaken allowing organs like the bladder, uterus and vagina to bulge into the vagina.
While pregnancy and childbirth, straining from chronic constipation, obesity and other factors that put pressure on the pelvic floor can contribute, aging and lowered estrogen in menopause can also contribute to weakening of supportive pelvic floor tissues (Office of Women’s Health). Pelvic organ prolapse can feel like you have a ball in your vagina or can cause a sensation similar to what a tampon would feel like if it was coming out.
Tell your ob/gyn if you are experiencing these symptoms. In addition to medical treatments and devices that might help, they may also refer you to other professionals who can provide assistance, for example, physical therapists with expertise in pelvic floor problems, couple therapists who help couples work through relationship problems including those that affect sexual intimacy, and sex therapists who can directly focus on sexual intimacy.
Other symptoms of perimenopause
Although I am focusing on these 5 symptoms because they are quite common, there are many other symptoms that can be present starting with the onset of perimenopause. For example:
· Brain fog including problems in memory and attention
· Changes in body shape, weight
· Skin changes
· Feeling tired
· Tinnitus
· Burning sensation in mouth
· Heart palpitations
· Stiffness and pain in joints
· Hair loss/thinning
· Headaches
Is it perimenopause, depression, anxiety–or all of the above?
Based on data from a large diverse study of midlife women, El Khoudary and colleagues (2019) reported that depressive and anxiety symptoms associated with perimenopause tend to be transient and that other factors such as stressful life events, low social support, sleep problems and low physical activity contributed more than perimenopause. So how do you know what’s causing what? As is often the case in life, there may not be an easy answer.
If you previously experienced major depression or bipolar disorder, perimenopause can make you more vulnerable to a recurrence of depressive symptoms (Horst, Cirino & Adams, 2025). But just because you feel depressed or anxious does not mean that you have a depressive or anxiety disorder. Things like trouble sleeping can really throw off the next day and make it hard to deal with stressors that in general you might have been dealing with just fine before.
Hormonal fluctuations can affect your mood and reactions, which may in turn make you feel less capable of managing the day-to-day stressors you were previously managing, and this may contribute to not feeling like yourself and feeling overwhelmed. And you may be managing more or different stressors – kids transitioning into adolescence or into young adults, aging parents, extra work stress, changes in your body and how it responds. Change, even positive change, can be super stressful! And when what used to work stops working, that in itself can cause us to feel overwhelmed and unsure.
All of this makes it really important to have a thorough assessment of you by your health provider that takes into account your biology, your history (including family history), your current, recent and upcoming life stressors, and your mental and emotional state. It is helpful to keep track of when your symptoms started, what was happening at the time, what makes them better (and worse), what you have tried (including diet and lifestyle changes supplements, etc.), and what you have noticed over time about their frequency and intensity. This timeline can help your doctor understand your experience better. It also helps because it can be hard to remember some of these things when you are sitting in your doctor’s office!
When should you talk to a healthcare provider?
Besides attending regular check ups as recommended by your doctor, if something is causing distress, problems, or anxiety, it is a good idea to see your healthcare provider. They can personally assess you to gain a better understanding of what might be contributing. We are all unique and will respond to hormonal and other changes in different ways, so talking to your ob/gyn or primary care provider to develop an informed individualized approach to treatment is always a good starting place.
How can therapy help during perimenopause?
While your primary care doctor or ob/gyn can help with the “biological” aspects of perimenopause, therapy can help with the psychological and emotional aspects. Some therapy approaches like Cognitive Behavioral Therapy for Insomnia target very specific problems like problems sleeping. And therapy can also help in many other ways.
Therapy can help you identify unrealistic beliefs that you may have learned in the past from your environment about how you should do things and what you should be able to expect from yourself. It can also help you identify unworkable or unsustainable patterns of behavior that you may have developed trying to “measure up” to these beliefs.
If lately, you have found yourself in a cycle of trying to do everything right, things not working as you were anticipating, feeling overwhelmed, thinking “I’m failing… I’m doing something wrong… I need to try harder” but it never feels like enough, that may be one sign that you have some unrealistic expectations.
It might even be that in the past you felt like you were able to stay on top of things, even if it was not easy. But now, between perimenopause symptoms and other life stressors, your stress level may have increased exponentially while your coping resources are stretched very thin and it may feel like too much. This might have you thinking “What’s wrong with me that I can’t handle this? I should be able to handle this, I was doing it before!” And maybe you were “doing it all.”
Taking care of everyone and everything (maybe except you), trying to fix everything (even if it wasn’t yours to fix) and assuming you were supposed to, it was your job, maybe you were even doing that for years and it was sort of working or even working well. And now it’s not.
So you find yourself still trying to do all the “right” things but now, it’s not working in the same way, so you try harder, but it still doesn’t work. And then you feel overwhelmed and out of control, you feel shame, fear, anxiety, inadequacy. You experience painful thoughts like “I’m too emotional, I’m broken, There is something wrong with me, I’m too old, Everything will be going downhill from now on, I’m too sensitive, I’m failing, I’m inadequate, not enough, I’m weak, I should be able to manage this” causing you to lose trust and confidence in yourself and your own abilities.
Therapy can help you uncover some of the underlying beliefs that can fuel these thoughts and help you identify different ways of looking at things that are based on your values, what you care about, and who and how you want to be in life now. And it can help you find new ways to respond that align with who you are now.
We humans don’t particularly like change! Like I said earlier, even positive changes can be quite stressful. And wow, does mid-life come with some changes! There are physical changes, including some of the hormonal changes that we have been talking about and your own body may feel out of control in some ways. There are also thoughts and beliefs about what these changes may mean for you and how they might impact the future.
And then there are potential role and life changes. You may not even recognize that some of those changes, for example, kids moving on with their lives, becoming the caregiver of a parent, career changes, etc., often lead to feelings of loss and grief. And you may have ideas about aging that may be limiting and may not apply to you at all.
Therapy can help you find a balance between acceptance and change. With your therapist you can learn ways to sit with your emotions without feeling overwhelmed by or controlled by them. Therapy can provide a confidential safe space for you to just show up with whatever you’ve got, without having to put on a mask or act like everything is ok. Where you can just be you.
Therapy can help you to catch the depression and anxiety loops I described earlier and find ways to step out of those loops. And therapy can help support lifestyle changes that you decide might be helpful in taking care of you. Like I said, change is hard!
We are more than just our hormones
Although hormonal changes can wreak havoc, they are just one facet of mental wellness in midlife and we are way more than just our hormones. This can be a time for major changes in career, parenting, priorities, and so on. Research suggests though that it doesn’t have to be a “mid-life crisis.” In fact, it can be a time of great growth … sometimes it’s just a rough journey getting there!
If you are on that journey but feeling stuck and needing some clarity, therapy can help. If you live in the Dallas area and would like to work with me or learn more, you can reach out to me by phone or email or schedule a free consult. I also offer video sessions across Texas.
Helpful perimenopause and menopause resources
American College of Obstetricians & Gynecologists (ACOG)
https://www.acog.org/womens-health/healthy-aging/menopause
U.S. Department of Health and Human Services Office on Women’s Health
https://womenshealth.gov/menopause
The Menopause Society https://menopause.org/patient-education
And to find a menopause practitioner:
https://portal.menopause.org/NAMS/NAMS/Directory/Menopause-Practitioner.aspx
The Pause Life: Dr. Mary Clare Haver’s website
My Meno Plan website
Helpful Books:
Fadal, T. (2025). How to menopause: Take charge of your health, reclaim your life, and feel even better than before. Balance.
Haver, M.C. (2024). The new menopause: Navigating your path through hormonal change with purpose, power and facts. Penguin Random House UK.
Haver, M.C. (2026).The new perimenopause: An evidence-based guide to surviving the zone of chaos and feeling like yourself again. Random House Large Print.
Mosconi, L. (2024). The menopause brain: New science empowers women to navigate the pivotal transition with knowledge and confidence. Avery.
References
El Khoudary SR, Greendale G, Crawford SL, Avis NE, Brooks MM, Thurston RC, Karvonen-Gutierrez C, Waetjen LE, Matthews K. The menopause transition and women's health at midlife: a progress report from the Study of Women's Health Across the Nation (SWAN). Menopause. 2019 Oct;26(10):1213-1227. doi: 10.1097/ GME.0000000000001424. PMID: 31568098; PMCID: PMC6784846.
Haver, M.C. (2024). The new menopause: Navigating your path through hormonal change with purpose, power and facts. Penguin Random House UK.
Hendricks, O., McIntyre, J.C., Rose, A.K., Sambrook, L., Reisel, D., Crockett, C., Newson, L., & Saini, P. (2025) Menopause and suicide: A systematic review. Women’s Health, 21, 1-18. DOI: 10.1177/17455057251360517
Horst, K., Cirino, N., & Adams, K.E. (2025). Menopause and mental health, Curr Opin Obstet Gynecol, 37, 102-110. DOI 10.1097/GCO.0000000000001014
Menopause Society. (2025). Menonotes: Genitourinary Syndrome of Menopause. https://menopause.org/wp-content/uploads/for-women/MenoNote-GSM.pdf
Mosconi, L. (2024). The menopause brain: New science empowers women to navigate the pivotal transition with knowledge and confidence. Avery.
Silver, N.E. pub April 2023, last reviewed Feb 2025 https://www.acog.org/womens-health/experts-and-stories/the-latest/mood-changes-during-perimenopause-are-real-heres-what-to-know