Perimenopause Anxiety

Introduction

Are you in your 40s, menstruate and experience unpredictable periods, sometimes accompanied by heavy bleeding? Do you often feel nervous, irritable, or exhausted, and struggle with sleep? Or perhaps you find yourself snapping at those around you? You’re not alone. These changes could be signs that you're going through perimenopause, the transitional years before menopause. In this section, we’ll explore the connection between perimenopause and anxiety.

What is perimenopause?

Perimenopause is the natural transition period that marks the shift from the physical, emotional, and hormonal changes of menopause to 12 months after your last menstrual period.¹ Once 12 months have passed without a period, you are officially considered to be in menopause.

Typically lasting anywhere from two to ten years, perimenopause is the phase during which your ovaries gradually stop functioning and release eggs less regularly. As a result, the production of oestrogen and other hormones declines, leading to reduced fertility. During this time, you may notice that your menstrual cycles become irregular, or that you occasionally miss a period.

Anxiety during the perimenopausal years

Many individuals assigned female at birth (AFAB) experience anxiety symptoms during midlife. Studies show that up to 51% of people AFAB between the ages of 40 and 55 report feelings of tension, nervousness, or irritability, with around 25% describing their anxiety as frequent. Those in perimenopause are at a higher risk for experiencing anxiety symptoms compared to their premenopausal counterparts.²

In addition to the hormonal changes that occur during perimenopause, this stage of life often brings external triggers for anxiety. For example, many people may be balancing responsibilities such as raising children, advancing in their careers, or managing concerns about ageing parents’ health. Life events like moving, experiencing a relationship breakdown, or feeling uneasy about natural ageing processes can also contribute to or trigger anxiety during this time.²

What causes perimenopausal anxiety?

During the perimenopausal phase, your oestrogen and progesterone levels decline with each menstrual cycle as your body transitions toward menopause. The fluctuations in these hormones can lead to mood swings, which is why many people also experience symptoms of depression during this time.¹

Research has shown that oestrogen plays a crucial role in regulating brain function, particularly in relation to mood and emotions. This hormone influences the release of neurochemicals like serotonin, dopamine, norepinephrine, and melatonin, all of which impact mood, emotions, and behaviour.

In addition, an imbalance between oestrogen and progesterone can trigger stress in the body. If you are already feeling stressed due to the changes and symptoms of perimenopause, your body is likely to produce more of the stress hormone cortisol.

The increased cortisol production can further disrupt the balance of oestrogen and progesterone, leading to additional mood changes and sometimes other health challenges.³

Symptoms

When going through perimenopause, mental health changes may go unnoticed amidst physical signs and changes. However, alongside physical symptoms such as hot flashes, night sweats, and the eventual end of menstrual periods, many people who menstruate experience mood changes too.⁴ 

Knowing the signs of perimenopause can help you to identify whether you may be entering, or in, this phase. This can support you in understanding whether your anxiety symptoms may be connected.⁴

Hot flashes

You can experience hot flashes (also known as hot flushes) differently. However, they may feel like a rapid surge of heat spreading through your body, and your skin might flush or feel sweaty. Hot flashes tend to be brief, although their length can also vary from person to person.⁵

During the early stages of perimenopause, hot flashes tend to be mild in nature.⁵ Their prevalence often begins to increase in the later stages. You might feel anxious about having hot flashes at work or in social situations. Opening a window, keeping a small fan handy, or wearing layers of clothing that can easily be removed during a hot flash may help you manage them.⁶ Becoming aware of any triggers for your hot flashes may also enable you to limit their frequency or severity.⁶

Sleep disturbances

People AFAB tend to experience changes in their sleep patterns during their 40s, which can be exacerbated by the menopausal transition. If you are experiencing significant stress and anxiety, you may find that worries or spiralling thoughts can also keep you awake, or wake you up during the night. 

Poor sleep is a common symptom of anxiety disorders, so, during perimenopause, multiple factors might make it difficult for you to get a good night’s rest.

In turn, sleep problems can cause you to feel tired during the day making it hard to start, focus on, or complete daily activities. These difficulties in being able to do the things you need to at work, home, or elsewhere may trigger further anxiety or low mood. Following the tips below for better sleep, or talking to your GP, could be useful for helping you to improve your sleep quality and the number of hours that it lasts.

Sleep disturbances can also happen as a result of hot flashes, which can produce night sweats. 

Vaginal dryness

Hot flashes and mood fluctuations tend to improve over time. However, like sleep disturbances, vaginal dryness does not usually get better without specific ongoing treatment.⁵ 

Vaginal dryness before, and following, menopause is caused by reduced levels of oestrogen and can lead to discomfort during sexual intercourse.⁵ This can affect how much you want or enjoy sex and might trigger anxiety about being intimate with a partner. 

However, products such as water-based lubricants are widely available without the need for a GP prescription. These can help to treat vaginal dryness and enable you to continue to enjoy an active sex life.⁶

Adverse mood

Depressive and anxiety symptoms are more likely to be reported by perimenopausal individuals. It is estimated that 10% to 20% experience mood-related symptoms during this phase. Anxiety symptoms may involve:^4,5,6

• Constant worrying 
• Muscle tension 
• Restlessness
• Sweating
• Concentration difficulties
• Sleep difficulties
• Dizziness, or heart palpitations
• Nausea

Anxiety is also a feature of other related conditions such as phobias, panic disorder, and post-traumatic stress disorder (PTSD).

People AFAB are more likely to report symptoms of depression, and to experience a major depressive episode.⁵ Typical symptoms of depression include:

• Continuous and persistent low mood 
• Low motivation and energy
• Low self-esteem and/or self-worth
• Feeling frequently irritated by, or intolerant of, other people
• Frequent feelings of hopelessness or helplessness
• Frequently feeling tearful
• Feeling guilt-ridden
• Finding it difficult to make decisions
• Feeling little enjoyment in life, or little interest in things
• Changes in appetite, sleep, and/or libido
• Unexplained aches and pains
• Becoming withdrawn, or avoiding others
• Thoughts of harming yourself, or taking your own life

Other symptoms of perimenopause

You may also notice other changes during perimenopause, such as changes in your weight or how it is distributed on your body, and needing to urinate more frequently. Some perimenopausal people also notice changes to their skin and hair. These changes may feel difficult to acknowledge and accept and may increase anxiety levels for some people.⁴

Self-care strategies, healthy eating, and regular exercise can all support a healthy perimenopause and menopause.³ Read on for more detailed tips and ideas.

Treatment

Talk with your GP or obstetrician/gynaecologist who can help identify symptoms related to anxiety. They can discuss with you the following options for medication, lifestyle changes, or other ways to alleviate or manage your symptoms.⁴

Medication 

Antidepressants are found to be helpful with depressive and anxious symptoms.^4,5 Your healthcare provider can discuss with you which may be most helpful for you. 

Hormone replacement therapy (HRT), and other medications, may be helpful for some physical menopausal symptoms.⁵ If these symptoms are exacerbating perimenopausal anxiety, they may provide some reduction in its severity.

Tips for better sleep

Sleep deprivation or poor-quality sleep may result in difficulties with decision-making, solving problems, controlling emotions and behaviour, and/or coping with change. Lack of sufficient sleep has also been linked to depression and suicidal tendencies.

Follow these steps in order to create an environment for comfortable sleep:⁴

• Maintain a regular sleeping routine
• Avoid any screen time for at least an hour before bedtime
• Consider taking lighter meals at least a few hours before bedtime
• Avoid consumption of caffeine in the afternoon — it can affect you for up to 8 hours after drinking it
• Keep your bedroom neat and sleep-friendly
• Keep a notebook and pen by your bed to jot down any thoughts or concerns that are going around in your head, keeping you awake. Don’t worry about writing in complete sentences, or with perfect spelling; the important thing is getting these fears or problems out of your head
• Keep a book or magazine by your bed, too. If you are finding it difficult to fall asleep, or you wake in the night and struggle to get back to sleep, staying in bed and reading may help (although avoid reading on a screen)
• If hot flashes and night sweats interrupt your sleep, consider using cooler bedding or having a fan on in your bedroom

Change your habits to improve mental and physical health

• Exercise regularly: Find enjoyable ways to get moving, such as walking or swimming with friends, joining a local dance or yoga class, or gardening. Aim to include at least some exercise that raises your heart rate and strengthens your muscles³
• Stop smoking: Seek support from your healthcare provider to reduce or quit smoking. This can help improve your breathing, sleep, your mood, reduce cancer risk, and offer numerous other health benefits
• Prioritise self-care: Practices like meditation, yoga, playing music, journaling, and massage therapy can help reduce stress.⁴ Talking with others who are going through perimenopause, whether in a support group or among similar-aged friends, can help normalize symptoms. Sharing experiences and struggles may provide helpful tips and strategies for managing them, while also allowing you to enjoy some fun moments together

Talk to your healthcare team

Continue regular visits to your GP, obstetrician, or gynaecologist, and keep them informed about how you're feeling. In between appointments, consider keeping a diary of your perimenopausal anxiety symptoms. This can help you identify patterns and triggers to discuss with your healthcare provider. Your healthcare team can offer support as you navigate this phase of life.⁴

Summary

Perimenopause is a natural transition towards menopause in individuals who menstruate, typically occurring between the ages of 40 and 55. During this phase, hormonal imbalances can lead to both physical and psychological changes, which may range from mild to temporary.

In addition to common symptoms like hot flashes, night sweats, and vaginal dryness, mood changes such as anxiety are also common. These symptoms are often manageable with the right medications and lifestyle adjustments. Seeking medical support can provide options for managing perimenopausal anxiety, helping you navigate this life stage with greater control.