Perimenopause and Mental Health: When You Don’t Quite Feel Like Yourself

Sunlight shining through green leaves to represent mental health challenges during perimenopause

Perimenopause and Mental Health: When You Don’t Quite Feel Like Yourself

Perimenopause can affect our mental health in unexpected ways. For example, we may feel more anxious or irritable, have a harder time regulating our emotions, struggle with sleep or concentration, or notice that the coping strategies we’ve relied on for years aren’t working as well anymore.

For some of us, these changes can be significant enough that we start to feel confused about what’s happening. Why am I so angry? Why does everything feel overwhelming? Why can’t I concentrate? Why am I suddenly anxious when I’ve never been an anxious person – or why is the anxiety I’ve always managed feeling harder to manage?

Hormonal changes can be part of the answer. However, they are rarely the whole answer.

The truth is: perimenopause often happens during an already complicated stage of life, and our hormones, sleep, physical health, relationships, stress, past experiences, and mental health can all interact. Understanding that bigger picture can help us make sense of what we’re experiencing – and ultimately figure out what can actually help us feel more grounded.

Perimenopause affects mental health and menstrual cycles

Perimenopause, the transition to menopause, can last for several years – and our hormones don’t simply decline in a smooth, predictable way. Estrogen and progesterone can fluctuate considerably throughout the transition.

Estrogen does much more than regulate our reproductive system. It also interacts with the brain, including systems involved in mood, memory, stress response, and emotional processing. During perimenopause, researchers are particularly interested in the effects of fluctuating estrogen levels, not simply declining estrogen.

Some studies suggest that greater fluctuations in estradiol may make certain women more sensitive to stress or more vulnerable to depressive symptoms. But we don’t all respond to hormonal changes in the same way, and hormones are only one part of what’s happening during perimenopause.

During this transition, it’s common to experience changes in mood, anxiety, irritability, sleep, concentration, memory, energy, or sexual desire. These changes can be influenced by hormonal fluctuations, but also by sleep, physical health, previous experiences with anxiety or depression, stressful life events, relationships, and social support. In other words, perimenopause is happening within the context of our lives – and both matter.

“Why can’t I handle things the way I used to?”

This can be an especially difficult question for those of us who have spent much of our lives being capable, productive, and accustomed to pushing through. We may still have the same jobs, families, relationships, and responsibilities. Yet, our internal experience of managing everything can suddenly feel different for a number of reasons.

Sleep disruption is common during the menopause transition. This matters greatly because poor sleep can make it harder to concentrate, tolerate frustration, manage stress, and regulate emotions. Hormonal fluctuations may also affect brain systems involved in mood and cognition.

At the same time, perimenopause frequently arrives during an already complicated period of life. We may be parenting children or teenagers, caring for aging parents, managing demanding careers, navigating changes in relationships, experiencing changes in our bodies, and/or beginning to question roles and expectations we’ve carried for decades.

It can be tempting to ask whether what we’re experiencing is hormonal or psychological. It can often be both because our minds and bodies are connected. 

Why our emotions may feel louder in perimenopause

Many of us describe feeling more emotionally reactive during perimenopause. We may notice more anxiety, tearfulness, impatience, irritability, or anger. Researchers have studied depression during the menopause transition extensively, while irritability and anger have received considerably less attention. 

Emotional regulation doesn’t mean not having strong emotions. It’s our ability to notice, understand, tolerate, and respond to emotions without becoming completely overtaken by them. When sleep, hormones, stress, physical symptoms, and the demands of our lives are changing at once, the space between feeling something and reacting to it can feel much smaller.

For some, the urge is to contain the emotion, rather than exploring why we are feeling it. Intense emotions are just as valid as quiet ones. 

When anger in perimenopause is worth listening to for our mental health

Increased irritability and anger is one of the most challenging aspects of perimenopause. It can be tempting to explain those feelings as simply another symptom of hormones. However, it is really important to consider the root of the anger, rather than getting lost in the experience of it.

Many of us had complicated relationships with anger long before perimenopause. Women often receive messages, both directly and indirectly, about which emotions are acceptable for us to feel and express. We may learn to be accommodating, keep the peace, avoid appearing difficult, or question whether we have a right to be angry in the first place. Research suggests these concerns aren’t imagined: women can experience social consequences for expressing anger. As a result, we may express less anger than we actually feel.

The goal here is to acknowledge that just because anger may feel louder during perimenopause, there may be reasons beyond hormones worth exploring. At the same time, we also can see that every angry feeling is not necessarily telling us that something fundamental needs to change in our lives. Ideally, we can get curious about both the intensity of the emotion and what may be underneath it.

We can ask ourselves what we are feeling so angry about. Maybe we’ve spent years taking care of everyone else. We might be noticing that we’ve become accustomed to saying “yes” when what we really mean is “no.” Maybe we’re carrying an unequal share of the responsibilities at home. Maybe we’re exhausted for reasons other than sleep cycle interruptions. It’s possible that something in a relationship hasn’t been working for a long time. For many, it can feel like we’ve spent years being the person everyone can rely on and we’ve rarely stopped to ask what we need.

Whether feelings are feeling intense or not, there is value in listening to what they are trying to say. 

What about anxiety and depression and other mental health challenges in perimenopause?

Of all the mental health concerns associated with perimenopause, depression has been studied most extensively. Research suggests that perimenopause can be a period of increased vulnerability to depressive symptoms, particularly for those with a previous history of depression. Anxiety symptoms are also common. Hot flashes, night sweats, and disrupted sleep may contribute to both as well.

It’s important to note that mood changes during perimenopause do not necessarily indicate a mental health disorder. We recommend being evaluated by a mental health professional. Either way, significant changes deserve attention, especially when they begin affecting our relationships, work, sleep, daily functioning, or quality of life.

How perimenopause can interact with things we’ve carried for a long time

For some of us, old emotional wounds, relationship patterns, or trauma responses may become more noticeable during midlife. Thankfully, researchers are beginning to study perimenopause and mental health more closely. Research suggests that the menopause transition may be a period of particular vulnerability for people with trauma histories. The science is still developing and there is no evidence that hormonal changes simply bring trauma back.

There may be a more complicated interaction happening. Sleep disruption, stress, physical symptoms, changes in emotional regulation, and major life transitions can all affect how we experience things we’ve carried with us for a long time. Sometimes strategies that helped us function for years stop working quite as well.

When trusted coping mechanisms are no longer doing the job, we may find ourselves overwhelmed by things that used to feel like no big deal.

What if we already have ADHD?

Mental health during perimenopause for those with ADHD is worth considering. Many women with ADHD report changes in attention, memory, organization, motivation, and emotional regulation during periods of hormonal change. Researchers have proposed that fluctuations in estrogen may interact with neurotransmitter systems involved in ADHD, including dopamine. However, the research is still relatively new.

Some studies have also found changes in attention, working memory, processing speed, and executive functioning, which can affect our ability to concentrate, hold information in mind, shift between tasks, or organize our thoughts. However, findings in these areas have been less consistent.

There is not enough evidence that worsening concentration during perimenopause means that we have ADHD, or that everyone with ADHD will experience worsening symptoms. However, many of the symptoms seem to overlap so it is a very good question. 

Is “brain fog” real?

The bad news and the good news: yes, brain fog is real. People in perimenopause frequently report cognitive challenges during this time. We may find ourselves searching for words, forgetting why we walked into a room, struggling to concentrate, losing track of information, or wondering why multitasking suddenly feels so much harder. The viral “We Do Not Care Club” pokes fun at perimenopausal moments when we are looking everywhere for our glasses and they’ve been on our head or face the whole time.  

Researchers have found some measurable cognitive differences during perimenopause, although findings vary depending on the population and the type of cognitive function being studied. The most consistent evidence points to small changes in verbal learning and memory. For example, the women studied reported needing more repetition to learn new information or having a harder time recalling a word, name, or detail quickly. 

Importantly, these changes are generally subtle. Thankfully, most women continue to perform within normal ranges on cognitive testing. So when we jump to concerns about dementia, it can bring some relief to know that just because we are having these symptoms now does not mean we will forever. Actually, for some women, cognitive efficiency may improve after menopause. It might help our mental health during perimenopause to know that things may get better. 

Sleep disruption, hot flashes, depression, anxiety, stress, ADHD, and physical health can also affect how clearly and efficiently the brain is functioning, making it difficult to separate the direct effects of hormonal changes from everything else happening during this stage of life.

Brain fog doesn’t automatically mean something is seriously wrong with our memory. However, significant or concerning cognitive changes are still worth discussing with a healthcare provider. 

Therapy can’t balance hormones, but it can really help our mental health in Perimenopause

Our mental health during perimenopause is one part of a larger picture. Depending on what we’re experiencing, it may make sense to speak with a physician or another qualified healthcare provider about physical symptoms, hormonal changes, medications, or menopause treatment options. The first place many women search is menopause.org, where there is a directory of Menopause Society Certified Practitioners listed. 

Therapy, on the other hand, gives us a place to understand what we’re experiencing rather than simply trying to push through it. 

With support, we can learn to:

Therapy can help us learn to regulate our response, but only after we understand what’s going on. We don’t need to convince ourselves that everything is fine or get better at burying emotions that are telling us something important. We want to understand what we are experiencing and give ourselves more agency about what comes next.

We don’t have to decide whether it’s “hormonal or psychological”

One of the frustrating things about perimenopause is the temptation to put every symptom into a category and the difficulty actually doing so. It is a natural reaction to want to manage the symptoms by first diagnosing ourselves. Whether it is anxiety, depression, hormones, adhd, relationship stress, lack of sleep, trauma, or burnout, it is often a combination of things causing our experience, not just one. Our minds and bodies don’t divide themselves so neatly. It’s important to look at the whole picture and give ourselves a break if we can’t identify the one cause of a particular symptom. 

We are still ourselves, even when we feel different

Perimenopause can be disorienting, particularly when changes begin before we even realize we’re in the transition. Some women start to notice changes in their cycle length, timing, or intensity. Others may find that they can’t seem to come up with the right word all of a sudden. It can cause us to question our own reality. 

We may feel different and not like ourselves. Therapy can help us see that we are still the same person, but perhaps it’s ok that we are losing patience for things we used to carry for others. Perimenopause is a time of great change and an opportunity to rethink how we want to live our lives, feel in our bodies, show up in our relationships, and talk to ourselves.  

If you are experiencing perimenopausal symptoms that are impacting your mood, focus, relationships, or overall outlook, you are not alone and we are here to help. We invite you to reach out to our Client Care team via email, phone, or by scheduling a brief consultation. 

Nashville Psych office, representing where to get support for mental health challenges during perimenopause