​This may not be a popular or widely accepted idea – in fact, in some circles, it may even be considered controversial. But here it is: I don’t believe that CBT helps eradicate perimenopausal symptoms.

CBT stands for Cognitive Behavioral Therapy. The American Psychological Association (APA) defines CBT as “a form of psychological treatment that has been demonstrated to be effective for a range of problems, including depression, anxiety disorders, alcohol and drug use problems, marital problems, eating disorders and severe mental illness.”

According to the APA, CBT helps people change their thinking patterns. The premise is that psychological problems are rooted in untrue or unhelpful thinking styles and behaviors. Additionally, the notion is that if people learn different ways of coping, they are achieve relief from symptoms and lead better lives.

It doesn’t elude me that the APA and other professional organizations whose members offer services like CBT have a vested interest in promoting it as a solution. Doing so keeps their appointments booked and a steady flow of clients who are hopeful that the remedies for what ails them is CBT.

So when I hear about women being recommended counseling or CBT for perimenopausal symptoms, I want to scream. Why?!

Perimenopause Is Not All In the Mind

Well, for starters, perimenopause is increasingly being considered as a complex, dynamic “neurological transition state.” Some go a bit further and classify it as a neuro-endocrine process that affects multiple body systems all at once – the brain, the reproductive organs, the adrenal system and all sorts of involved hormones and neurotransmitters.

What this means, exactly, is pretty involved. At a minimum perimenopause is not relegated to the reproductive tract. It affects more than the ovaries and includes the involvement of the brain, its structures and its chemicals, and every place and function in a woman’s body that estrogen touches. Estrogen-related systems include those responsible for temperature control, sleep and circadian rhythms, cognitive function, mood, bone health and more.

Some of the most common symptoms of perimenopause are not just those hot flashes and night sweats so many people hear about. Instead, some of the most disruptive consequences of the hormonal changes are the emergence of anxiety or depression, trouble with sleep, the onset of headaches, the occurrence of new aches and pains and even dryness of the skin, tissues and eyes.

When women present to their doctors with these symptoms, many are often told one of two main things:

1. “You’re too young to be in menopause.” This is frequently said by doctors who are pretty unfamiliar with the difference between perimenopause and menopause, and who have limited knowledge of the fact that hormone changes begin in the 30s. They tend to think of menopause as the end of menstrual cycles – and only that – discounting the many associated symptoms that can offer beforehand.
2. “Let’s get you an antidepressant.” This is usually offered by gynecologists and general medicine doctors who are afraid to prescribe hormone replacement therapy, who know almost nothing about perimenopause or who are going for the lowest common denominator in terms of menopause management.

Sadly, when some women hear this, they walk out of the doctor’s office feeling dejected and unheard. And, moreover, they begin to think that maybe all these symptoms really are in their minds – that they need some emotional help – aid that comes in the form of therapy.

Perimenopause Is a Time Ripe for Spending Money Unnecessarily

Also, even more sadly, there are many social workers, counselors and therapists ready and willing to take women’s money and time, claiming that therapy sessions will help resolve their physical perimenopause symptoms. Some promote the concept that 1:1 counseling will temper the night sweats, the racing heartbeats and the sudden feeling of doom. The problem with this is that these perimenopause symptoms are physiological in nature – that means they stem from the way we, as human organisms, and our actual internal bodily systems, are working (or not working). Most of the time, these disruptions boil down to the same thing: the consequences of erratic and shifting hormones.

Fortunately, more is coming out about the ineffectiveness of CBT. For example, “After analyzing 70 studies conducted between 1977 and 2014, researchers Tom Johnsen and Oddgeir Friborg concluded that CBT is roughly half as effective in treating depression than it used to be.” The paper, titled The Effects of Cognitive Behavioral Therapy as an Anti-Depressive Treatment Is Failing: A Meta-Analysis, is long and extensive and available online.

There’s even information about CBT for menopausal insomnia, known as CBTMI. Between 30-60% of perimenopausal and menopausal women experience insomnia, sometimes related to night sweats and often not related to any vasomotor symptoms. CBT for insomnia features strategies like sleep restriction (limiting time in bed), stimulus control (going to bed or the bedroom only when time for bed – no other activities) and sleep hygiene.

Every perimenopausal woman I’ve heard of who suffered from insomnia has tried these tactics on her own, often with no success. Why? Because the issue, at its core, is hormonal!

What CBT Might Help

While I don’t believe CBT does anything for the actual physical manifestations of hormonal changes endemic to perimenopause, it may help for specific issues women are apt to have during this time of life. For example, if a woman is having trouble accepting the fact that she’s aging, therapy could help her reframe her thinking to see maturing, instead, as a welcome life stage. It may help her see this time as a period for renewal and novelty rather than one of irrelevance and burdens.

Similarly, CBT may help those struggling with empty-nest syndrome, changing marital dynamics, finding a sense of purpose and modifying their lifestyle.

What Works (often, anyway)
Perimenopause is a time of vulnerability and fragility for many women. It is a time of mystery and inconvenience, as some are completely caught by surprise by the alien experience they now have in the bodies they occupy and cannot predict how they may feel from one day to the next. CBT and other forms of counseling may help women feel better about this transition and help them start to view the situation more objectively. But it cannot treat the actual physical, physiological symptoms of perimenopause.

For those symptoms, I suggest doing this instead (if medically possible):

• Get on hormone replacement therapy (HRT). HRT for perimenopause usually consists of estradiol and progesterone – the former in the form of a transdermal patch or gel, and sometimes a pill, and the latter as an oral capsule. Research increasingly supports that the sooner, the better with the initiation of HRT before the age of 60. The old WHI study linking HRT with catastrophic health outcomes for healthy women has long been decried as faulty and harmful, even by the North American Menopause Society (NAMS).
• Get on an antidepressant, too, if you need it. For some women, who either 1) are not candidates for HRT, 2) don’t want HRT or 3) are already on HRT but need more support, antidepressants can provide added relief. Antidepressants can help reduce hot flashes and night sweats. They can also help with mood (anxiety or depression) and sleep. In these cases, they are usually prescribed at much lower doses than used for treating standard anxiety or depression. Some are even used off label to help with headaches. I know of two perimenopausal women in their 40s who had never been on antidepressants in their lives until now. One is on an antidepressant for hormonal headaches, which have now abated. The other was put on one for hot flashes, and says she hardly has any now, plus she realizes she had a low level of depression that has lifted.

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If you want to seek therapy, by all means, go ahead and do so. It may help you better contextualize perimenopause and cope with the changes it entails more fluidly. But it will not help with the actual physical symptoms of this change of life. As with all things, one’s mileage may vary, and buyer beware.

In online perimenopausal communities, two major camps or philosophies quickly emerge: women who are pro-pharma for the treatment of their symptoms and women who are on the naturopathic path. These two schools of thought each have their own merits, and many women, over time, end up combining modalities once they discover the mix that works best for them.
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But what about meditation? It’s often seen as a hocus-pocus, “woo-sah” hobby some people dismiss and make fun of. But when perimenopause strikes, even the most anti-holistic medicine women find themselves turning to it.

In the drive to delay prescribed medical interventions or to incorporate a holistic regimen as part of their perimenopausal game plan, some women meditate to restore a sense of calm to the process. There different types of meditation, such as transcendental meditation, concentrative meditation, mindfulness meditation or progressive relaxation. But meditation is generally defined as “a practice where an individual uses a technique, such as mindfulness, or focusing the mind on a particular object, thought or activity, to train attention and awareness, and achieve a mentally clear and emotionally calm and stable state.”

If the real world and social media are any indication of how perimenopausal women are using meditation, then it appears to be a tactic broadly adopted or, at least, tried. Women seem to use meditation for a number of reasons, many related to mood, as they try to calm anxiety or ease depression. Others test it as a way to relieve physical symptoms, like hot flashes, chills and heart palpitations. And, finally, some women use it as a new lifestyle practice to gain perspective, maintain optimism and boost emotional stability.

But, the real question may be, does it work? Does meditation help? Is it really doing anything?

Axing the Anxious State

It turns out that when it comes to feelings of panic or doom, meditation is a solid tool. According to the University of Washington’s School of Medicine, meditation calms the sympathetic nervous system. This is key because the sympathetic nervous system, when revved up, lends to sensations of fight or flight. They say, “[t]hrough meditation, you are essentially deactivating your sympathetic nervous system and turning on the parasympathetic branch. Initial studies have found that over time this practice can help reduce pain, depression, stress and anxiety.”

This is important, as panic attacks can show up for the first time during perimenopause, when fluctuating hormones take women on a rollercoaster ride. Symptoms of panic attacks include nausea or abdominal distress, chills, hot flushes, rapid heart rate, dizziness, sweating, shortness of breath, chest pain, trembling, sense of losing control, de-realization and a few more (as if these weren’t enough!).

In one study, 56 percent of women surveyed had never experienced panic symptoms prior to perimenopause, and one-third of study participants’ panic disorder symptoms went undiagnosed and untreated.

More than Meets the Mind

Meditation, even short-term stints at it, can have measurable benefits on health. One study from 2009 reported that just five days of meditation at 20 minutes per session improved “physiological reactions in heart rate, respiratory amplitude and skin conductance response.” Brain imaging even showed changes related to emotional regulation.

Additional studies have found that meditation has many other add-on benefits, including delaying brain aging, reducing ruminating thoughts, improving concentration and attention, and even assisting in recovery from substance abuse. Moreover, meditation has been associated with reduced blood pressure, decreased pain and strengthened immune system function.

Worth a Try?

Many of the benefits that meditation allegedly and empirically improves are the very same symptoms women need relief from during perimenopause. Less anxiety? Check. Better focused thinking? Absolutely. Reduced stress and lowered blood pressure? For sure. A regained sense of personal control? Yes.

The problem with meditation, however, may be that it requires a commitment. Sure, some people will feel a difference after just one session. But in order to sustain it, meditation must become a practice – that is, a habit or a routine aspect of daily living. Most sources suggest aiming for 20-30 minutes of meditation a day. Since it can be challenging for women to find that bit of undisrupted time, some suggested time frames to do it are:

• Early in the morning, before anyone or anything demands your attention
• After your workout, as part of your cool-down process
• During or after lunch, especially for those who work from home
• In the evening before bedtime, as everyone else in the house is winding down

How to Find Meditations?
Just as there are many types of yoga (yin, ashtanga, vinyasa, kundalini, and so forth), there are various styles of meditation. Generally two main themes emerge: guided meditation and unguided meditation. In a guided meditation, a speaker sets the tone and verbally walks you through imagery, ideas and themes to reflect and focus on. It may or may not be accompanied by music or nature sounds. In an unguided meditation, there is no one speaking, simply silence or perhaps some accompanying music or sounds to inspire and soothe you.

There are also various types of meditation, often by purpose or topic. Meditations are available on specific themes, like Christianity, relationships, finances, stress and more. And the great thing is, meditation can be obtained for free. A quick YouTube search will unearth more meditations than you’ll ever have time for.

While HeadSpace and Calm are meditation apps popularly used, they come at a cost. Free trials or restricted free access may be available, but the unpaid experience is rather limiting.

Meditations for Menopause

Would you believe it? Yes, there are actually meditations for menopause that some thoughtful creators have put together and made widely available. This isn’t a time to get too wrapped up in particulars though – these meditations are great for perimenopause, too.

Female Hormone Balancer Relaxation Meditation
Guided Meditation for Relieving Menopause Symptoms
Hormone Rebalance Hypnosis
Magical Menopause Full Hypnotherapy Session with Binaural Beats Frequencies
Women of Wisdom Menopause Guided Sleep Meditation

Anxiety and depression are common, though lesser talked about, symptoms of perimenopause and menopause. For the first time in their lives, women may begin feeling out of sorts, as if they can no longer function as they used to or take on the world with the same sort of ease and vigor they once did. They may feel distant, aloof and alone, and they might even stop enjoying things that once brought them incredible joy, inspiration and satisfaction.

To be blunt, many women begin to wonder if they are losing their minds.

Anxiety and depression that first manifest during perimenopause and menopause without any history of mental health conditions and may look and feel like typical anxiety and depression in other people, but the cause is not quite the same. Mental health concerns during perimenopause and menopause are truly, at the root, a symptom of hormonal dysfunction – primarily the withdrawal of estrogen (estradiol) and progesterone from a woman’s body during this phase of life.

To put it simply, erratic fluctuations of estrogen and progesterone throw the body into a topsy-turvy round of unpredictability. This erratic tailspin causes most of the well-known perimenopausal physical symptoms, such as night sweats, vaginal dryness, hot flashes, sore breasts, irregular menstrual cycles and much more. And it also causes first-time onsets of anxiety and depression. But why?
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The most credible and oft-cited hypothesis is that declining levels of estrogen lead to reduced levels of key brain neurotransmitters, especially serotonin, which is responsible for feelings of happiness and well-being. Serotonin is also connected to sleep, appetite and digestion. If or when estrogen starts to bottom out, it can have the opposite effect on cortisol, also known as the stress hormone, which begins to rise. A higher level of cortisol combined with a bottoming out of serotonin (which, in turn, came from low estrogen in the first place) leads to unpleasant and devastating mood symptoms, like anxiety or depression. As if these factors were not enough, production of melatonin, the sleep hormone, can dip by this age, too – amping up the insomnia associated with anxiety.

What Is Anxiety?

Some level of anxiety is normal in our lives and is simply part of being alive. But when minor daily worries torpedo into life-altering rumination and the inability to cope, that’s a sign that there may be more to it than routine everyday concerns.

Symptoms of anxiety include (but are not limited to) irritability, restlessness and hypervigilance, or a sense of being on guard. Women may feel they are trapped in a fight, flight or freeze mode. They may not be able to switch off their minds, no matter how much they want to relax and wish to sleep. Anxiety shows up in an inability to concentrate, too. Physical symptoms like heart palpitations, inner tremors, insomnia, shakiness and shivers may appear as well. Women find that when investigated through routine medical checkups, deeper-level testing and thorough bloodwork, no physiological anomalies show up related to, or that explain, these symptoms.

What Is Depression?

Depression is more than just having a bad day or feeling sad for a legitimate reason. Depression has emotional, physical and cognitive identifiers, including a loss of pleasure in activities, mood swings, excessive crying, insomnia or fitful sleep, loss of appetite, fatigue, changes in weight, social isolation, apathy and even suicidal ideation*. Studies show that women who’ve previously experienced post-partum depression or premenstrual dysphoric disorder (PMDD) are at greater risk / likelihood of experiencing a relapse of depression with the onset of perimenopause or menopause. Still, some women with a history of depression describe hormonal depression as feeling “different” from their prior depression and unresponsive to prior medications and methodologies.

* If you are feeling suicidal or thinking of harming yourself, please call the National Suicide Hotline at 800.273.8255 and get in touch with a friend, family member or trusted confidante.

What to Do

If anxiety or depression are new to you, you may have no idea where to turn or what to do. The first step is honestly acknowledging that there is an issue and that it’s not your fault. Though stigma still surrounds mental health issues, hormonal anxiety or depression has a true medical cause, which is assuring to some who may think of it as a personal weakness, personality flaw or “crutch they need to get over.” After all, more than 40 percent of those taking antidepressants in the U.S. are woman ages 45 and up – the very age range that corresponds to the onset of perimenopause and menopause.

Treatment plans should be individualized. What worked for a friend or relative may or may not work for you. A combination of lifestyle, naturopathic, hormonal and / or pharmaceutical treatments are options that have proven effective and given many women “their life back.”

While this is no substitute for official medical advice, treatments for perimenopausal anxiety or depression may include:

• Hormone Therapy
• Cognitive Behavioral Therapy (CBT) / Counseling
• Physical Movement – aerobic exercise, yoga, resistance training
• Lifestyle Changes – stress reduction, meditation, mindfulness
• Supplements
• Medications – SSRIs and other classes of antidepressants; other medications prescribed off label to treat insomnia, night sweats and anxiety *

*The decision to begin taking medication is a serious one that should be made with full, clear transparency about potential side effects, expected duration of treatment and discontinuation protocols, if applicable. Some suggest that initiating medications like antidepressants or benzodiazepines should be made with informed consent.