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.
 
 

Though commonly stigmatized and all-too frequently (and wrongly) mistaken as conventional mental health disorders, anxiety and depression may show up for the first time during perimenopause due to the hormonal rollercoaster.

Women without a prior history of mental health concerns may suddenly find themselves with an onset of anxiety or depression – and often with no tangible or discernable cause or catalyst.

These materials and research uncover the many layers involved in mood changes during perimenopause. There is an inter-relationship between female reproductive hormones (namely estrogen and progesterone), key brain neurotransmitters (such as serotonin) and other hormones associated with the HPA (hypothalamus-pituitary-adrenal) axis responsible for anxiety and depression during perimenopause.

​Treatment approaches vary, from lifestyle interventions to mental health medications and menopause hormone therapy (MHT) / hormone replacement therapy (HRT).

Note: This list of resources is continually updated.

3 Common Myths about Antidepressants Debunked! – Heather Hirsch, MD, Oct. 11, 2021 - https://www.youtube.com/watch?v=DcvZGC9ME9M

Acupuncture: A Promising Approach for Comorbid Depression and Insomnia in Perimenopause – Department of Psychiatry, Shanghai Municipal Hospital of Traditional Chinese Medicine, Fei-Yi Zhao, Qiang-Qiang Fu, Sarah J. Spencer, Gerard A. Kenney, Russell Conduit, Wen-Jing Zhang, Zhen Zheng, Oct. 12, 2021 – https://www.dovepress.com/acupuncture-a-promising-approach-for-comorbid-depression-and-insomnia--peer-reviewed-fulltext-article-NSS

After Two Decades, I Decided to Go off Antidepressants – Ashley Abramson, The Paper Gown, Zoc Doc, April 11, 2019 – https://thepapergown.zocdoc.com/after-two-decades-i-decided-to-go-off-antidepressants/

Antidepressants During and After Menopausal Transition: A Systematic Review and Meta-Analysis, Scientific Reports, Ching-Kuan Wu, Ping-Tao Tseng, Ming-Kung Wu, Dian-Jeng Li, Tien-Yu Chen, Fu-Chen Kuo, Brendon Stubbs, Andre F. Carvalho, Yen-Wen Chen, Pao-Yen Lin, Yu-Shian Cheng, Cheuk-Kwan Sun, May 15, 2020 – https://www.nature.com/articles/s41598-020-64910-8

Antidepressants for Menopause – Everything You Should Know – Winona, March 3, 2021 - https://bywinona.com/journal/antidepressants-for-menopause/

Antidepressants May Not Be All They’re Cracked Up to Be – Gabrielle Glaser, The Daily Beast, March 2, 2018 – https://www.thedailybeast.com/antidepressants-may-not-be-all-theyre-cracked-up-to-be

As Menopause Nears, Be Aware It Can Trigger Depression and Anxiety, Too - NPR Morning Edition, Jan. 16, 2020 - https://www.npr.org/sections/health-shots/2020/01/16/796682276/for-some-women-nearing-menopause-depression-and-anxiety-can-spike 

Depression and Related Disorders during the Female Reproductive Cycle – Women’s Health, Future of Medicine, Ltd., Laura J. Miller; Christina Girgis; Renu Gupta, 2009 – https://journals.sagepub.com/doi/pdf/10.2217/WHE.09.44

Depression During the Menopausal Transition: An Update on Epidemiology and Biological Treatments, Luciano Minuzzi, MD, PhD., Benicio N. Frey, MD, PhD., Claudio N. Soares, MD, PhD, FRCPC, Focus: The Journal of Lifelong Learning in Psychiatry, Jan. 1, 2012 – https://focus.psychiatryonline.org/doi/10.1176/appi.focus.10.1.22

Depression or Menopause? Presentation and Management of Major Depressive Disorder in Perimenopausal and Menopausal Women, Anita H. Clayton, MD, and Philip T. Ninan, MD., Journal of Clinical Psychiatry, 2010 – https://www.psychiatrist.com/pcc/depression/depression-menopause-presentation-management-major/

Estrogen and the Brain – Jan Shephard, MD, FACOG - http://npsymposium.com/wp-content/uploads/2021/05/A4-Estrogen-and-the-Brain-Shepherd-1-up-Color.pdf

First-Ever Guidelines for Detecting, Treating Perimenopausal Depression – The University of Illinois College of Medicine - https://chicago.medicine.uic.edu/first-ever-guidelines-for-detecting-treating-perimenopausal-depression/

​Help, Am I Going Mad? Mental Health and Menopause – A Meaningful Midlife, Aug. 8, 2019 – https://www.ameaningfulmidlife.com/blog/2019/8/4/help-am-i-going-mad-mental-health-and-perimenopause

Hormone Imbalances and Depression – Things You Should Know – Winona, March 29, 2021 - https://bywinona.com/journal/hormonal-imbalances-depression/

Hormones and Emotional Health – Women’s International Pharmacy, 2020 – https://www.womensinternational.com/blog/hormones-and-emotional-health/

HRT vs. Antidepressants in Perimenopausal Depression - Professor Jayashri Kulkarni, Sept. 26, 2020 – https://psychscenehub.com/video/hrt-vs-antidepressants-in-perimenopausal-depression-by-prof-jayashri-kulkarni/

The Impact of Hormones on Serotonin in Depression – The ZRT Laboratory Blog, Dr. Kate Placzek, Feb. 9, 2018 - https://www.zrtlab.com/blog/archive/impact-hormones-serotonin-depression/

“It Feels Impossible to Beat” – How I Was Floored by Menopause – Rose George, The UK Guardian, Aug. 16, 2018 – https://www.theguardian.com/news/2018/aug/16/it-feels-impossible-to-beat-how-i-was-floored-by-menopause

Low Mood and Depressive Symptoms during Perimenopause – Should General Practitioners Prescribe Hormone Replacement Therapy or Antidepressants as the First-Line Treatment? – Mandy Leonhardt, June 27, 2019, Post Reproductive Health – https://journals.sagepub.com/doi/10.1177/2053369119847867

Menopause and Mental Health – Is It Wreaking Havoc with Your Moods? – Harley Therapy Counselling Blog, Sheri Jacobson, June 17, 2021 – https://www.harleytherapy.co.uk/counselling/menopause-and-mental-health.htm

Menopause: Is It All In Your Head? – The ZRT Laboratory Blog, Dr. Kate Placzek, June 3, 2016 - https://www.zrtlab.com/blog/archive/menopause-all-in-your-head

Mental Health Issues Are the Menopausal Side Effect We’re Not Talking About – Meryl Davids Landau, Woman’s Day, March 11, 2022 – https://www.womansday.com/health-fitness/a30515712/how-menopause-affects-mental-health/

Perimenopause and Depression – Honor Health – https://www.honorhealth.com/healthy-living/perimenopause-and-depression

Perimenopausal Depression: A Review of Diagnosis and Management – Psych Scene Hub, Jan. 21, 2022 – https://psychscenehub.com/psychinsights/perimenopausal-depression-diagnosis-and-management/

Perimenopause Ups and Downs Can Last Years – Amy Burkholder, CNN, Jan. 10, 2007 – https://edition.cnn.com/2007/HEALTH/01/10/peri.menopause/

Psychiatry and the Menopausal Transition: Clinical Caveats – Psychiatric Times, Marlene P. Freeman, MD, Sept. 3, 2014 - https://www.psychiatrictimes.com/view/psychiatry-and-menopausal-transition-clinical-caveats

These Mental Health Symptoms of Menopause Don’t Get Mentioned Enough but Affect the Majority of Women – Well + Good, Kara Jillian Brown, May 22, 2021 - https://www.wellandgood.com/mental-health-symptoms-menopause/

Use of Antidepressants during Perimenopause – Deborah R. Kim and Hadine Joffe, Women’s Health, July 1, 2006 - https://journals.sagepub.com/doi/10.2217/17455057.2.4.627

When Anxiety, Insomnia Aren’t Just in Your Head – The Wall Street Journal, Melinda Beck, Oct. 12, 2010 - https://www.wsj.com/articles/SB10001424052748703794104575546072780597414

When Depression Sneaks Up on Menopause – Natasha Gilbert, Knowable Magazine, Jan. 27, 2022 – https://knowablemagazine.org/article/mind/2022/when-depression-sneaks-menopause