How menopause can impact your mental health

Menopause is no longer a word that need not be uttered out loud. Gen X is the first generation of women to, as they’ve aged into midlife, speak more openly about the challenges that come with the menopause transition and demand solutions. Even its more, shall we say, high profile members (see Halle Berry, Drew Barrymore, Naomi Watts) have no problem sharing about their hot flashes and vaginal dryness and night sweats. But it’s not just your body that can take a hit. Your brain can too.

Your mind on perimenopause

As we’ve begun to talk more frequently and openly about menopause, it’s important to underscore that the transition involves far more than the end of your period. According to the menopause staging criteria known as STRAW + 10 (Stages of Reproductive Aging Workshop), perimenopause — the stage that precedes menopause — begins when a woman experiences consistent cycle length differences of seven or more days. It ends 12 months after the last menstrual period. This stage can last for up to a decade. And while so much of what happens during perimenopause remains nebulous because of a glaring lack of research, more information is emerging that highlights the often profound psychological changes that accompany this transitional period.

“Changes in mood are really a perimenopause phenomenon,” says Pauline Maki, PhD, a professor of psychiatry, psychology, and obstetrics & gynecology at the University of Illinois Chicago. In 2024, the University College of London released findings that said that women in perimenopause are 40% more likely to experience depression than premenopausal women. Hormones play a significant role.

Lisa Mosconi, PhD, a neuroscientist and author of The Menopause Brain, has written about the effect of estrogen and progesterone on our brain chemistry in regulating the production of feel-good neurotransmitters like serotonin and dopamine, as well as the anti-anxiety neurotransmitter GABA. Estrogen, says Maki, promotes all three. And this is key to regulating processes like mood, appetite, body temperature, sleep, and cognition. Estrogen and progesterone also impact the HPA (hypothalamic-pituitary-adrenal) axis, which links the brain with the ovaries and adrenal glands and guides our stress response.

But, despite chatter online suggesting otherwise, says Maki, it’s not simply about the disappearance of hormones. “It’s not the loss, it’s the variability,” Maki explains, adding that greater estradiol irregularity (that it’s up, then down, and so on) can predict the development of perimenopausal depression, especially during periods of extreme stress. These fluctuations can lead to actual changes in the brain.

Judith Joseph, MD, a board-certified New York-based psychiatrist and the author of High Functioning, points to studies that have looked at brain imaging which shows decreasing gray matter (which matters because that’s where the body of the neurons or brain cells exist) and that using menopause hormone therapy may have neuroprotective benefits.

“One study that came out this year shows that the brain starts to upregulate the amount of estrogen receptors in response to the changes, making more nets to catch more estrogen because of the depleted state,” says Joseph, adding that the “nets” being made at all is a sign for doctors that there wasn’t an adequate supply. So the feeling some women have during perimenopause of forgetfulness or an inability to focus or increasing sadness isn’t just in their head; it’s a symptom of what’s going on in their heads.

Mood symptoms that may arise

Joseph shares that many of her patients in perimenopause report an onset of sadness, moodiness, and irritability. But because it’s not as severe or persistent as major depressive disorder (clinical depression), oftentimes these symptoms can go unnoticed by others. “Women will not quite feel like themselves — a little low, more edgy, like their patience is shot. [There’s] a bit more anxiety, lack of motivation, like they have PMS all the time. But because they continue to function pretty close to where they were, nobody else might notice it,” says Hadine Joffe, MD, a professor of psychiatry at Brigham & Women’s Hospital.

Cognitive issues like brain fog and inability to focus are extremely common, but for some women they can be so disruptive to their daily functioning that, says Joseph, they think they have ADHD (attention-deficit/hyperactivity disorder). But even if women don’t get diagnosed with ADHD until midlife, it has always been there.

ADHD, something characterized by ongoing inattention or hyperactivity, is a neurodevelopmental disorder which means it occurs in the development of the nervous system when you’re young. Having ADHD means your dopamine levels are low. The hormone fluctuations of perimenopause can impact their production even more. “Women are diagnosed at lesser rates and later times with ADHD when they truly have it, however ADHD by definition happens in childhood before the age of 12,” says Joseph. “So if you have no childhood history of ADHD and suddenly have symptoms of forgetfulness and poor organization in midlife this is likely perimenopause or menopause brain fog.”

Why some women are more susceptible than others

Perimenopause falls squarely during a time when women simply have a lot on their plate — career demands, tending to relationships and friendships amidst increasingly busy schedules, caring for children and, often, aging parents simultaneously. All of which can put its own pressure on our mental health.

Adding to perimenopause’s mental health pressure cooker are the physical expressions wreaked by hormonal cascades. See: libido loss, skin and hair changes, weight gain particularly around the midsection, and, perhaps most broadly impactful, sleep challenges. Women report having a hard time falling asleep and staying asleep, or not getting restful sleep. Studies have linked hormonal fluctuations to an inability to achieve deeper sleep. “Over time with age, and also because of hormones, your sleep architecture changes, which will also impact your mood and your thinking,” says Joseph.

For women who have historically struggled with mental health challenges, perimenopause tends to resurface them. “It's a vulnerable time for people with a history of mood and anxiety [issues],” Joffe explains. That’s particularly true, adds Joseph, if you’ve had premenstrual dysphoric disorder (PMDD), postpartum depression, bipolar disorder, schizophrenia, or have a history of trauma. The majority of women who’ve experienced clinical depression earlier in life will have a recurrence, says Maki.

Dealing and (most importantly) not ignoring it

One of the most important ways to prepare for the potential perimenopausal mood shifts is to first acknowledge their existence. Women often spend the bulk of their lives tending to others’ needs ahead of their own and are pros at hiding and feeling guilty about their own struggles. Being open with and leaning on your community (either a few friends or family members) is vital, as is finding a healthcare provider who will not brush off your concerns and present options for how to contend with any symptoms that arise.

Every woman’s mental health picture will be slightly different. Hormone replacement therapy (or HRT), while an effective option for some, is not a one and done salve for all. “I have to be really definitive that the solution is not simply to replace the estrogen,” says Maki. While she points to promising evidence from a randomized trial that women who start transdermal estrogen in very early perimenopause have a lower risk of elevated depressive symptoms, more research is needed for it to be reliably recommended in clinical practice. For women contending with hot flashes and depression that’s situational, not clinical, HRT can be beneficial, says Joffe. But if it’s significant or severe depression, she doesn’t suggest it as a first-line approach.

“Hormone therapy can and often is used in combination with and concurrently with serotonergic agents [SSRIs],” Joffe adds. Plus cognitive behavioral therapy as a rule. But if after a few months on hormone therapy your mood symptoms are not improving, talk to your doctor. “I always tell people don’t take a long time to go back and say it’s not working,” she says. Joffe warns that estrogen therapy can sometimes make anxiety worse: ruminative worrying, or what doctors call generalized anxiety can see an improvement, but for those who have panic attacks or are hypervigilant or super physically anxious, not so much. If you have had previous mental health issues and are already on SSRIs, something that could have been working may suddenly not be as effective. So, it’s important to monitor your mood and keep in constant communication with your doctor.

The importance of lifestyle

Embracing certain lifestyle revisions can make the transition through perimenopause more bearable for many women. Joseph advises her patients to start preparing in their late thirties or early forties and, if you’re a Black woman, even earlier since research shows that their experience happens sooner and is often more intense.

Creating a sense of community and fostering relationships that you can rely on when you are in crisis is hugely important. So is becoming more intentional with diets (more protein, fiber, and hydration and less alcohol, ultra-processed foods, and added sugar, which can worsen inflammation), regular movement (particularly weight-bearing exercises), and, Joffe adds, daily exposure to real light (at least 10-20 minutes a day outside, not just for the Vitamin D but to positively impact mood and regulate circadian rhythms). And, of course, sleep; and specifically sleep that emphasizes quality over quantity.

“It’s about getting deep, consolidated, uninterrupted sleep,” says Joffe. “We’ve done a lot of work showing that even if people get a sufficient number of hours, if it’s interrupted by hot flashes or snoring bed partners or kids coming into the room or pets or noise or light, these kinds of things can, in a very insidious way, stop people’s energy and motivation.”

Perimenopause is also a time when our identity, and how we once saw ourselves, begins to evolve, and that can be overwhelming. “When your body and brain start to change, you start to question your sense of self, and that’s especially true for women because we are so value- based on how we look,” says Joseph.

We shouldn’t assume, says Joffe, that the identity crisis many women feel is simply because of a lack of reproductive potential or an empty nest. It’s that we are losing an image of ourselves that is familiar and staring into what feels like the great unknown. It’s a period of self-reflection and reckoning and radical acceptance too. And while preparation is good, panicking about it all isn’t. “The majority of women do not get a major mood problem,” says Joffe. A reason to feel less fearful — and more free — in the lead-up to this next stage.

The bottom line

The transition to menopause can have a significant impact on women’s bodies and brains, driven by the up-and-down variability — not just the disappearance – of the hormone estrogen during the perimenopause stage. Common mood changes include sadness, moodiness, and irritability; cognitive issues like brain fog and inability to focus are also common. Beyond the hormonal piece, the midlife period brings its own stressors — balancing career, family, and friends, facing changes in the body, and running on less sleep. Everyone’s treatment looks different. Medications can help, such as serotonin reuptake inhibitors (SSRIs) and hormone replacement therapy (HRT), which is sometimes called menopause hormone therapy (MHT). Certain lifestyle shifts can also have a positive impact on mood, such as fostering community, focusing on a more nutrient-rich diet and regular activity, and getting quality sleep.