Perimenopause mood swings and anxiety

Perimenopause can make you more anxious, irritable or tearful because estrogen and progesterone, two hormones that help steady your mood, stop following a predictable rhythm. In large studies, depressive symptoms were more likely during the transition than before it. The same studies found that life stress and low support often mattered as much, or more.¹

That second finding is worth sitting with, because many women meet this part of perimenopause as a change in who they are. You snap at someone you love. A worry that would once have passed in an hour sits on your chest at 3 a.m. It can feel like losing your grip. It is better understood as a nervous system working with a less reliable hormonal signal, in a decade that is already demanding.

What is happening in your brain when your mood shifts in perimenopause?

Estrogen and progesterone do far more than run your cycle. Estrogen receptors are especially dense in the prefrontal cortex, which supports decision-making and mood regulation, and in the hippocampus, which supports memory and emotional responses. Reviews describe estrogen as influencing serotonin, dopamine and GABA, chemical messengers involved in mood, motivation and calm.² You can read more about what estrogen does and how serotonin works.

Progesterone is often described as the calming counterweight to estrogen's more energizing effect. When it dips, which is common in perimenopause, some women may feel more anxious, irritable or emotionally sensitive. The key word in perimenopause is erratic. The Menopause Society describes the ovaries' production of hormones as erratic during this time.³ It is the swing, not only the low, that your brain has to keep adapting to.

How common are mood swings and anxiety in perimenopause?

The best data come from SWAN, the Study of Women's Health Across the Nation. It followed 3,302 women aged 42 to 52 for five years and measured depressive symptoms with a standard questionnaire. Compared with women who were still premenopausal, the odds of a high score were about 1.3 times higher in early perimenopause and about 1.7 times higher in late perimenopause.¹ These were symptoms on a questionnaire, not diagnoses, and the study shows an association over time, not proof that the transition causes depression.

Some women are more exposed than others. The Menopause Society notes that women are particularly vulnerable to depression in the perimenopause years, and that the greatest risk is in women who have had depressed mood earlier in life.³ Mayo Clinic adds that past premenstrual mood changes, depression or anxiety also raise the likelihood of mood changes in perimenopause.⁴

Anxiety is less clear-cut. Cleveland Clinic notes that many people report feeling more anxious in perimenopause, and that there are only a few studies of anxiety specific to this stage.⁵ One review of the research reports that SWAN women with low anxiety at the start were about 1.6 times as likely to have high anxiety in perimenopause or after, while another systematic review found no consistent rise tied to menopausal stage.² For some women anxiety arrives for the first time. For others it is an old companion that gets louder. Hot flashes can add to it: the NHS notes they can cause palpitations or anxiety.⁶

Is it your hormones or your life?

Often it is both, and the research will not let you pick one. In the SWAN analysis, having two or more very stressful life events was linked to more than four times the odds of a high depressive symptom score. That was a larger effect than menopausal stage. Poor social support and frequent hot flashes or night sweats were also linked to higher odds.¹

Now look at what midlife tends to contain: children leaving home, career changes, caring for aging relatives, a sharper awareness of your own aging. A shifting hormonal baseline arrives at the same time as the biggest load of your adult life. If you feel disconnected from the person you used to be, that is not weakness. It is a reasonable response to a lot of change at once, with less biological padding than before.

Sleep is part of the loop. The NHS notes that mood and memory symptoms may feel worse if you are sleeping badly, and that poor sleep can leave you feeling irritable, stressed and anxious.⁶ If nights are the problem, start with sleep and stress in perimenopause.

What can help with perimenopause mood swings and anxiety?

Write it down. Journaling will not change your hormones, but it gives your feelings somewhere to go that is not an argument or a 3 a.m. spiral. The goal is not to solve anything. Try one of these prompts and write without editing:

• What feels true for me at this moment?

• What do I need more of in my life, and what do I need less of?

• How am I changing, and what does that bring up?

• What is my body telling me?

• What am I discovering about myself at this stage?

Look for patterns. Noting your mood alongside sleep, hot flashes and, if you still have periods, where you are in your cycle can show whether the worst days cluster. Tracking this in the Moody Month app is one way to do it. A notebook works as well. Either way, a few weeks of notes gives your doctor something concrete to work with. There is more in watching for patterns in your moods.

Try talking therapies. Cognitive behavioral therapy (CBT) and mindfulness-based stress reduction (MBSR) teach practical ways to work with anxious thoughts and the body's stress response. Harvard Health lists CBT, medication or both as routes for treating depression or mood problems around menopause.⁷ Grounding techniques such as slow breathing, gentle yoga and muscle relaxation can also take the edge off acute anxiety. They are low-risk and worth trying alongside, not instead of, medical advice.

Protect sleep, movement and company. A regular sleep schedule, daily movement and people who understand what you are going through are not glamorous, but each one lowers the load on a mood system that is already working harder. Connection matters in the data too: in SWAN, poor social support was linked to higher odds of depressive symptoms.¹

Be careful with supplements. Ashwagandha is often suggested for stress. The NIH Office of Dietary Supplements says some studies lasting six to eight weeks suggest it may reduce stress and anxiety, but products and doses varied across studies, long-term safety is unclear, and extracts have been linked to liver injury in some people. It may also interact with thyroid, diabetes and blood pressure medicines and with sedatives, and may not be safe in pregnancy or breastfeeding.⁸ Check with your doctor or pharmacist before trying it. Our guide to natural and lifestyle alternatives to HRT covers the wider evidence.

Know that there are medical options. The NHS says antidepressants may be offered for low mood, depression or anxiety linked to perimenopause or menopause.⁹ Your doctor may also talk to you about hormone therapy. Whether it suits you is a conversation to have together, and our guide to HRT and hormone testing explains the basics.

When should you see a doctor about mood changes?

Mayo Clinic's advice is simple: if any symptom of perimenopause bothers you, see your healthcare professional.⁴ Do not wait for it to be unbearable. Book an appointment if mood changes are persistent or are affecting your daily life or relationships, if you have intense mood swings, severe anxiety or panic, if sadness will not lift, or if something simply feels wrong. A rapid heartbeat, dizziness or shortness of breath can come from anxiety, but they can have other causes, so mention them too.

If you are having thoughts of harming yourself, call or text 988, the Suicide and Crisis Lifeline in the US, or go to your nearest emergency room.

Read next: Brain fog in perimenopause, What are the symptoms of menopause