Mental Health & Hormones

A work in progress…

Understanding Mental Health Changes During Perimenopause

multiple combined treatment options can address multiple issues

difference between symptoms vs diagnosable psychiatric d.o.

What Is Perimenopause?

Perimenopause is the transition period before menopause, typically starting around age 47 when your menstrual cycles begin to change. This phase usually lasts about five years and ends 12 months after your final period. During this time, your body experiences significant hormonal changes that can affect both your physical and mental health.

Many women notice changes in their mood and emotional well-being during perimenopause. Common mental health symptoms include:

Depression and Low Mood: You may feel sad, tearful, or lose interest in activities you once enjoyed. Research shows that women are 2 to 5 times more likely to experience depressive episodes during perimenopause compared to earlier in life.
Suicidal thoughts or plans
Anxiety: Feelings of worry, nervousness, or being on edge are common and tend to peak during late perimenopause.
Mood Swings: You might notice rapid changes in your emotions, feeling fine one moment and irritable or upset the next.
Difficulty Concentrating: Some women report "brain fog" or trouble focusing on tasks.
Sleep Problems: Difficulty falling asleep or staying asleep can worsen mood symptoms.

The mental health changes during perimenopause are linked to fluctuating hormone levels, particularly estrogen and progesterone. Unlike the steady hormone levels you had during your reproductive years, perimenopause brings unpredictable ups and downs in these hormones. Greater variability in estrogen levels and lower progesterone are associated with more depressive symptoms.

These hormonal changes affect brain chemicals like serotonin and GABA that regulate mood, sleep, and stress responses. Additionally, physical symptoms like hot flashes and night sweats can disrupt sleep, which further impacts mental health.

The Connection to PMDD

If you previously experienced premenstrual dysphoric disorder (PMDD)—severe mood symptoms before your period—you may notice these symptoms worsen during perimenopause.[5] PMDD involves marked mood swings, irritability, anxiety, and depression that occur in the days before menstruation.

During perimenopause, the hormonal fluctuations can intensify PMDD symptoms or cause similar patterns of mood changes even if you didn't have PMDD before. Women with a history of PMDD should be particularly vigilant about mood changes during this transition.

While not all women experience mental health problems during perimenopause, certain factors increase your risk:

- Previous history of depression, anxiety, PMDD, perinatal mood issues, ADD/ADHD, PCOS, and endometriosis

- Severe or frequent hot flashes and night sweats

- Stressful life events

- Longer duration of perimenopause

- Surgical menopause (removal of ovaries)

- Lack of social support

It's important to know that most women do not develop severe depression during perimenopause.Only about 10-30% of women without a history of depression report significant depressive symptoms during this time.

The good news is that effective treatments are available:

Treatment Options and Self-Care Strategies for Perimenopausal Mental Health

Psychotherapy

- Cognitive Behavioral Therapy (CBT) is first-line treatment for depression and anxiety

- Reduces depression, anxiety, and improves sleep

- Also helps with hot flashes and vasomotor symptoms

- Average 11 hours total therapy time

Mindfulness-Based Interventions

- 8-week programs using meditation and yoga techniques

- Prevents depressive symptoms and builds resilience

- Particularly effective for women with previous depression or recent stress

- Average 18 hours total therapy time

Antidepressant Medications

- SSRIs and SNRIs are first-line medications

- Treat both depression AND hot flashes

- Start at low dose, increase gradually over 1-2 weeks

- Common options: bupropion, escitalopram, sertraline, desvenlafaxine

- Side effects (nausea, headache) often improve after 1-2 weeks

Hormone Therapy

- NOT FDA-approved for depression treatment

- May help mood IF you also have bothersome hot flashes and have previously experienced hormone-related mental health issues

- Not recommended as primary treatment for depression alone

Self-Care Strategies

Physical Activity

- Low to moderate intensity exercise significantly reduces depression and anxiety

- Benefits seen across all menopausal stages

- Effective types: aerobic exercise, yoga, Pilates, tai chi, stretching

- Aim for 60-90 minute sessions a few times per week for best results

Sleep Management

- Treat sleep disturbances to reduce depression risk

- Exercise improves sleep quality

- CBT effective for sleep problems

Stress Reduction

- Mindfulness meditation and yoga reduce stress and anxiety

- Music therapy, dance therapy, and art therapy also beneficial

- Building psychological resources: optimism, healthy self-image, sense of control

Social Support

- Increase social connections and support networks

- Group-based exercise or therapy programs provide dual benefits

- Combining approaches (therapy + exercise + lifestyle changes) often works best

- Early treatment prevents symptoms from worsening

- Benefits from exercise and mindfulness can appear within 2 weeks

- Women with previous depression, PMDD, or recent stress may benefit most from preventive interventions

For General Population (Depression/Anxiety):

Strong evidence

1. St. John's wort - Multiple meta-analyses showing comparable efficacy to antidepressants

2. Omega-3 fatty acids (EPA/DHA) - Large effect sizes as both adjunct and monotherapy

3. Saffron - Large effect sizes for depression and anxiety

Moderate evidence:

4. SAMe - Effective as adjunct and monotherapy

5. Zinc - Particularly strong as adjunct with antidepressants

6. Curcumin - Effective as adjunct and monotherapy

7. Probiotics, Vitamin D, Magnesium, Methylfolate - All with significant but smaller effect sizes

For Perimenopausal/Menopausal Women Specifically:

Strongest evidence:

1. Black cohosh - Significantly reduced depression and anxiety in all reviewed studies

2. St. John's wort - 5 of 7 trials showed significant improvement

3. Phytoestrogens (isoflavones) - Meta-analysis showed significant benefit

Moderate evidence:

4. Kava - Significantly reduced anxiety in 4 of 8 trials

Contact your healthcare provider if you experience:

- Persistent sadness or hopelessness lasting more than two weeks

- Loss of interest in activities you normally enjoy

- Significant anxiety that interferes with daily life

- Thoughts of harming yourself

- Symptoms that disrupt your work, relationships, or quality of life

Perimenopause is a natural transition, and while it can bring challenges, you don't have to suffer through it alone. Mental health symptoms during this time are real, treatable, and temporary. With the right support and treatment, most women successfully navigate this transition and maintain good mental health.

Talk openly with your healthcare provider about any mood changes you're experiencing. Tracking your symptoms in a diary can help identify patterns and guide treatment decisions. With proper care, you can feel like yourself again.

This patient-facing article provides evidence-based information about mental health symptoms during perimenopause, including anxiety, depression, and the connection to PMDD. The content is written in accessible language while maintaining medical accuracy, citing research showing that perimenopause increases risk of depressive episodes 2-5 fold, that hormonal fluctuations drive mood changes, and that effective treatments including psychotherapy, antidepressants, and lifestyle interventions are available.[1][2][8][9]

The article emphasizes an important point from recent research: while some women are at increased risk, not all women experience mental health problems during perimenopause.[8] This balanced perspective helps reduce unnecessary anxiety while validating the experiences of those who do struggle with mood symptoms.