Perimenopause and mental health

Perimenopause, the years leading up to a woman’s last period, can affect emotional and mental well-being as well as the body.⁴ Studies that followed women over many years have found that the risk of depression goes up during this stage.^1,2 Yet many women don’t know their symptoms may be related to menopause, and many health care workers get little training in it.⁴ Knowing the connection can make it easier to ask for the right help.

What perimenopause is

The time leading up to menopause is called the menopausal transition, or perimenopause.⁵ The World Health Organization says perimenopause starts when the first signs appear, usually changes in the menstrual cycle, and ends one year after the final period.⁴ Menopause itself can only be confirmed after a full year without a period.⁵

Read more: Perimenopause and menopause: symptoms, timeline, and what helps

Most women begin the transition between ages 45 and 55, and it may last for several years.⁵ ACOG says the amount of estrogen the ovaries make begins to rise and fall in a woman’s 30s and 40s.⁶ The National Institute on Aging puts the average age of menopause in the U.S. at 52, while ACOG gives it as 51.^5,6 Menopause can also happen suddenly after surgery to remove both ovaries, or after treatments such as chemotherapy or radiation that stop the ovaries from working.⁴

During the transition, the ovaries make much less estrogen and progesterone, and these changes may explain the symptoms some women have.⁵ Symptoms related to menopause can last from two to eight years, and timing and symptoms vary a lot from one woman to the next.⁵

How it can affect mood

WHO lists changes in mood, depression, and anxiety among the symptoms of menopause, along with hot flashes, night sweats, and trouble sleeping.⁴ Some women have few symptoms, while for others symptoms are severe enough to affect daily life.⁴

You might feel moodier or more irritable around the time of menopause, and scientists don’t know exactly why.⁵ The National Institute on Aging says stress, family responsibilities such as raising children or caring for aging parents, depression, or feeling extra tired could all play a part.⁵ Forgetfulness and trouble concentrating are also among the symptoms some women notice.⁵

What the research shows

Depression

Experts who wrote clinical guidelines in 2018 describe perimenopause, including the first years after the last period, as a “window of vulnerability” for both depressive symptoms and major depression.⁷

The Study of Women’s Health Across the Nation (SWAN) is a long-term NIH-funded study of the menopausal transition.⁵ In a U.S. study that followed 221 women through midlife, women were two to four times more likely to have an episode of major depression when they were perimenopausal or early postmenopausal than when they were premenopausal.² In that study, the link held even after accounting for past depression, upsetting life events, hot flashes, and hormone levels.² A past history of major depression was a strong predictor of depression throughout the study.²

The risk isn’t limited to women who have been depressed before.⁸ U.S.In a Boston-area study of 460 women with no history of major depression, those who entered perimenopause were twice as likely to develop significant depressive symptoms as women the same age who were still premenopausal.⁸ The added risk was somewhat greater in women who reported hot flashes or night sweats.⁸

A 2024 review pooled results from studies that followed women over time.¹ A 2024 review of prospective studies found that women in perimenopause had about 1.4 times the odds of depressive symptoms or a depression diagnosis compared with women who had not yet started the transition.¹ The same review did not find a significantly higher risk after menopause compared with before the transition.¹ Still, the 2018 guidelines note that most midlife women who have a major depressive episode during perimenopause have had depression before.⁷

Why might this happen? In a small trial at the NIH Clinical Center, researchers studied women who had once had perimenopausal depression that improved with hormone therapy; when their estradiol (a form of estrogen) was switched to a placebo without their knowing, their depressive symptoms came back, while women with no such history stayed symptom-free.⁹ The researchers concluded that normal changes in estrogen may trigger depression in some women who are especially sensitive to them.⁹

Anxiety

In a U.S. study of nearly 3,000 midlife women, those with low anxiety at the start were about 1.6 times as likely to report high anxiety during perimenopause or after menopause as before the transition.¹⁰ That held even after accounting for life stress, money strain, health, and hot flashes.¹⁰ Women who already had high anxiety before the transition tended to stay anxious, but their risk did not go up at particular stages of menopause.¹⁰

Hot flashes, sleep, and mood

Hot flashes and night sweats are among the most common symptoms of menopause, and night sweats can disrupt sleep.⁵ They can last a long time.¹¹ In a large U.S. study, frequent hot flashes or night sweats lasted a median of 7.4 years in total; for African American women, the median was 10.1 years.¹¹ Women who had more depressive symptoms and anxiety when their hot flashes began were more likely to have hot flashes that lasted longer.¹¹

In SWAN, trouble falling asleep and staying asleep became more likely as women moved through the transition, and more frequent hot flashes were linked with more sleep problems.¹² The National Institute on Aging says hot flashes, especially night sweats, and mood changes, especially depression, can all contribute to poor sleep.¹³ Lack of sleep can in turn make you feel irritable or depressed.¹³

Why it gets missed

It can be hard for you and your doctor to tell whether you are in the menopausal transition.⁵ According to the 2018 guidelines, depression in midlife often shows up alongside menopause symptoms such as hot flashes and poor sleep, and the two overlap and complicate each other.⁷

Silence plays a part too. WHO notes that menopause is often not discussed in families, communities, workplaces, or health care settings.⁴ Women may not know their symptoms are related to menopause, or may feel embarrassed to ask for support.⁴ Health care providers may not be trained to recognize menopause symptoms, and menopause gets limited attention in many training programs.⁴

To tell these conditions apart, the 2018 guidelines recommend that clinicians identify the woman’s menopause stage, assess both mental health and menopause symptoms, consider the pressures common in midlife, and use validated screening questionnaires.⁷

Treatment options sources describe

The National Institute on Aging encourages women with mood changes to talk with a primary care provider or a mental health professional, and says treatments are available.⁵ Read more: Finding mental health care.

For depression. The 2018 guidelines say proven depression treatments, antidepressants and psychotherapy, are the first-line treatments for depression during perimenopause.⁷ Estrogen therapy is not approved to treat perimenopausal depression. There is evidence that it has antidepressant effects in perimenopausal women, especially those who also have hot flashes, but data on estrogen combined with progestin are sparse and inconclusive.⁷ In the NIH withdrawal trial, the researchers advised that women with a history of perimenopausal depression be alert to the risk of depression returning when stopping hormone therapy.⁹ That is worth discussing with a clinician before any change.

For hot flashes. The Menopause Society’s 2022 position statement says hormone therapy is still the most effective treatment for hot flashes and night sweats.¹⁴ Its 2023 statement on nonhormone options recommends cognitive behavioral therapy, clinical hypnosis, certain antidepressants (SSRIs and SNRIs), gabapentin, and fezolinetant, based on good and consistent evidence.¹⁵ The same statement does not recommend supplements or herbal remedies.¹⁵ The National Institute on Aging says black cohosh, DHEA, and soy isoflavones are not proven to work, and some carry risks such as liver damage.¹⁶ Our article on menopause hormone therapy covers the benefits, risks, and recent label changes in more detail.

For sleep. The National Institute on Aging says cognitive behavioral therapy for insomnia has been shown to help improve sleep in women with menopause symptoms.¹³ It also says over-the-counter sleep aids and prescription sleep medicines may help for a short time but are not a cure and should not be used long term.¹³

If you are in crisis or thinking about suicide, the 988 Suicide & Crisis Lifeline offers free, confidential support 24/7 by call, text, or chat.¹⁷

What we don’t know yet

• Why it happens. Scientists don’t yet know why mood changes happen around menopause.⁵ Stress, hormones, sleep, and life circumstances are hard to separate, and researchers have called for more studies on whether hot flashes, hormone therapy, and life events each change the risk.⁸
• Inconsistent research methods. Studies use different definitions of the menopause stages and different measures of depression, and there are too few long-term studies comparing perimenopause directly with postmenopause.¹
• Treatment evidence. When the 2018 guidelines were written, the authors said clinical recommendations for identifying and treating perimenopausal depression were lacking, and evidence on estrogen plus progestin remains sparse.⁷
• Older data. Much of what we know comes from SWAN, which began collecting data in 1996.¹¹
• Who is missing. WHO notes there is little data on how trans and gender-diverse people experience menopause.⁴

Questions to ask your doctor

• Could my changes in mood, sleep, or anxiety be related to perimenopause? How would we tell?
• Should I be screened for depression or anxiety?
• I’ve had depression before. Does that change what we should watch for now?
• What are my options for treating depression or anxiety, and how do they fit with treating my menopause symptoms?
• Could treating my hot flashes or night sweats help my sleep and mood?
• If I’m using hormone therapy or thinking about stopping it, what should I watch for with my mood?
• Would cognitive behavioral therapy for insomnia or for hot flashes be a good fit for me?
• Can you refer me to a mental health professional who works with women in midlife?

This article summarizes published research and official health information. It has not been reviewed by a clinician and is not medical advice. How we source.