Explore next steps to improve your mental health. 
When we think about approaching perimenopause, most of us brace for the obvious stuff: irregular periods, hot flashes, maybe some new chin hairs. But many women are less prepared for the mental and emotional symptoms that can completely upend how you feel day to day.
Research shows that up to 70 percent of women experience psychological symptoms during perimenopause—things like brain fog so thick you can’t remember your colleague’s name, anxiety that hits out of nowhere, or irritability that makes you want to scream at every minor inconvenience. Yet many doctors still lack education around perimenopause and aren’t sure what to do when women come to them with these concerns.
“This is an underserved group,” says Kathleen Jordan, M.D., a Menopause Society certified provider and chief medical officer of Midi Health, a clinic that specializes in the treatment of perimenopause and menopause. “Perimenopausal women in particular are struggling because there’s very little research, meaning national treatment guidelines have very little to say on the issue.”
A 2023 study of nearly 1,000 women seeking help for perimenopause symptoms found that many felt dismissed by their healthcare providers.
“I was brushed off, told that I’m getting older,” one woman told researchers. Another said her doctor insisted her symptoms weren’t hormonal because she was “too young and healthy” and had normal periods.
Researchers and providers who focus on women’s health in their 30s, 40s, and 50s know better.
“When we look at patients who seek care from our clinic, we find that the challenges women face in perimenopause are equal to or even more so than in menopause,” Dr. Jordan says. In a recent report that surveyed hundreds of patients, nine out of 10 perimenopausal women at Midi reported mood challenges, brain fog, and disrupted sleep.
The bottom line: “Perimenopause is a metabolic stressor that’s very real,” Dr. Jordan says. Brain scans and basic science confirm that changes in estrogen and progesterone directly influence neurotransmitters like serotonin, dopamine, and GABA—the chemicals in your brain that heavily influence your mood and concentration.
Perimenopause At a Glance
How Hormonal Changes Affect Your Brain
During perimenopause, your ovaries start producing inconsistent amounts of estrogen, throwing off other hormones like progesterone (which helps regulate your menstrual cycle and supports sleep). The result is a biochemical rollercoaster where hormone levels can swing dramatically from day to day, or even hour to hour, setting off unpredictable symptoms like mood swings, flares of anxiety and depression, and other issues.
Perimenopause typically starts in your mid-40s (though it can begin anywhere from your mid-30s to mid-50s) and usually lasts about four years. This stage officially ends one year after your last period, when you reach menopause. But those years of transition can feel endless when you’re living through unpredictable symptoms.
Why Estrogen Matters So Much for Your Mental State
Estrogen receptors are scattered throughout your brain, including areas involved in reasoning and mood regulation. When estrogen levels are stable and adequate, the hormone acts like your brain’s built-in protector, stabilizing mood and cognitive function.
Estrogen also controls two critical types of brain chemicals:
- Feel-good neurotransmitters like serotonin, dopamine, and GABA
- Neuropeptides, which are proteins that help nerve cells communicate to regulate mood, pain, stress, appetite, memory, and more
When estrogen dips or fluctuates unpredictably, like it does during perimenopause, you become more vulnerable to stress, low mood, and memory lapses or brain fog.
Why Hormone Fluctuations Hit Harder Than Low Levels
Fluctuating estrogen levels can cause more problems than steady low levels would. “Some people call it the chaos of perimenopause,” Dr. Jordan says. “Perimenopause is harder metabolically in some ways than menopause. The swings create more cellular distress than being just at a low, flat level of hormones.”
This explains why puberty, PMS, and perimenopause can all feel so emotionally volatile—they’re all times when hormones fluctuate rapidly rather than staying steady.
“The symptoms aren’t consistent: They’ll go away at times and come back at times, making women question whether it’s all in their head.”
These swings also make perimenopause tricky to diagnose. “The symptoms aren’t consistent: They’ll go away at times and come back at times, which makes women question whether it’s all in their head,” Dr. Jordan says. The fluctuations also make hormone testing unreliable, since levels change so quickly that lab results don’t necessarily predict how severe your symptoms are.
How Are Perimenopause Mood Swings Different From Puberty and PMS?
While puberty, PMS, and perimenopause all involve hormonal mood changes, each stage works differently:
| Life Stage | What’s Happening Hormonally | How It Affects You |
|---|---|---|
| Puberty | Bursts of gonadotropin-releasing hormone (GnRH) trigger the creation of sex hormones, including estrogen | Affects self-esteem, mood swings, and stress sensitivity |
| PMS | A surplus of estrogen combined with low progesterone | Causes irritability, anxiety, and restlessness |
| Perimenopause | Sharp fluctuations in estrogen directly impact your brain’s production and usage of neurotransmitters and brain proteins that regulate mood, stress, and memory | Brings a combination of mood swings, anxiety, brain fog, and other mental health disruptions all at once |
Now that you understand the science behind these changes, let’s dive into the specific mental and emotional symptoms you might be experiencing and what you can do about them.
Perimenopause Depression: Understanding the Connection
Research shows that perimenopausal women face a two to five times higher risk of major depressive disorder compared to both premenopausal and postmenopausal women. A 2024 meta-analysis found that approximately 34 percent of perimenopausal women worldwide have depression, compared to the average seven percent of all adults.
This isn’t about occasionally feeling sad or overwhelmed by life changes. Depression is a persistent mood disorder that sticks around for at least two weeks, causing sadness and loss of interest in things you used to enjoy. It can also show up as body aches, changes in appetite, or sleep problems.
Why Perimenopause Depression Happens
One of the main culprits is estrogen fluctuations that disrupt serotonin production. Serotonin is often called the “feel-good” chemical because it helps you feel happy, calm, and emotionally stable. Low levels of serotonin are linked with depression, which is why many antidepressant medications focus on increasing serotonin availability in the brain.
Women who’ve experienced major depression earlier in life face higher risk of recurrence during perimenopause. Other factors can compound the problem: sleep disruption from hot flashes or night sweats (interrupted sleep makes you up to 10 times more likely to develop depression), plus life stressors like caring for aging parents or kids leaving home.
What You Can Do About Perimenopause Depression
1. Talk to your doctor about antidepressants.
Antidepressants are often the first-line treatment for perimenopausal depression. Your doctor—and your tolerance and preferences—should guide your choice around which one(s) to try, as there is no consensus about which drugs work best specifically for perimenopausal depression. SSRIs (like Prozac and Celexa) increase serotonin availability, while SNRIs boost availability of both serotonin and norepinephrine in the brain.
No matter what depression medication you choose, it can take anywhere from two to 12 weeks to feel relief.
2. Connect with a therapist.
Therapy, either alone or in combination with medication, is another first-line treatment for depression. Cognitive behavioral therapy (CBT) has strong research backing for reducing depressive symptoms. CBT helps you identify thinking patterns and cognitive distortions that influence your behavior and beliefs, then offers tools to correct unhelpful thoughts and get relief.
3. Exercise in a way that feels good to you.
A 2024 review of more than 200 randomized trials found that regular walking, jogging, yoga, strength training, or tai chi all moderately improve depression symptoms. The exact method is less important than simply moving your body in a way that feels good to you—no need for the “perfect” workout routine. For some people, exercise may work as well as antidepressants.
4. Consider hormone therapy.
An increasing number of studies, including high-quality randomized controlled trials, show that estrogen therapy can help relieve perimenopause depression. Estrogen therapy is not FDA-approved as a depression treatment, but clinical trials showed it significantly improved depressive symptoms—even beyond the relief from hot flashes.
Perimenopause Brain Fog: Cognitive Symptoms Explained
Perimenopause brain fog is different from occasionally misplacing your keys. It’s a noticeable change in your ability to focus and think clearly. Research suggests 40 to 60 percent of women notice cognitive problems during the menopause transition—things like losing your train of thought mid-sentence, being easily distracted, forgetting appointments, or struggling to remember common words and numbers.
“Brain fog is not a medical diagnosis,” Dr. Jordan says. “It’s really a turn of phrase that refers to a constellation of different things that are somewhat related, such as difficulty concentrating, difficulty with recall, difficulty with learning or focus. It can mean slightly different things to different people.”
The encouraging news is that these cognitive changes aren’t signs of dementia or permanent decline. Research suggests that at least some aspects of brain fog improve once you reach postmenopause and are no longer in hormonal transition.
What Causes Perimenopause Brain Fog
Estrogen fluctuation is one of the main drivers, since this hormone directly impacts brain circuits involved in memory and cognitive function. The prefrontal cortex—your brain’s executive control center—is particularly sensitive to these hormonal swings.
Sleep disruption from hot flashes, night sweats, or general hormonal changes makes brain fog worse, since quality rest is essential for memory consolidation. Depression can also cause cognitive difficulties that feel like brain fog.
What You Can Do About Perimenopause Brain Fog
While there isn’t solid research on ways to improve brain fog specifically during perimenopause, there are several things you can do to support your overall brain health, including:
1. Exercise most days.
Regular physical activity can sharpen memory and improve problem-solving ability. It could also protect you from dementia as you age: One study found that sedentary people report cognitive decline symptoms almost twice as often as active people. The data isn’t clear on what kind of exercise is best for the brain, but the CDC recommends at least 150 minutes of moderate-intensity exercise (like brisk walking, recreational swimming, or dancing) or 75 minutes of vigorous activity (like running, swimming laps, or jumping rope) per week.
2. Consider hormone therapy.
Research shows that starting hormone replacement therapy during perimenopause can improve memory and positively impact brain activity. (Starting hormone therapy in late menopause, however, can have the reverse effect.) Estrogen comes in pill, patch, spray, and gel forms and needs to be prescribed by a doctor who can discuss risks and benefits with you.
3. Eat more fish.
“There is quite a bit of data suggesting that omega-3 fatty acids like those found in seafood improve brain health,” Dr. Jordan says. If you don’t like fish, randomized clinical trials show that omega-3 supplements can increase blood flow to the brain and boost memory and learning.
Brain fog can be disturbing and frustrating, but it’s important to remember that it is mostly temporary and not progressive, Dr. Jordan says. You may think doing brain games like crosswords or sudoku could help, but those are most useful for true cognitive decline associated with aging, not the temporary changes women experience in perimenopause.
Perimenopause Insomnia and Sleep Problems
About 40 percent of women experience disturbed sleep or insomnia during perimenopause. Unfortunately, poor sleep amplifies other mental and emotional symptoms, including depression, anxiety, and brain fog. It’s a frustrating cycle where mood problems interfere with sleep, and sleep problems worsen mood issues.
Why Perimenopause Disrupts Sleep
Fluctuating estrogen and progesterone are the main culprits of perimenopausal sleep problems. Scientists don’t fully understand exactly how it works, but we know that estrogen and progesterone receptors are found throughout brain regions that control sleep and wakefulness.
Estrogen appears especially important because it directly and indirectly influences sleep-regulating brain cells. Progesterone increases production of GABA, a neurotransmitter that promotes drowsiness and helps calm brain activity.
Hormone-driven night sweats and hot flashes obviously disrupt rest, as can sleep apnea and restless leg syndrome, both of which become more common during the menopause transition.
What You Can Do About Perimenopause Sleep Issues
Sleep is critical for emotional wellness and brain health. It helps neurons communicate and may even “clean” toxins from the brain. While good sleep hygiene—consistent bedtimes, dark rooms, no screens before bed—is always worth doing, it’s unlikely to solve true hormone-related sleep disruption on its own. Here are more targeted approaches:
1. Increase physical activity.
Research shows that regular exercise improves sleep quality and duration. For example, one study found that people who work out for at least 30 minutes a day sleep an average of 15 minutes longer than those who don’t exercise (every little bit counts).
Exercise likely works in several different ways: It reduces stress; boosts the production of melatonin, a hormone that regulates sleep-wake cycles; and regulates body temperature in a way that promotes sleepiness.
2. Consider a sleep study.
You may not think you have a sleep disorder, but sleep apnea is underdiagnosed in women, and the risk of this serious condition increases during perimenopause and menopause.
In obstructive sleep apnea (OSA), tissues in the throat sag during sleep, blocking your airway and causing frequent breathing interruptions. While loud snoring is the most talked-about symptom, morning headaches, dry mouth upon waking, and frequent heartburn can also signal this disorder. Untreated OSA causes fatigue, brain fog, irritability, and is a major risk factor for heart disease.
3. Talk to your doctor about hormone therapy.
Research suggests that taking estrogen and/or progesterone can improve women’s sleep in perimenopause and menopause. One study followed women for four years and found that those who took hormone therapy experienced improved sleep quality, more sleep satisfaction, and fewer sleep disturbances than those who didn’t.
Anxiety, Mood Swings, and Irritability During Perimenopause
According to Dr. Jordan, 96 percent of perimenopausal patients at Midi Health reported some degree of moodiness, anxiety, or depression when specifically asked about these symptoms. Browse any online forum for women in their 40s and you’ll see this playing out in real time.
As one Redditor put it: “I’ve been wondering if perimenopause is hitting me. I’m so angry all the time! Every minor inconvenience sets me off! Alternately, I cry about everything. Something sweet, something slightly sad, something beautiful, pretty much everything.”
While there’s less research on anxiety and mood swings in perimenopause than depression, available studies support what women report:
- One 2024 study found more than half of all perimenopausal and menopausal women had anxiety symptoms.
- Another study that followed women for 10 years found participants were 56 percent more likely to have anxiety during perimenopause than during their reproductive years.
- Research also shows perimenopausal women are 41 percent more likely to experience irritability than premenopausal women.
Anxiety & Mood Changes by the Numbers
What’s Behind the Emotional Volatility
The causes mirror those of perimenopause depression: Fluctuating estrogen affects mood because estrogen receptors are throughout brain areas that control emotions and thinking. Estrogen also influences how your brain uses serotonin and noradrenaline, chemical messengers crucial for mood regulation and overall well-being.
The dramatic mood swings likely stem from that hormonal “roller coaster,” where levels can shift significantly from day to day or even hour to hour.
It’s important to remember that not every mood change during this time is purely hormonal. Life circumstances that often coincide with perimenopause—aging parents, children leaving home, career changes, or other major transitions—can significantly impact how you feel too.
You don’t have to suffer through it alone. Finding a community of women going through the same thing can help immensely, as can therapy. If you find that anxiety, mood swings, and irritability are harming your quality of life or creating problems in your relationships, talk to your medical provider about it. There are interventions that can help. (Keep scrolling for details.)
Treatment Options for Perimenopause Symptoms
Mental and emotional perimenopause symptoms don’t have a simple explanation or cure. Because they stem from both biological factors (hormone fluctuations) and situational ones (life stressors), they require a holistic approach to care, says Kari Anderson, DBH, a licensed professional counselor who treats many women in perimenopause.
When she’s counseling a client in perimenopause or menopause who has anxiety, depression, or other issues, Anderson doesn’t make assumptions about the causes or treatments.
“We know that things like blood sugar imbalances and gut health also affect brain chemistry, so mood difficulties are not always what they seem,” she says. “It’s important not to assume everything is ’emotional.’ We need to look at the whole person—emotions are just felt experiences in the body, messaging to us that something’s up, [whether it’s hormones or another underlying condition].”
“Mood difficulties are not always what they seem. We need to look at the whole person.”
Dr. Jordan agrees there’s no magic bullet. “More often than not, multiple things will help. I don’t think any patient leaves Midi Health with just a hormone prescription. We’re also going to work on sleep hygiene and other lifestyle issues like alcohol intake,” she says. “Some women only need lifestyle interventions. Some women need hormones. For most people, it’s a holistic approach.”
Here’s a comprehensive look at what can help with perimenopause symptoms, broken down by lifestyle changes, medical treatments, and therapy options:
Lifestyle Changes for Perimenopause Symptoms
1. Get more sleep–even a little bit.
A lack of sleep can exacerbate perimenopause symptoms like depression, anxiety, and brain fog. While good sleep hygiene is unlikely to solve hormone-related sleep issues, it provides a foundation for better rest.
Start with the basics: Set regular bedtimes and wake times, create a calming bedtime routine, and sleep in a cool, dark room. Then address bigger issues like mood disorders or undiagnosed conditions like sleep apnea.
Research also suggests that hormone therapy with estrogen and/or progesterone can help women get better rest. Because sleep is such a personal and complex issue, the best way forward is to talk to your doctor about your specific difficulties.
2. Cut back on alcohol, especially in the evening.
Dr. Jordan often counsels women about reducing drinking during this time of life. Alcohol can worsen perimenopause symptoms like hot flashes and night sweats. And while it may make you feel calm and drowsy at first, it can interrupt crucial REM sleep later in the night.
3. Eat to support your changing brain.
Research in the emerging field of nutritional psychiatry shows that diets full of whole foods, lean proteins, and healthy fats protect mood and cognition, while low-quality diets heavy on sugar can have the opposite effect. While the exact reasons are still under investigation, scientists believe this works partly through the gut microbiome and how food affects your bacterial balance. The Mediterranean diet—low in processed foods, high in seafood and vegetables—offers good inspiration.
One thing you might want to avoid if you get hot flashes and night sweats? Spicy foods, which can actually trigger changes in your body temperature.
4. Move your body most days.
We’ve said it before but it’s worth repeating: Exercise is an excellent protector of mental and emotional wellness. Regular exercise not only boosts brain function and memory, it also helps reduce depression symptoms and improves sleep quality by cutting stress and boosting melatonin production—particularly helpful when your natural hormone production is erratic.
Medical Treatments for Perimenopause Symptoms
Several medications and supplements have been shown to help with mental and emotional perimenopause symptoms like depression, insomnia, and brain fog. Talk to your healthcare provider about what might be best for you.
Antidepressants
There is no consensus about which antidepressants work best for perimenopausal depression, but SSRIs and SNRIs are commonly prescribed for women with hot flashes or perimenopause-related mood problems. SSRIs work by boosting serotonin availability in the brain, while SNRIs enhance the availability of both serotonin and norepinephrine. Symptom improvement typically occurs within two to 12 weeks of starting treatment.
Hormone Therapy
Research shows hormone therapy with estrogen, progesterone, or both can help relieve many perimenopausal symptoms, including hot flashes, night sweats, depression, sleep problems, and memory issues. While risks and benefits vary from person to person, more women are using hormone therapy now that research has shown earlier concerns about breast cancer and other risks were overblown.
Supplements
The thinking on which supplements truly help with perimenopause symptoms seems to change whenever a new study drops. In a 2023 statement on non-hormonal therapies released by the Menopause Society, they did not recommend any supplements or herbal remedies as safe and effective. That said, many experienced clinicians suggest certain ones based on research and what they’ve seen in their practices, including:
- Omega-3s: Dr. Jordan recommends omega-3s due to substantial brain health research supporting their benefits.
- Magnesium: This supplement is popular in the perimenopause community. Though research is mixed, some data suggests it may help with anxiety, depression, and sleep. Nearly half of women in the U.S. don’t get enough magnesium from food, and it’s crucial for healthy brain chemistry—helping produce feel-good serotonin and increasing the release of calming GABA in the brain. If you want to give it a try, the recommended daily dose is 320 milligrams for women over 31. As always, check with your doctor before taking any new supplements.
Therapy Options for Perimenopause
Psychotherapy is a very effective treatment for many mental health symptoms, including depression, anxiety, and insomnia. The type of therapy you seek may depend on the providers available in your area, what resonates with you, and your specific mental and behavioral health history. Here’s what you should know about several modalities that can be useful to women in perimenopause.
Acceptance and Commitment Therapy (ACT)
This approach helps you accept difficult emotions and physical sensations rather than fighting them, while committing to actions aligned with your values. Research on ACT for menopausal women shows promising results, with a 2022 randomized controlled trial finding that ACT-based counseling improved mood in menopausal women.
“I think compassion-based and value-based approaches, like ACT, work best with a more mature client,” says Anderson. “They are more complex and need respect.” She often combines ACT with other body-centered approaches that help women understand the physical sensations of their emotions and how their nervous system responds to stress.
Cognitive Behavioral Therapy (CBT)
CBT helps you recognize thinking patterns and cognitive distortions, and how they influence your behavior and beliefs. It’s one of the most studied psychological interventions for anxiety and depression.
Dialectical Behavior Therapy (DBT)
DBT is an approach that teaches four core skills: mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. DBT’s emphasis on emotion regulation skills helps people develop healthy coping strategies and improve their relationships. Women with eating or substance-use issues can also benefit from DBT, Anderson says.
The Bottom Line
The mental and emotional changes you’re experiencing during perimenopause are real, scientifically documented, and treatable. From brain fog and irritability to anxiety and depression, these symptoms stem from hormonal fluctuations that affect your brain in measurable ways.
You don’t have to power through this transition hoping things will eventually get better. Lifestyle changes, medical interventions, and therapy can all provide relief. Many women find that combining approaches works best, addressing both the biological and situational factors at play. And the future looks promising: A groundbreaking 2025 study published in Molecular Psychiatry is opening the door to more targeted treatments beyond hormone therapy.
If your healthcare provider dismisses your concerns or suggests you’re “too young” for perimenopause symptoms, seek a second opinion or find a provider who specializes in women’s hormonal health or menopause medicine. You’re navigating a major biological transition that deserves proper care. With the right support and treatment plan, you can feel more like yourself again.
