Perimenopause and Mental Health: What’s Really Happening

You wake up in the middle of the night for no reason. Your heart is racing. You feel flooded by adrenaline, wide awake despite being exhausted. Later, in the light of day, you might find yourself suddenly overwhelmed, snapping at someone you care about, or crying in the car. Things that never used to bother you suddenly feel impossible to manage. You begin to question whether something is wrong with your mental health. The answer isn’t simple, but your experience is valid—and you’re not alone.

Perimenopause primarily affects people with ovaries, typically those assigned female at birth. While many use the term "women" to describe those going through this transition, it is important to recognize that trans men and nonbinary individuals who have not undergone certain gender-affirming surgeries or hormone regimens may also experience perimenopause. Mental health support during this stage should be inclusive, affirming, and tailored to the needs of those navigating these hormonal changes.

Perimenopause can affect mental health in ways that are often misunderstood or missed entirely. While many people associate this transition with hot flashes or irregular periods, fewer recognize that the hormonal fluctuations during this time can profoundly affect mood, sleep, memory, and overall psychological wellbeing.

For many, perimenopause arrives in the late 30s or 40s and unfolds gradually. It is the phase before menopause when estrogen and progesterone levels begin to fluctuate unpredictably. These hormonal shifts do not just affect the body; they impact the brain. Neurotransmitters like serotonin, dopamine, and GABA all respond to changes in estrogen and progesterone. This means that as hormones shift, so can emotional stability, sleep, focus, and energy.

Perimenopause can bring surprises and new understanding. Support and good care can help you feel like yourself again during this change.

Common Mental Health Changes in Perimenopause

Some people experience symptoms that mimic clinical anxiety or depression, even if they have never had a history of either. Others find that their longstanding mood or anxiety disorder becomes harder to manage during this time.

Symptoms may include:

• Increased irritability or anger

• Panic attacks or new onset anxiety

• Depressive episodes, often with fatigue and hopelessness

• Severe insomnia, sometimes unrelated to external stressors

• Loss of motivation or pleasure

• Brain fog, forgetfulness, or slower cognitive processing

• Heightened sensitivity to stress

• Crying spells or emotional lability

These experiences are not trivial, and they are not just about getting older. Hormonal shifts during perimenopause can impact the brain in complex ways that deserve recognition and informed care. They are real biological responses to fluctuating hormone levels that affect your nervous system.

Why Perimenopausal Mental Health Is Often Overlooked

Many people are told they are just overwhelmed or need to manage stress better. Even in psychiatric care, symptoms are often misdiagnosed as new-onset major depressive disorder, generalized anxiety disorder, ADHD, or personality disorder. The overlap in symptom presentation can lead to ineffective treatment if the underlying hormonal component is not recognized.

Additionally, standard lab tests like basic hormone panels may appear normal, even when symptoms are severe. Hormone levels fluctuate daily in perimenopause, which makes a single blood draw an unreliable marker of what is actually happening.

Understanding the Brain-Hormone Connection

Estrogen plays a central role in the regulation of serotonin and dopamine, both of which are essential for mood, motivation, and emotional balance. It also supports the GABA system, which helps regulate anxiety and calm the nervous system. Testosterone, although less frequently discussed in the context of perimenopause, also plays a role in mood, motivation, and cognitive function. Levels of testosterone naturally decline with age, and lower levels may contribute to fatigue, low libido, and reduced emotional resilience in some individuals during this transition.

Progesterone and its metabolite allopregnanolone modulate GABA-A receptors, contributing to a sense of relaxation. As progesterone levels decline, many people lose this stabilizing effect and report increased restlessness, anxiety, or insomnia.

The stress response system can also become more pronounced during perimenopause. Cortisol levels may rise more easily, and resilience to stress can decrease, especially when combined with sleep disruption or blood sugar instability.

Treatment Approaches That Actually Help

There are many ways to support mental health during perimenopause. An integrative psychiatric approach can offer a flexible, personalized framework for care.

Conventional options include:

• SSRIs or SNRIs for mood or anxiety symptoms

• Low-dose antidepressants for sleep (e.g., trazodone, mirtazapine or doxepin)

• Gabapentin or clonidine for night sweats and sleep support

• Hormone Replacement Therapy (HRT), which may include estradiol, progesterone, and in some cases testosterone, prescribed carefully based on timing, symptoms, and individual hormone levels

Evidence-informed supplements that may support mood and nervous system balance:

• Magnesium glycinate

• Omega-3 fatty acids (EPA/DHA)

• N-acetylcysteine (NAC)

• Creatine monohydrate

• Saffron extract

• Melatonin (low dose for sleep reset, not for nightly use)

Lifestyle factors that matter:

• Consistent, nutrient-rich meals to stabilize blood sugar

• Gentle movement, especially strength training or walking

• Daily natural light exposure, preferably in the morning

• Reducing alcohol, marijuana, and caffeine

• Sleep hygiene and wind-down routines

• Connection with others

Therapy modalities that may be especially useful include CBT for sleep or anxiety, internal family systems (IFS) for identity transitions, and trauma-informed approaches like EMDR if past experiences are resurfacing.

Advocate for Yourself

Keeping a journal of symptoms, sleep, cycle patterns, and emotional changes can help identify hormonal patterns. You may want to request labs that go beyond basic hormone checks, including vitamin D, B12, ferritin, TSH with free T3 and T4, and inflammatory markers.

Work with providers who listen. Bring documentation of how your symptoms align with your cycle or major hormonal transitions. Advocate for treatment that considers both your mental health and hormonal context.

Tracking symptoms, mood, and cycle changes can reveal patterns and give you tools to advocate for care that fits.

A Moment For Validation

This transition is real. It’s difficult. And it’s often dismissed or misunderstood. If your emotional reactions feel unfamiliar or your sense of self feels altered, that doesn’t mean you’re imagining it. This is a physiological shift with psychological effects, and it deserves to be taken seriously.

You don’t have to navigate it alone. There are ways to feel more grounded again. And there are professionals who take this stage seriously, without minimizing what you're going through.

If you're looking for specialized support, some of my clients have had good experiences with Midi Health, a telehealth platform that focuses on perimenopause and menopause care. I'm not affiliated with them, but their services may be worth exploring.

Recommended Listening
For an expert perspective on the hormonal shifts of perimenopause and how they impact long-term health and sexual wellness, consider listening to Dr. Peter Attia’s interview with Dr. Rachel Rubin. Dr. Rubin, a leading urologist and sexual health specialist, explains why women’s hormone care is often overlooked and shares evidence-based guidance on HRT and how to support healthy aging through menopause.