Anxiety, irritability and mood changes in perimenopause

Key takeaways

• Mood changes in perimenopause are a recognised medical effect of hormone change. They are not a weakness and not a personality change.
• The risk of depression goes up at the start of perimenopause. A past history of depression raises it further, but women with no history are also affected.
• NICE recommends considering hormone therapy for low mood arising from menopause, and CBT for low mood or anxiety.
• For a full depressive episode, antidepressants and talking therapy remain the main treatments.
• If you have thoughts of harming yourself, seek help the same day. Tele MANAS, India's free mental health helpline, is available on 14416, around the clock.

What do mood changes in perimenopause actually look like?

Many women don't walk into my room talking about hot flushes. They come in and say, "Doctor, I have become a different person. I shout at my children. I cry for no reason. I feel anxious all the time." Or simply, "I don't feel like myself anymore." The common patterns I see:

• New or worse anxiety, sometimes with a racing heart, a sense of dread, or panic attacks for the first time
• Irritability and rage that feels out of proportion, often aimed at the people closest to you
• Tearfulness and low mood, sometimes clustered before periods
• Loss of confidence, especially at work
• Feeling flat, less interested in things you used to enjoy
• Mood swings within the same day

Women in joint families often tell me the hardest part is that the family notices before they do. A mother-in-law's comment, a husband's silence, a teenager's door slammed. Everyone in the house feels it.

Why does perimenopause affect mood at all?

People think hormones are only about periods. They are not. Estrogen and progesterone act on the brain chemicals that keep mood and anxiety steady, including serotonin. And in perimenopause these hormones don't fall gently. They swing, up and down, without warning. Think of it like the voltage in your house going up and down all day. The fan, the fridge, everything struggles. Your brain is trying to keep up with that.

Then come the knock-on effects: - Broken sleep. Night sweats and 3 am waking leave you exhausted, and when you are exhausted your patience is the first thing to go. - Hot flushes. Frequent flushes are uncomfortable and embarrassing, and they can come with a surge of anxiety. - Brain fog. Forgetting words or losing focus in a meeting chips away at your confidence. - Midlife load. Children's exams and careers, ageing parents, work pressure, finances. All of this peaks at exactly the same time as the hormone changes.

So when a woman tells me she is snapping at everyone, I don't see a bad temper. I see a tired brain on a hormonal rollercoaster carrying a very heavy bag.

Is it perimenopause or is it depression?

See, I'll tell you, both can be true at the same time. The first expert guidelines on perimenopausal depression, published in 2018 by a panel convened by The North American Menopause Society (now The Menopause Society) and the National Network of Depression Centers, made a few clear points:

• The risk of depression rises with the onset of perimenopause.
• A history of depression is an important risk factor, but many women with no prior history also develop it.
• Perimenopausal depression often overlaps with menopausal symptoms such as poor sleep, fatigue and difficulty concentrating, which makes it harder to recognise.

This is how I help women think about it:

This table is a guide, not a diagnosis. If you see yourself in the right-hand column, please speak to a doctor soon. Don't wait for it to pass.

Which treatments actually have evidence?

Talking therapies. NICE recommends considering cognitive behavioural therapy (CBT) for low mood or anxiety arising from menopause. CBT is a practical, structured way of working on thoughts and habits. It also helps with how bothersome hot flushes feel and with insomnia.

Hormone therapy. NICE recommends considering menopausal hormone therapy for low mood that arises as part of the menopause. The 2018 perimenopausal depression guidelines also noted that estrogen has shown mood benefits in studies, particularly when mood changes come with hot flushes and night sweats. It is a prescription decision, made only after I have looked at your full health history. Read more in Menopausal hormone therapy explained.

Antidepressants. For a major depressive episode, the 2018 guidelines name antidepressants and psychotherapy as the frontline treatments. NICE adds that there is no clear evidence that SSRIs or SNRIs help low mood in menopausal women who do not have depression. So they should not be the automatic answer to "I feel low and irritable" in perimenopause. The right choice depends on what is really going on.

Lifestyle foundations. These don't replace treatment when you need it, but they genuinely help: - Regular physical activity, including strength training, which supports mood and sleep - Cutting back on alcohol, which worsens anxiety, sleep and flushes - Fixed sleep and wake times - A small daily thing that is only yours: a walk, music, a call with a friend

Why does your husband need to understand this?

This is something I say to so many couples. Mood changes in perimenopause are hormones. They are not a change in who your wife is. It's not her fault. When a husband understands this, the arguments shrink and he becomes part of the solution instead of the target. That is exactly why I welcome partners into the consultation, and daughters too. A daughter who understands this now will be kinder to herself in twenty years.

A few things that help at home: - Naming it together: "This sounds like the hormones talking. Shall we take a break and talk later?" - Sharing household load during the bad weeks, without being asked - Encouraging, not forcing, a doctor's visit

How I approach this at Dr Tvacha

At Cocoon × Dr Tvacha in Thane West, I take mood as seriously as hot flushes or periods. I look at sleep, hormones, thyroid, iron, medicines and life stresses together, go through hormonal and non-hormonal options with you, and refer you to a psychiatrist or psychologist when that is the right step. Partners and daughters are welcome. You can read about the Right Stop Programme on our women's health page, and see Brain fog in perimenopause.

Written by

Dr Anagha KarkhanisGynaecologist and Fertility Specialist · Reg. No. 2006/02/1187

Leads midlife women's health at Cocoon × Dr Tvacha, Thane.