Anxiety doesn’t always announce itself as anxiety. For many women in perimenopause – like many of my friends experiencing it now – it sneaks in as a racing mind and heart at 3am, a creeping sense of dread before a perfectly ordinary day, or an irritability that feels wildly out of proportion. You might have put it down to what’s happening in the world right now (which is a lot, of course!), work stress, aging, or just being a bit “highly strung” lately. But here’s what the research is now making clear: hormones play a very big role when you’re in your perimenopause years.
These 4 menopause podcast episodes and blog on anxiety walk you through what may be happening, why it matters, and the most evidence-based actions you can take in perimenopause and beyond. Looking for more podcasts on anxiety? We’ve got you covered here.
Perimenopause is associated with an increased risk of anxiety disorders, largely due to hormonal changes affecting the body’s regulatory feedback mechanisms. And it’s far more common than most of us are told. Between 15% and 50% of perimenopausal and postmenopausal women may experience psychological and emotional symptoms such as anxiety, depression, insomnia, and forgetfulness. Yet many go undiagnosed, or are handed a prescription for anti-anxiety medication without anyone mentioning the hormonal connection.
Key takeaways on anxiety in perimenopause & menopause
Estrogen and progesterone both influence the brain’s mood and stress regulation systems. When they fluctuate and fall, anxiety can follow. The more severe the perimenopause symptoms, the higher the incidence of adverse mood. Anxiety in perimenopause often looks different from “classic” anxiety, and it can present as heart palpitations, irritability, a sense of doom, or feeling overwhelmed rather than traditional worry.
A prior history of depression or anxiety is one of the strongest predictors of mood symptoms during the menopausal transition — but perimenopause can also trigger new-onset anxiety in women who’ve never experienced it before. Global projections suggest that by 2035, the burden of anxiety disorders in perimenopausal women will rise significantly, making this a growing public health priority.
Cognitive behavioral therapy (CBT), HRT, mindfulness, and lifestyle approaches are all evidence-backed tools, and often work best in combination. You are not overreacting. You are not going crazy, even if you feel like it. This is biology – fortunately or unfortunately for us!
What’s actually happening in your brain?
Your hormones don’t just govern your reproductive system. Estrogen and progesterone have a profound effect on the brain — particularly on the neurotransmitters that regulate mood, stress, and sleep.
Fluctuations in estrogen and progesterone levels during menopause affect neurotransmitter systems, including serotonin, norepinephrine, and dopamine, as well as hypothalamic-pituitary-adrenal axis function. In plain terms: as your hormones fluctuate unpredictably in perimenopause (rather than simply dropping), your brain’s emotional regulation system gets destabilised. It’s not a character flaw. It’s neurochemistry.
Sleep is also part of the picture. Poor sleep (itself a common perimenopause symptom) amplifies anxiety significantly, creating a feedback loop that can be hard to break without addressing the hormonal root.
Are you at higher risk?
Research points to some factors that may make anxiety in perimenopause more likely:
- A personal or family history of anxiety, depression, or PMS/PMDD
- Severe vasomotor symptoms (hot flashes, night sweats) — these are closely linked to mood disturbance
- Poor or disrupted sleep
- High chronic stress or major life events happening simultaneously (hello, midlife)
- Surgical menopause or early menopause
- Adverse childhood events, stressful life events, and trait neuroticism are among the psychological factors associated with anxiety during perimenopause
- If you see yourself in this list, it’s worth taking your symptoms seriously and talking to a clinician who understands the hormonal connection.
5 things to help manage anxiety in perimenopause
1. Know it’s biological, not you
Your anxiety has a physiological cause. Estrogen and progesterone directly influence the brain chemicals that keep you calm, including serotonin and GABA. When they fluctuate, your nervous system is genuinely operating under different conditions. This isn’t stress, weakness, or a personality trait. It’s biology. And that reframe alone can change how you talk to yourself on a hard day.
2. Ask a doctor with menopause knowledge
If you’ve been handed an antidepressant without anyone mentioning perimenopause, push back. Speak with your doctor about where you are in the menopausal transition. For many women, anxiety that’s hormonally driven responds far better to HRT than to anything else, because it treats the root cause, not just the symptoms. It’s not the right fit for everyone, but it’s absolutely worth the conversation.
3. Move your body regularly
Exercise is one of the most effective anxiety tools available and the research backs it up. Aerobic movement boosts serotonin and GABA, lowers cortisol, and directly counters many of the neurochemical shifts behind perimenopausal anxiety. Even a consistent 20-minute daily walk makes a measurable difference. Resistance training on top of that? Even better for your mood, your sleep, and your bones.
4. Try CBT or mindfulness
CBT has the strongest evidence base of any psychological treatment for anxiety. Mindfulness-based stress reduction (MBSR) has also shown real results in perimenopausal women in clinical trials — and may even positively influence hormone levels. You don’t necessarily need a therapist to start — there are solid structured apps and programs out there if access is a barrier.
5. Take your sleep seriously — and try magnesium
Poor sleep and anxiety feed each other in a loop that’s hard to break, and perimenopause makes it worse. CBT for Insomnia (CBT-I) is the first-line recommendation from the American Academy of Sleep Medicine, and it works. It’s also worth looking at your magnesium levels. Estrogen helps your body process magnesium, so as estrogen falls during perimenopause, magnesium levels can drop too. Magnesium supplements have been shown to reduce cortisol and improve anxiety symptoms. Magnesium glycinate is the most commonly recommended form for anxiety and sleep — gentle on the stomach and well absorbed. As always, check with your doctor before adding any supplement, especially if you’re on medications.
Final thoughts: You deserve peace
Anxiety in perimenopause is not a life sentence. It is a symptom; one that is increasingly well-understood and, for many women, very treatable. As always, if you’re concerned about your mental health during perimenopause or menopause, please talk with your healthcare provider. You deserve to feel like yourself again.
Sources
Zhang Y, et al. Global, regional, and national burden of anxiety disorders during the perimenopause (1990–2021) and projections to 2035. BMC Women’s Health. 2025. https://pubmed.ncbi.nlm.nih.gov/39773442/
Huang S, et al. Anxiety disorder in menopausal women and the intervention efficacy of mindfulness-based stress reduction. American Journal of Translational Research. 2023. https://pmc.ncbi.nlm.nih.gov/articles/PMC10086901/
Sowers MF, et al. The Study of Women’s Health Across the Nation (SWAN): a multi-site, multi-ethnic, community-based cohort study of women and the menopausal transition. 2000. https://pubmed.ncbi.nlm.nih.gov/11023202/
Freeman EW, et al. Associations of hormones and menopausal status with depressed mood in women with no history of depression. Archives of General Psychiatry. 2006. https://pubmed.ncbi.nlm.nih.gov/16520434/
Soares CN. Mood disorders in midlife women: understanding the critical window and its clinical implications. Menopause. 2014. https://pubmed.ncbi.nlm.nih.gov/24473530/
Lang XL, et al. From physiology to psychology: An integrative review of menopausal syndrome. World Journal of Psychiatry. 2025. https://pmc.ncbi.nlm.nih.gov/articles/PMC12635657/
Okpete UE, et al. Optimizing perimenopausal mental health by integrating precision biomarkers, digital health interventions, and psychosocial care. World Journal of Psychiatry. 2025. https://pmc.ncbi.nlm.nih.gov/articles/PMC12305144/
The Menopause Society (NAMS). The 2023 Menopause Society Position Statement on Hormone Therapy. Menopause. 2023. https://menopause.org/professional-resources/position-statements
National Institute for Health and Care Excellence. Menopause: diagnosis and management. NICE Guideline NG23. Updated 2024. https://www.nice.org.uk/guidance/ng23
British Menopause Society. BMS Consensus Statement on Psychological Symptoms in the Menopause. 2023. https://thebms.org.uk/publications/consensus-statements/
Sateia MJ, et al. Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: an American Academy of Sleep Medicine clinical practice guideline. Journal of Clinical Sleep Medicine. 2017. https://pubmed.ncbi.nlm.nih.gov/27998379/
Boyle NB, Lawton C, Dye L. The effects of magnesium supplementation on subjective anxiety and stress — a systematic review. Nutrients. 2017. https://pmc.ncbi.nlm.nih.gov/articles/PMC5452159/
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