Some experts call the perimenopause stage "reverse puberty," a description they believe accurately reflects what a woman goes through during this transitional phase, which may last between 4 and 10 years before reaching menopause.
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During this time, the body not only gradually loses its reproductive capacity, but hormone levels also undergo significant fluctuations. While puberty is often associated with mood swings and intense emotions, this stage may bring back similar feelings, but in middle age.
During these years, many women feel they are "not themselves." They may become more easily angered, experience a decrease in libido, and struggle with concentration and mental clarity, and may also develop symptoms of anxiety or depression.
Dr. MargEva Morris Cole, an assistant professor of obstetrics and gynecology at Duke University School of Medicine and a member of the American Menopause Society (NAMS), explains that these symptoms are not only related to hormonal changes, but also to the stage of life a woman is going through at this age, according to Women's Health Magazine .
Cole says that middle age is often stressful, but many women focus on hormones and ignore the impact of these stressors. In their forties and fifties, women juggle work and family responsibilities while simultaneously beginning to feel the effects of aging and declining energy, which increases their psychological burden.
When all these changes come together, it can seem as though a woman's personality has completely transformed overnight. But does this really happen? And how can these emotional ups and downs be managed? To answer these questions, Women's Health spoke with several experts, including Wendy Perello, a licensed psychotherapist with MSW and LCSW degrees, who practices in Massachusetts, New Jersey, and New York.
How does perimenopause affect the brain and mental health?
Cole confirms that hormones, particularly estrogen, progesterone, and testosterone, play a key role in mood during this phase, but their effect varies from woman to woman. In her clinical experience, she has observed recurring patterns among her patients.
She explains that the problem in the early stages of perimenopause lies not in the low hormone levels themselves, but in the sharp fluctuations they experience.
Estrogen levels may rise significantly during ovulation, then drop rapidly later during the menstrual cycle, leading many women to experience severe mood swings and outbursts of anger.
As women progress through the later stages of menopause, estrogen levels gradually decline, leading to a range of symptoms. Cole notes that many women at this stage begin to complain of brain fog, anxiety, low mood, and a persistent feeling of unease. She adds that some patients describe the experience as being constantly under a "heavy cloud," without being able to pinpoint a clear cause, simply feeling a weight on their shoulders.
Hormones are not the only cause.
Despite the significant role hormones play, experts emphasize that they are not the sole factor responsible for mood swings during this stage.
Other common symptoms of perimenopause, such as hot flashes and night sweats, can indirectly affect mental health.
If night sweats consistently wake a woman at 3 a.m. and disrupt her sleep, it's natural for her to wake up the next day feeling more irritable and less rested. Experiencing a sudden hot flash during an important business meeting or personal appointment can also be embarrassing or increase feelings of anxiety.
Licensed psychotherapist Wendy Perello says that many women do not visit the clinic because of menopause itself, but because they feel anxious or depressed.
She adds: "My job is to get to the real reason for these feelings. When I deal with women in this age group, I talk to them about perimenopause and menopause, because many of them don't even realize that this stage may be the reason for what they are feeling."
Studies suggest that this effect may be significant. A systematic review published in 2023 in the Australasian Psychiatry journal concluded that menopause is associated with an increased risk of anxiety and depression, stating that this stage "increases susceptibility to depression and anxiety."
Researchers suggested that the cause is related to fluctuating hormone levels, but they also did not rule out the impact of hot flashes and other menopausal symptoms on mental health, emphasizing the need for further studies to understand this relationship more precisely.
The review also showed that women with a history of major depression are more likely to experience a recurrence during the menopausal transition.
Finally, Cole explains that the physical changes the body goes through during this stage are naturally reflected in mood, and may lead a woman to behave in ways that are not like her usual personality, whether by getting angry at her partner for simple reasons, or by crying at work after receiving a lower-than-expected job evaluation.
Are these changes permanent?
The two experts interviewed by the magazine believe that menopause, while a significant milestone in a woman's life, does not fundamentally alter her personality but rather represents a temporary transitional phase.
The good news is that many symptoms begin to subside or disappear after menopause.
Dr. Marg Eva Morris-Cole explains that brain and mood symptoms often stabilize within about two years after the last menstrual period.
Regarding brain fog or difficulty multitasking, she points out that the brain has the plasticity to reorganize itself, helping most women regain their mental efficiency and ability to function, albeit sometimes in ways different from what they were used to, after developing new coping mechanisms and ways to manage their lives.
Regarding postmenopausal depression, the review published in Australasian Psychiatry shows that the results are still mixed; some studies have found an increased risk of postmenopausal depression, while other studies have reached the opposite conclusion, indicating the need for more research in this area.
How can this stage be dealt with and utilized?
If mood swings during perimenopause are causing distress for women, there are many ways to alleviate them, according to Dr. Marg Eva Morris Cole, who emphasizes that treatment doesn't rely on a single solution.
She says, "In both perimenopause and menopause, we don't rely on one approach to address the problem; rather, we utilize a range of treatment options."
She explains that the first step doctors usually recommend is to make lifestyle changes.
She adds: "This is the right time to make changes that can improve your health and quality of life in the long run.
Ask yourself:
How can I reduce sources of stress?
How can I set healthy boundaries in my relationships with family and friends?
How can I make time for myself?Do I eat food that makes me feel better?
Do I exercise regularly? And most importantly, what method personally helps me manage my mood?"
She notes that many women may also need psychotherapy, as a therapist can help them understand the reasons for the feelings they are experiencing and discover positive ways to deal with them.
For her part, Wendy Perillo says it is important to first identify the reason why a woman feels this way.
She explains: "If anxiety is the problem, do you practice meditation? Breathing exercises? Journaling? It's important to recognize that this phase is a part of life, and you may not be able to completely control it, but you can learn ways to cope with it, such as hormone therapy."
Hormone therapy is one of the options Cole points to, as the doctor may prescribe, depending on each woman’s case, a combination of estrogen, progesterone or testosterone to help restore balance to hormone levels, which may have a positive effect on mood stability.
In addition to, or as an alternative to, hormone therapy, a doctor may prescribe medications from the selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) classes to help manage symptoms. These medications not only improve mood, but studies suggest they may also help alleviate hot flashes, even in women not using hormone therapy.
While many women focus on the negative aspects of this stage, Cole and Perillo argue that it also has positive aspects. After menopause, the fear of unplanned pregnancy ends, and many women are relieved of painful or heavy periods.
Perillo points out that for many women, this stage coincides with other life changes, such as children becoming independent or leaving home, which may give a woman a new opportunity to take care of herself and rediscover her priorities.
She says: "This can be a period that gives a woman a sense of liberation, because she begins to focus more on herself. How do I take care of myself at this stage? What does my body need? Often, a woman becomes more aware of how she feels because she has had to take care of her sleep, her food, and exercise, which ultimately helps her."
Perillo concludes by emphasizing that women are not alone in this experience, as millions of women around the world go through perimenopause or menopause, adding: "If we can look at this stage positively, let's do it."
