Anxiety in perimenopause and menopause

What it can feel like

Anxiety in perimenopause doesn't always look like worry. It can be just as physical as it is emotional, and it often comes in waves. Women describe:

• A sense of dread or unease, often worse first thing in the morning
• Racing thoughts, overthinking and imagining the worst
• Palpitations, chest tightness or feeling short of breath
• Irritability, feeling overwhelmed and less able to cope with noise or demands
• Panic attacks, sometimes out of the blue or in the middle of the night
• Losing confidence at work, socially or with things like driving

It can be frightening, particularly if it's new. Many women worry that something is seriously wrong, or that they are always going to feel like this, which usually isn't the case .

What's happening in the brain in perimenopause?

Oestrogen and progesterone don't just act on the ovaries and the womb. The brain is full of receptors for both, particularly in the areas that regulate mood, sleep, temperature and how we respond to stress.

Oestrogen plays a role in how the brain makes and uses serotonin and dopamine, the chemical messengers that help to keep mood steady and support motivation and focus. It also helps to regulate the body's stress response. When oestrogen levels swing up and down in perimenopause, this steadying effect becomes less reliable, and the brain can become more reactive to stress.

Progesterone has a different but equally important role. It is broken down into a substance called allopregnanolone, which acts on the GABA pathway in the brain. GABA is our main calming pathway, a bit like the brake pedal of the nervous system. It's the same pathway that many sedative medications, and alcohol, act on. As ovulation becomes less regular in perimenopause, progesterone is often one of the first hormones to fall, and with this we lose some of the natural calming effect of progesterone.

It's often the fluctuation, rather than simply low levels, that causes the most difficulty. This is why anxiety can be so changeable in perimenopause, with good weeks and bad weeks, and why it often settles once hormone levels become more stable.

Why it happens

There are usually several things going on at once.

Hormone fluctuations make the brain more sensitive to stress, so anxiety is more easily triggered, even by small things.

Night sweats and hot flushes disrupt sleep, and poor sleep is one of the most powerful drivers of anxiety there is - feeling tired often magnifies normal worry and can lead us to catastrophise.

Hot flushes themselves can feel a lot like panic, with a sudden surge of heat, a pounding heart and a sense of alarm. The two can feed into each other, and it isn't always easy to tell which came first.

Women who have previously been sensitive to hormonal changes, for example with PMS, PMDD, postnatal depression or low mood on the contraceptive pill, are more likely to notice mood changes in perimenopause.

And then there's life. Perimenopause often lands at a time of peak responsibility, with work, children or teenagers, ageing parents and relationships all competing for attention - at a time when our capacity for stress is lower due to hormonal change.

Anxiety isn't always about hormones

Perimenopause is a very common cause of new anxiety in midlife, but it isn't the only one, and it's important not to assume that everything is hormonal. Sometimes it's a combination of factors, and sometimes it's something else entirely.

Other common contributors include

• Thyroid problems, particularly an overactive thyroid
• Low iron or anaemia, especially if periods have become heavier
• Low vitamin B12 or vitamin D
• Caffeine, including energy drinks and pre-workout supplements
• Alcohol, which can cause rebound anxiety the following day
• Poor sleep from any cause, including sleep apnoea
• Some medications, such as steroids, decongestants or salbutamol
• Blood sugar dips from skipped or rushed meals
• Heart rhythm problems, if palpitations are a main symptom
• ADHD and autism, where perimenopause can intensify existing difficulties
• Ongoing stress, bereavement, caring responsibilities or past trauma

If anxiety is a new symptom for you, it's worth talking to your GP about what could be going on and potentially some routine blood tests, such as a full blood count, iron levels and thyroid function. If you are having palpitations along with chest pain, fainting or significant breathlessness, please get these checked promptly rather than assuming they are hormonal.

For women who are neurodivergent, perimenopause can feel particularly challenging. Because of the action of oestrogen on dopamine, women with ADHD are often very sensitive to the hormonal fluctuations of perimenopause, and coping strategies that have worked well for years can suddenly stop working and exaggerate any existing anxiety.

Is it menopause or an anxiety disorder?

Some women develop anxiety for the first time in perimenopause, and it improves as their hormones are stabilised. Others have lived with anxiety for many years and find that it becomes much harder to manage.

Clues that hormones may be playing a part include anxiety that is new or noticeably different, symptoms that worsen in the days before a period, and anxiety that comes alongside other perimenopausal symptoms such as night sweats, poor sleep, joint pains, brain fog or changes to your cycle. Keeping a simple symptom diary for a couple of months can be really helpful in spotting a pattern, and it gives us useful information if you come to see us.

If anxiety is affecting your ability to get through the day, or you are having thoughts of harming yourself or that life isn't worth living, please don't wait. Speak to your GP, contact NHS 111 and select option 2 for urgent mental health support, call the Samaritans at any time on 116 123, or text SHOUT to 85258. If you feel you are in immediate danger, please go to your nearest A&E.

What can I do about anxiety? What helps?

There is a lot that can help, and small changes can make a real difference. None of this is about giving you more things to do or simply 'thinking more positively' but instead are about making adjustments that will help reduce the impact of anxiety in perimenopause and menopause.

Protect your sleep

Sleep and anxiety are closely linked, and poor sleep makes everything harder. A consistent wind-down routine, a cool bedroom, and keeping screens and work out of the last 1-2 hours before bed can all help. Getting outside for some natural light first thing in the morning helps to support the circadian rhythm.

CBT for insomnia has a good evidence base, and Sleepstation and The Good Sleep Clinic both offer evidence-based programmes. Seeing a good sleep therapist for some one to one sessions can also be helpful.

Look at caffeine and alcohol

Many women find their tolerance changes in perimenopause. Caffeine can trigger or amplify palpitations and that jittery, wired feeling. Alcohol might feel relaxing in the moment, but it often disrupts sleep and makes anxiety worse the next day. Cutting back on both, even for a few weeks as an experiment, can be really revealing.

Move your body

Regular movement is one of the most effective things we can do for anxiety, and it doesn't have to be intense. Walking, strength training, swimming and yoga all count. Strength training has the added benefit of supporting bone and muscle health, which becomes increasingly important through menopause. Movement works because it helps the body to process and metabolise the stress hormones like adrenaline that lead to symptoms of anxiety.

Calm the nervous system

Anxiety lives in the body as well as the mind. Slow breathing with a longer out-breath, gentle somatic movement and certain mindfulness practices can help to shift the nervous system out of threat mode. These are skills, and like any skill they get easier with practice. Start small, even a few minutes a day.

Keep doing the things that matter to you

When anxiety is high, it's completely natural to want to avoid the things that trigger it. Skipping the work social, letting a friend's call go to voicemail, or choosing not to drive on the motorway can bring real relief in the moment.

The difficulty is that avoidance tends to grow. Each time we step back from something, the brain learns that it was dangerous and that avoiding it kept us safe. The next time feels harder, and gradually our world gets smaller.

That smaller world has a knock-on effect. We see less of the people and do less of the things that bring us joy, which can lower mood. Confidence takes a hit too, and the gap between where we are and where we'd like to be can start to feel bigger than it really is.

Where you can, try to keep doing the things you enjoy and the things that matter to you, even if you feel anxious doing them. It's fine to adapt. You might go for a shorter time, take a friend with you, or start with a smaller step and build up. Anxiety often peaks early and then eases if we stay with it, and each time we do, it becomes a little easier.

This isn't about forcing yourself through everything or ignoring how you feel. It's about gently keeping your world open while you get the right support for your symptoms.

Talk to someone

NICE recommends menopause-specific cognitive behavioural therapy (CBT) as an option for low mood and sleep problems in menopause, either alongside HRT or instead of it. CBT doesn't suggest your symptoms aren't real. It gives you practical tools to make them less overwhelming. Talking things through with someone you trust can also help, as can knowing that what you're experiencing is common and that you are not alone.

CBT isn't the right fit for everyone, and that's okay. Other approaches can be just as helpful. Acceptance and commitment therapy (ACT), for example, focuses less on changing anxious thoughts and more on making room for them, while still moving towards the things that matter to you. Finding an approach and a therapist that feel right for you is what matters most.

Will hormone replacement therapy (HRT) help my anxiety?

For many women, yes, particularly when anxiety has come on in perimenopause alongside other symptoms.

HRT can help in a few different ways. Stabilising oestrogen levels can smooth out the hormonal swings that make the brain more reactive to stress. Treating night sweats improves sleep. And when hot flushes settle, the physical surges that can feel so much like panic often settle too. NICE recommends HRT as the first-line treatment for menopausal symptoms, and notes that there is no clear evidence that antidepressants help low mood in menopause for women who have not been diagnosed with depression.

The type of HRT matters. We usually recommend oestrogen through the skin, as a patch, gel or spray, which gives steadier levels and does not increase the risk of blood clots. Micronised progesterone (Utrogestan), taken at night, acts on the GABA calming pathway, and many women find it helps with both sleep and anxiety. On the other hand, some women are sensitive to certain synthetic progestogens and notice that their mood or anxiety gets worse. If that sounds familiar, it's worth discussing, as there are usually other options.

HRT isn't a cure-all, and it isn't the right answer for everyone. If anxiety started long before perimenopause, or other factors are involved, HRT may help but is unlikely to be the whole answer. Many women do best with a combination of approaches, and HRT can sit very comfortably alongside CBT, lifestyle changes and, where needed, antidepressant medication. You can read more on our About HRT page.

Will testosterone help my anxiety?

Testosterone is currently recommended for low libido that hasn't improved with HRT, and there isn't evidence that it treats anxiety. However, some women do tell us they feel more confident, energised and motivated when a low level is replaced, but it needs to be discussed with your doctor to understand whether it might be appropriate to trial off licence. For some women, if anxiety is very high, adding in testosterone can exacerbate anxiety in the short term if the rest of the HRT isn't already optimised so this needs to be considered with care. In the UK, testosterone for women is prescribed off-licence and needs regular blood test monitoring.