A woman in her mid forties sits down and tells me she no longer recognises herself. She has always been capable, the one others lean on. Now she wakes at three in the morning with her heart racing, and she has started to dread situations she once handled without a thought. Her doctor has checked her heart and her thyroid. Everything is normal. Nobody has mentioned perimenopause.
This happens far more often than it should.
The years before the change
Perimenopause is the transition before periods stop. It can last for several years and often begins in the early to mid forties. Most women expect hot flushes and irregular cycles. Far fewer expect what can come first: anxiety, irritability, low mood, broken sleep and a kind of mental fog.
The evidence is now hard to ignore. A study by the Mayo Clinic and Flo Health, published last month and covering women in 20 countries, found psychological symptoms were 1.5 times more severe in perimenopause than before it, with exhaustion showing the biggest difference. A review of 102 studies found anxiety in 29% of women in perimenopause.
Yet awareness is strikingly low. A UK survey earlier this year found only 28% of women knew menopause could trigger anxiety or depression. A survey of 1,000 women published this week by LifeStance Health found more than a third were surprised that these symptoms can look like a separate mental health condition, and many had put off getting help as a result.
Why it happens
Oestrogen does far more than regulate the menstrual cycle. It affects brain chemicals involved in mood and sleep, including serotonin. In perimenopause, hormone levels do not fall smoothly; they swing. For some women those swings are felt most strongly in the mind.
This shift rarely arrives alone. It tends to coincide with teenagers at home, ageing parents, career pressure and, for some, the end of a marriage. The body and the life are changing at the same time, which makes it very easy to blame one for the other.
What helps
Keep a simple diary for two or three months, noting mood, sleep, anxiety and where you are in your cycle. Patterns often appear that are invisible day to day, and a diary is the most useful thing you can bring to a doctor.
Ask the question directly. If you are over 40 and anxiety has appeared or worsened without a clear reason, ask your GP or gynaecologist whether perimenopause could be playing a part. Hormonal and non-hormonal treatments both exist, and the decision is one to make with a doctor who knows your history.
Protect your sleep. Poor sleep and anxiety feed each other. A cool bedroom and less alcohol in the evening make a real difference for many women.
Talk about it. Women who learn that what they are feeling has a name often describe enormous relief. You are not failing to cope. Your body is going through a real transition.
Where therapy fits
Therapy does not replace medical care in perimenopause, but it works well alongside it. In the LifeStance survey, 83% of women who had therapy for these symptoms found it helpful. It offers practical tools for managing anxiety, and room to make sense of the wider changes that so often arrive at the same moment.
I normally see clients online, but face to face meetings are possible in all my locations, depending on my travel schedule; please ask.
Katya Thain
Sources: Mayo Clinic and Flo Health, Menopause journal, July 2026; LifeStance Health survey, August 2026.