Anxiety and low mood: hormones, or life?

Summary

"I don't feel like myself." It is one of the sentences women in perimenopause use most often. Irritability out of nowhere, crying for no reason, anxiety that was never there before, a loss of interest. None of this is imagined: perimenopause is a well-described window of vulnerability for depressive symptoms and anxiety, and the risk rises even in women who have never experienced them. But hormones are not the only cause; disturbed sleep, hot flashes, the load of midlife and your own history all work together. The good news: there are effective treatments, and there is no need to "put up with it until the hormones settle".

What is happening?

Estrogen regulates brain systems involved in mood, such as serotonin and norepinephrine. In perimenopause the problem is not that estrogen is low but that it is erratic; the size of the fluctuation is what correlates with depressive symptoms. Added to that:

• Disturbed sleep: Broken sleep directly affects mood and increases anxiety.

• Hot flashes: Frequent and severe vasomotor symptoms run alongside depressive symptoms.

• Life context: Caring responsibilities, career pressure, changes in relationships, aging parents, children leaving. These coincide with the same years as menopause.

• Your history: Having had mood changes after childbirth or before periods raises the risk in this period too; the brain's sensitivity to hormonal fluctuation is individual.

Symptoms sit on a spectrum, from mild irritability and ups and downs through to low mood that disrupts daily functioning. Working out where on that spectrum you are is a clinical assessment.

What do we know?

• The risk genuinely rises: In SWAN, the risk of major depression in perimenopause and early postmenopause was found to be 2 to 4 times higher than before menopause, and the risk is highest in those with a past history of depression ¹. In the Penn cohort, even in women who had never had depression, the risk of depressive symptoms in perimenopause was around four times higher and the risk of a diagnosed depressive disorder about 2.5 times higher, and this was linked to hormonal fluctuation ².

• There is a joint guideline: The 2018 guideline from the Menopause Society and the National Network of Depression Centers recommends the following for the assessment and treatment of perimenopausal depression: screening with validated scales, psychotherapy and antidepressants as first-line, and HRT as potentially helpful for perimenopausal depressive symptoms — particularly where vasomotor symptoms accompany them — but not recommended for postmenopausal depression ³.

• Estrogen may be protective: In a randomized trial in perimenopausal women, transdermal estradiol and micronized progesterone reduced the development of clinically meaningful depressive symptoms compared with placebo ⁴. This does not mean HRT is a treatment for depression; but it is a data point in your doctor's assessment.

• CBT and psychotherapy are effective: NICE recommends CBT for low mood and anxiety, and notes that HRT may also have an effect on low mood while not being a first-line treatment for depression ^{5 6}.

• Antidepressants can do two jobs at once: Some SSRIs and SNRIs improve both mood and hot flashes, which is an advantage in women who cannot use HRT (see the separate article on non-hormonal options).

What does this give you?

• Record the symptoms, as carefully as sleep and hot flashes: A mood record lets you tell your doctor "20 bad days in the last month, most of them after nights with sweats". In Lumia, mood, anxiety and irritability can be marked separately.

• Ask for a tool to measure yourself: Short, validated scales (PHQ-9, GAD-7, for instance) show both your baseline and your response to treatment; your doctor can administer them.

• The "hormones or life" dilemma is a false one: The two work together, and treatment can work in both directions too: targeting sleep and vasomotor symptoms often improves mood as well, while psychotherapy increases your capacity to cope whatever the hormones are doing.

• Things you can do today: Regular movement (one of the best-evidenced non-drug approaches), a sleep routine, cutting back on alcohol, not being alone. The breathing and mindfulness tools in Lumia can help during episodes of anxiety; they do not replace treatment.

• Asking for help is not weakness: The mood changes of this period have a biological basis, and they can be treated.

Sources

1. Bromberger JT, et al. Major depression during and after the menopausal transition. Psychol Med. 2011;41(9):1879-1888.
2. Freeman EW, et al. Associations of hormones and menopausal status with depressed mood in women with no history of depression. Arch Gen Psychiatry. 2006;63(4):375-382.
3. Maki PM, et al. Guidelines for the evaluation and treatment of perimenopausal depression. J Womens Health. 2019;28(2):117-134.
4. Gordon JL, et al. Efficacy of transdermal estradiol and micronized progesterone in the prevention of depressive symptoms in the menopause transition. JAMA Psychiatry. 2018;75(2):149-157.
5. NICE. Menopause: identification and management (NG23). 2015; updated November 2024.
6. The Menopause Society. The 2022 Hormone Therapy Position Statement. Menopause. 2022;29(7):767-794.

Related articles

• Why does sleep break down? 5 min read
• Hot flashes and night sweats 5 min read
• How do hormones change during this period? 5 min read
• Are there non-hormonal options? 6 min read