15-05-2025
Menopause and Mental Health: Coping with Mood Swings and Anxiety
Two of the biggest symptoms in menopause that women experience aren't just physical; mood swings and anxiety can emerge during the midlife transition, shaped by both external and hormonal factors.
'Your mood is never always going to be good,' Dr. Lisa Weinstock, a board-certified psychiatrist and Let's Talk Menopause advisory board member, told Flow Space. 'You're supposed to be angry sometimes, you're supposed to be sad.'
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During perimenopause and menopause, however, women may find that their moods aren't aligned with their experiences or that their moods rapidly change throughout the day.
While anxiety is a broad umbrella term, Weinstock—who specializes in psychotherapy and medication management with a subspecialty in mood changes related to perimenopause and menopause—also shared that women come to her because of increased panic attacks or a sense of worry that doesn't fade throughout the day. There's also a lot of overlap for them, she added, when it comes to anxiety and irritability.
'Women experience increased vulnerability to mood at certain reproductive stages or windows across the lifespan,' Dr. Rajita Patil, a board-certified OB-GYN, Menopause Society certified expert and Founder and director of UCLA's Comprehensive Menopause Program, explained.
During menopause, 'irritability, low energy, sadness, rage, panic, anxiety [and] instability of mood' are all symptoms resulting from a fluctuation in estrogen that impact neurotransmitters involved in mood regulation, which can lead to lower serotonin levels.
Data suggests that 15% to 30% of women will experience their first case of depression during menopause; 50% to 70% of women who have previously experienced anxiety or depression will see symptoms intensify or change.
A global study published in 2024 found that women in perimenopause are around 40% more likely to experience depression than women who haven't begun the transition.
In other words: When estrogen drops, it can trigger depressive symptoms or worsen symptoms for women already struggling with mental health challenges. And in a landscape where half of women 40 to 49 feel 'hopeless' about menopause, it is time we started talking about how to cope.
Approximately 2.2 million women enter menopause each year, but only 31.3% of U.S. obstetrics and gynecology (OB-GYN) residency program directors surveyed in 2024 reported having a menopause curriculum in their residency program. In order for medical professionals to gain expertise in menopause, they need to pursue extra training—often at their own expense.
Because of this massive gap in menopause education, it may take women several appointments with various providers to receive a menopause diagnosis. Women may also be presented with medical misinformation, misdiagnosed or offered inadequate treatment options.
This may be one reason that data shows women in midlife are disproportionately being prescribed anti-depressants, despite menopause guidelines stating that antidepressants shouldn't be the first option for addressing mood swings linked to perimenopause.
'If people understood menopause and really got the knowledge that they needed around this space and curriculum as they're going through med school, or as they're in the workplace,' Patil asserted, 'there wouldn't be a one-size-fits-all approach.'
Mood stabilizing medication is crucial for certain patients, particularly those with clinical depression and anxiety or those who have struggled with mental health prior to the menopausal transition. For these patients, Weinstock has seen results from 'SSRIs, SNRIs, gabapentin, as well as other anti-anxiety medications.'
'There is a societal stigma around using mood stabilizers,' Patil asserted. 'And we have to acknowledge that this is a problem in our society.' Approaching changes in mood and anxiety during menopause as an issue of unstable neurotransmitters, she offered, reframes the approach and leaves room for all modalities, 'one of which could be therapeutic modalities to address stress and all of that, and one could be that we give hormones to stabilize the serotonin levels—or we might use SSRIs or SNRIs or other medications, to stabilize the neurotransmitter.'
'It is important to evaluate mood swings and anxiety symptoms in all women during perimenopause and menopause in order to come up with an appropriate response,' Weinstock added. 'There's going to be a subset of people who are more depressed because they have histories of depression, or they're becoming depressed in perimenopause, and they should go on an SSRI if that's the right treatment for depression.'
Hormone replacement therapy (HRT) can also be effective at treating menopause symptoms—both physical and emotional.
'There's good data to show that [with HRT] there's potentially 60% to 80% improvement, for partial remission or total remission of symptoms, for people that don't have clinical depression or anxiety,' Patil shared. 'You don't have to have hot flashes to try to use hormone therapy for this.'
She added that mood stabilizers, such as SSRIs, SNRIs and others, work 'synergistically' with HRT and are important top-line forms of care—in particular, for women who have clinical depression or anxiety.
For Weinstock, 'it depends where the preponderance of the symptoms are… For some of the physical symptoms, hormones are the way to go—and for some of the psychological symptoms, like if you're a little irritable or you're a little tired. But if you're having classic symptoms of depression or anxiety, without those other things,' she explained, that may change what treatment makes the most sense.
What is needed, for real menopause relief, is an approach that addresses all of the factors at play when it comes to women's midlife mental health.
'Reasons for mood and anxiety symptoms during perimenopause and menopause,' Weinstock delineated, can be biological and physical—'insomnia, hot flashes, the impact of hormonal fluctuations on brain function'—or psychosocial, such as symptoms related to or impacted by changes in life circumstances that come with age—empty nesting, changes in romantic relationships and issues at work.
The menopause program at UCLA that Patil founded leverages a proprietary clinical support tool to treat the physical, hormonal and psychological aspects of menopause; she likens the interplay between various factors as that of a 'big Venn diagram.'
'It's not like mental health just sits in a silo, and there's just like one thing that's affecting it,' she clarified. And while hormones may be one large circle impacting women's mental well-being, other factors often overlap and directly impact women as well.
'Stressors are a big one,' Patil declared. 'Women are usually at their busiest during perimenopause and menopause, juggling enormous responsibilities at home, in the workplace. They're often at the peak of their jobs, in high level positions and then they're still taking care of the home. They may be either empty nesting, or they're taking care of children, and sometimes the elderly. They're super women at this time.'
When hormones fluctuate, the state of equilibrium these super women have cultivated can shift out of balance—and when the balls drop, women in midlife can find themselves burned out, treading water and struggling to take care of themselves.
'Stress causes inflammation. Inflammation is bad for the organs,' Patil noted. During perimenopause and menopause, women's bodies also become more impacted by stress, due to the lack of estrogen, which, throughout our lives, 'really is a little buffer,' she explained, helping us 'bounce back' from stressful events.
Stress can also rewire the brain.
'Stressful life events,' she added, 'reduce the number of serotonin receptors that attach to available serotonin. They impair serotonin production, they speed up the rate at which serotonin is breaking down, and chronic stressors—things that are there for a really long time—they can even shut down part of the brain that allows estrogen to do its job at that neurotransmitter level, which then further affects how serotonin is going to work.'
The physical symptoms women experience during menopause also contribute to shifting mental health.
'Vasomotor symptoms have been shown to directly affect mood,' Patil explained. 'The worse that someone has hot flashes, the more they're bothersome and affecting their day and their night functioning, the more correlation there is with mood disturbance.' Losing sleep—either from stress, hot flashes or the act of trying to juggle it all in midlife—also has a 'direct correlation' with mood disorders.
'If you have hot flashes and sleep disturbance, it's a double hit,' she said.
Menopause symptoms can even create an anxiety loop: Women may have anxiety about their physical symptoms, and then their physical symptoms trigger further anxiety.
'People are waking up in the middle of the night and having trouble sleeping, and then they're anxious about sleeping,' Weinstock acknowledged, adding that anticipatory anxiety about hot flashes—'What if I have one of these [hot flashes] in the workplace? What if I have one of these when I'm out to dinner with my friends?'—comes up in her practice as well.
The symptoms of hot flashes can also feel like anxiety, or a panic attack, in the body: 'Your heart starts to beat, and you feel hot, and maybe you're sweating, and you're paying more attention to other people looking at you.' That reinforces expert observations that even attitudes towards the physical symptoms of menopause—our culture's widespread dismissal of women's physical health—can take a toll on women's mental health.
Addressing mood swings and anxiety during menopause requires addressing all of the aspects of the Venn diagram that makes up women's mental health. Lifestyle changes can provide much-needed relief during menopause, and stress reduction practices are key 'to really decrease that inflammation that's going on in the body,' Patil explained, 'that would affect stress and how it affects the mood.'
Weinstock cited the benefits of meditation and creative endeavors in reducing stress. Patil emphasized the importance of good sleep practices and regular movement. Other experts have encouraged women to eat well and limit foods high in sodium or saturated fats, avoid drinking and smoking, and maintain a regular yoga practice.
Cultivating a stronger social life is also a big way to boost your mental health.
'There's so much evidence around how destructive being isolated is to our body and to our health, and that includes our mood,' Patil said. 'Social relationships really bring a lot of meaning to life and really bring happiness and joy. We all need each other.'
Cognitive behavioral therapy (CBT), a structured form of psychotherapy, can be a lifeline for midlife women facing mental health challenges. Patil called CBT 'a slam dunk for the Venn diagram,' noting that it can provide relief for hot flashes, sleep disruptions and 'helps patients assess and modify distorted thoughts or depression symptoms.'
Lifestyle changes during menopause can go a long way, even for women relying on mood stabilizers or HRT to manage their transition.
'We should always start with non-medication,' Weinstock asserted. 'Medications are great, and it's great that we have them. We didn't have them 300 years ago. But if we can manage these things without medication, that's great. If we can manage these things with less medication, because we're doing these other things, I think that's great, too.'
The benefits of mental health practices also extend beyond menopause. Women in midlife 'don't really have the time to pay attention to themselves,' Weinstock added. Cultivating practices centered on the self can be an important way to flip that narrative.
If you're experiencing persistent mental health symptoms in midlife, it's important to pursue treatment and care from a trained professional—whether you believe it's lifestyle factors or hormonal changes causing the shift in your moods and/or anxiety.
'[Menopause] is confusing, because everyone kind of comes at it with a different approach,' Weinstock acknowledged. 'The meditation and the exercise, avoiding alcohol and self-care, are super important. But if that's not enough, don't be embarrassed to go to your doctor, and talk to them; make sure that they're really explaining it all to you.'
Don't be surprised, either, if you need to visit more than one provider to get a tight grasp on where you're at in the transition and how you can best be supported.
'Communication between providers is key,' Weinstock added. 'OB-GYNs, primary care physicians and mental health providers should not be working in a vacuum; rather, they should be communicating with each other to tailor the best individual response to both physical and psychological aspects of menopause.'
While medical training (hopefully) catches up to the rapidly-expanding menopause conversation, women should also be prepared to be their own advocates as they begin to experience symptoms of menopause, especially those related to mental health.
'Think in advance of what symptoms and what changes you're noticing, and try to articulate as best as you can that this is a change,' Weinstock advised. If you're feeling fatigued, she explained, be sure to tell your doctor that you're more fatigued than usual and that nothing notable has changed in your lifestyle that should have you feeling that way.
Weinstock also encouraged women to ask for more comprehensive care.
'Describe your symptoms, both in terms of psychological symptoms and physical symptoms, and say, 'What are my options for this? What are my non-medication options? What kinds of things can I do for myself? What kinds of other practitioners can I go to? What are my medication options, and how are they going to help me? What are the risks and benefits?''
Due to gaps in medical expertise around menopause and women's health more broadly, Patil noted that it's important for women to do their own research, 'because then you can recognize what's going on… and you can say, 'These are the symptoms I'm having. This is the timing as to which I really started experiencing these. This is what was going on before that. I really think this is maybe related to perimenopause or menopause. What do you think?''
If you want more answers than your doctor seems willing or able to offer, ask them to send you to someone with more knowledge or find someone yourself to get another opinion. Patil recommended finding doctors through The Menopause Society, or even going to an academic institution to find a healthcare professional, where 'you're more likely to find providers who know what they're doing just because they practice the latest evidence-based guidelines.'
