Shifting Foundations: Perimenopause and the Increased Prevalence of Mental Health Conditions

Petra
Jun 22
7 min read

While I've written other blog posts about feminising hormones generally and premenstrual dysphoric disorder, I thought it was time for a post specifically on mental health difficulties in perimenopause, the transitional phase before menopause. It's not just physical changes to cycles and hot flashes that perimenopause can bring. It can also lead to first episodes of mental disorders such as depression and anxiety, with those with previous histories being more at risk. And it appears that neurodivergent people are more at risk than neurotypicals.

I screen for perimenopause symptoms in my assessment and therapy clients aged in their late 30s onwards. I have already met many women who have started menopause hormone treatment (MHT) either prior to seeing me, or while seeing me, and who have experienced significant improvements in mood, anxiety, energy levels, not to mention the many physical symptoms of perimenopause.

In this post, I’ll explore how perimenopause interacts with several mental health conditions, including ADHD, anxiety, depression, bipolar disorder, psychosis, autism, and suicide risk, by doing a brief review of the research literature (I used ChatGPT's deep research feature to find relevant articles for me). I've included in-text links to studies, and a list of studies at the end if you'd like to read more about a particular mental health issue.

This is a long blog post with lots of links to research articles, so buckle up.

Why does perimenopause affect mental health?

Perimenopause usually begins around 10 years before the final menstrual period that begins the menopausal phase (which is defined as 12 months since the last menstrual period). For some, this can be in their late 30s onwards. Estrogen and progesterone levels start to fluctuate with a declining trend, affecting not only the reproductive system but multiple body systems, including the brain. Testosterone levels also drop from the 30s onwards. These hormones interact with key neurotransmitters like dopamine and serotonin, which help regulate mood, attention, memory, and sleep.

For women with existing mental health conditions, this hormonal upheaval can make symptoms worse. Others may find that previously manageable symptoms become more disruptive or don't respond to treatment as well, or that new mental health issues emerge for the first time.

Below is an evidence-based summary of how perimenopause can affect several different mental health conditions.

ADHD: When the wheels come off

For many women with ADHD, perimenopause marks a turning point in their symptom severity. As estrogen levels drop, symptoms like distractibility, forgetfulness, overwhelm, and emotional reactivity can worsen. Tasks that were once manageable with structure or effort may start to feel near impossible.

Many women are diagnosed with ADHD for the first time in their 40s or 50s, after years of coping. It’s not uncommon for them to say that while they always felt different and struggled with some things, they now feel overwhelmed and can no longer keep up.

We know that ADHD can make hormone-related changes harder to tolerate. One study by Dorani et al. (2021) found that women with ADHD were more likely to experience severe premenstrual and perimenopausal symptoms, including anxiety, low mood, and sleep disruption.

What helps? Treatment may include ADHD medication, hormone therapy, or both, alongside strategies to reduce cognitive overload and emotional stress. Many women also benefit from working with a psychologist familiar with both ADHD and midlife changes.

Depression: A new low, or an old one returning

Research consistently shows that the risk of depression increases during perimenopause, especially for women with a history of mood issues. If you’ve experienced depression in the past, you may be more vulnerable during this transition. And for some, depression begins for the first time in midlife.

This isn’t just about the stress of ageing or life changes. Estrogen, progesterone and testosterone can all play a role in regulating mood, and their decline can directly affect brain chemistry. Women with a history of premenstrual mood problems or postnatal depression may be especially sensitive to these hormonal changes.

A recent meta-analysis by Badawy et al. (2024) confirmed that perimenopausal women have a significantly higher risk of developing depression than premenopausal or postmenopausal women.

The good news? Depression during perimenopause is treatable. Therapy, medication, lifestyle changes, and hormone therapy can all help. The most important thing is to recognise the symptoms and get support.

Anxiety: More than just nerves

Anxiety often goes hand-in-hand with perimenopause. Even women without an anxiety disorder may find themselves feeling more jumpy, irritable, or tense. For those who already experience anxiety, symptoms can intensify during this transition.

Hormone fluctuations can disrupt the body’s stress response, making it harder to self-soothe. Hot flushes and night sweats can also trigger or worsen anxiety, creating a vicious cycle.

A 2021 study by Jaeger et al. found that 58% of perimenopausal women experienced significant anxiety symptoms, and that women who were more sensitive to anxiety were also more likely to be bothered by hot flushes and night sweats. This suggests that the relationship between anxiety and physical symptoms is not one-directional; each can amplify the other.

In some cases, anxiety might even be an early sign of perimenopause, appearing before menstrual changes begin. Therapy, exercise, medication, and hormone therapy may all have a role in managing anxiety during this time.

Bipolar disorder: A time of instability

For women with bipolar disorder, perimenopause can bring increased mood instability. Some report more frequent or severe depressive episodes, while others experience faster mood cycling or more irritability.

This may be due to the impact of hormonal changes on mood regulation and sleep. Women who have had postpartum mood episodes may be especially vulnerable.

Although research is still limited, a review by Perich et al. (2017) found early evidence that the menopausal transition may be a time of increased mood disturbance in women with bipolar disorder. Bipolar disorder is a serious mood disorder that can be difficult to manage at the best of times. Anticipating changes in perimenopause and seeking treatment early could make all the difference.

Psychosis and schizophrenia: A higher risk of relapse

Emerging research shows that women with schizophrenia and related conditions face an increased risk of relapse during perimenopause and early postmenopause. Estrogen appears to have a protective effect on the brain, and its loss can reduce the effectiveness of antipsychotic medications.

A large Finnish cohort study led by Sommer et al. (2023) highlighted this increased relapse risk, especially in women over 45.

More recently, a study by Brand et al. (2024) found that hormone therapy was associated with a 16% lower risk of psychotic relapse in women with schizophrenia and schizoaffective disorder; a promising finding for hormone-aware care.

Autism: Masking gets harder

Autistic women (many who also have ADHD) often go undiagnosed until adulthood, and perimenopause can be the time when things fall apart. Longstanding strategies to “mask” autistic traits may no longer work when hormones fluctuate and stress levels rise.

Sensory sensitivities, emotional regulation issues, and overwhelm may all increase. Some women seek assessment for the first time in midlife, recognising that autism may be part of their experience.

There’s still little research on autism and menopause. A study by Groenman et al. (2022) found that autistic women reported more severe menopausal symptoms and higher levels of depression than non-autistic women.

A 2023 review by Behrman & Crockett in BJPsych Bulletin also calls for greater awareness of how menopause affects women with severe mental illness, autism, ADHD, and psychotic disorders.

Brain fog and cognitive changes

Even women without a diagnosed condition often notice cognitive shifts during perimenopause: difficulty focusing, remembering words, and staying on task. For those with ADHD, autism, or mood disorders, this “brain fog” can feel especially disruptive.

These changes are linked to hormone shifts and often improve after menopause. But they can be deeply unsettling at the time.

One trial by Epperson et al. (2015) found that lisdexamfetamine (commonly used for ADHD) improved attention, memory, and executive functioning in perimenopausal women experiencing cognitive difficulties, even when they didn’t have ADHD. I can't imagine anyone in New Zealand receiving a stimulant to treat perimenopausal symptoms at this stage, so those with ADHD are perhaps lucky here in that they can receive a medication that has shown some effectiveness for cognitive changes in perimenopause.

Suicide Risk: A Silent Red Flag

While not often openly discussed, suicide risk during perimenopause also appears to increase. Emerging research suggests that the hormonal shifts of this life stage may contribute to increased vulnerability, particularly among women with a history of depression, trauma, or pre-existing mental health conditions.

A 2012 cross‑sectional European survey (European Journal of Public Health) of over 8,700 women found that those in perimenopause had a rate of reported suicidal thinking seven times higher than pre‑ or post‑menopausal women, even after adjusting for the presence of mood and anxiety disorders.

Treatment options include psychological support, psychiatric medication, hormone therapy, and practical adjustments to reduce overwhelm. What’s most important is not dismissing these symptoms as “just hormones.” If suicidal thoughts emerge or intensify during midlife, they deserve the same attention and care as at any other life stage.

Clearly, you’re not imagining it

If you’ve felt like your mental health has changed during midlife: more anxious, less focused, more overwhelmed, you’re not alone, and you’re not imagining it.

As shown in the studies cited above, perimenopause can exacerbate or reveal mental health conditions, especially for neurodivergent women or those with a history of mood or anxiety issues. Understanding this link can be a relief as it opens the door to seeking targeted support.

Whether that’s through therapy, medication, peer support, hormone treatment, or a combination of these, there are ways forward.