Why Anxiety Feels Different in Perimenopause (and Why It’s Not ‘Just Stress’)

Wondering where this sudden burst of anxiety is coming from? Perimenopause anxiety is quite common in your 40s and beyond. Let’s dive into why it’s not all in your head- and what you can do about it!

This blog is all about perimenopause anxiety- and why it’s not just stress!

Key Takeaways

• Perimenopause often triggers anxiety due to significant hormonal fluctuations, including estrogen and progesterone and the effects these shifts have on cortisol and testosterone.
• Up to 50% of women experience anxiety or depressive symptoms during perimenopause.
• Lifestyle factors, such as exercise and nutrition, can help alleviate anxiety symptoms.  Supplements may also be helpful.
• Hormone Replacement Therapy (HRT) may be an effective treatment for managing anxiety during perimenopause.
• Understanding the connection between hormonal changes and mood can empower women to seek support, as perimenopause is often underrecognized as a cause of sudden, changing, or moderate to severe anxiety.

Why Anxiety Feels Different in Perimenopause (and Why It’s Not ‘Just Stress’)

Have you suddenly found yourself lying awake at 3 AM, heart racing, mind spiraling with worries that never bothered you before? You’re not losing your mind, and this doesn’t mean you have to stay stuck in this worry spiral – you might be experiencing perimenopause anxiety, a very real and often misunderstood aspect of the years leading up to menopause (i/e perimenopause).

Up to 50% of women experience significant mental health symptoms during perimenopause, yet many suffer in silence, believing that it’s stress, life circumstances, inevitable, etc.

Understanding Why Anxiety Feels Different in Perimenopause

That racing heart, tight chest, and constant worry or sleep interruption aren’t just everyday stress (usually).  During perimenopause, your body is going through some chaotic hormonal shifts

Your anxiety might feel different because, well, it is different – it’s intricately connected to the biological changes reshaping your nervous system.  These changes can include estrogen surges and plummets, the gradual (and impactful) decline of progesterone, and the difference between the levels of these two hormones.

What Perimenopause Is and When It Begins

Perimenopause typically begins in your late 30s to mid-40s, marking the gradual shift toward menopause. This phase can last anywhere from 2 to 10 years before your final menstrual cycle.

During this time, your body experiences significant hormonal fluctuations as your ovaries gradually decrease hormone production.  Signs that the ovaries are starting to experience these shifts include rising levels of FSH (follicle-stimulating hormone) and LH (lutenizing hormone).   Perimenopause is not just one set of symptoms or labs- it often comes in stages.  And the anxiety can present in either Stage 1 (where estrogen surges and falls and progesterone falls) or Stage 2 (where estrogen is declining and progesterone continues to decline).

How Hormonal Changes Affect the Brain and Nervous System

The hormonal shifts of perimenopause don’t just affect your body—they directly change how your brain processes stress and emotion. As estrogen fluctuates and gradually declines, its stabilizing effect on neurotransmitters like serotonin and GABA becomes less reliable, making the brain more sensitive to stress and more prone to anxiety.

At the same time, progesterone—often the first hormone to drop due to more frequent anovulatory cycles—plays an important calming role through its metabolite allopregnanolone, which enhances GABA activity. When progesterone levels fall, this communication system struggles,  leaving the nervous system more reactive and less resilient to stress. The combination of fluctuating estrogen and low progesterone creates a state of heightened nervous system sensitivity, helping explain why perimenopause anxiety can feel sudden, physical, more severe, and unfamiliar—or show up even in women who have never struggled with anxiety before.

As estrogen levels fluctuate and eventually decline, and progesterone declines, your brain’s chemistry changes, potentially leading to:

• Heightened stress responses
• Increased sensitivity to adrenaline
• Disrupted sleep patterns
• Changes in braing fog, memory, and cognitive function (though typically mild and reversible)

How Common Anxiety Is During Perimenopause

If anxiety has shown up out of nowhere in your 40s, it very much could be a sign of hormone chaos- and you’re definitely not alone. Anxiety symptoms are surprisingly common during perimenopause, even in women who have never struggled with anxiety before. Large population studies show that up to 1 in 4 women report significant anxiety symptoms during early perimenopause, so it’s quite common during Stage 1 (to learn more about Perimenopause Stages check out this blog).
In one well-known study, 21% of early perimenopausal medical visits included high anxiety symptoms, compared with 16% of postmenopausal visits (many of which occurred after hormone therapy had already been started). Other research has found that women in perimenopause have a 30–50% higher risk of new-onset anxiety or mood symptoms compared to women who are premenopausal.

Common Ways Perimenopause Anxiety Shows Up

Perimenopause anxiety doesn’t always look like traditional anxiety. It often manifests in ways you might not immediately recognize:

• Waking at 3 AM with racing thoughts
• Sudden panic attacks without obvious triggers
• Heightened worry about health issues
• Feeling overwhelmed by previously manageable tasks
• Heart palpitations or racing heart rate
• Persistent sense of dread or impending doom
• Difficulty making decisions or brain fog

Hormonal Fluctuations and Their Impact on Mood and Stress Response

As noted above perimenopause shifts in progesterone and estrogen impact anxiety.  Cortisol is also affected, and testosterone can play a role.

• Estrogen fluctuations: Estrogen doesn’t just affect your reproductive system – it influences serotonin, dopamine, and norepinephrine, all neurotransmitters that regulate mood.
• Progesterone levels: This calming hormone decreases, removing its natural anti-anxiety effect on neurotransmitters like GABA.
• Cortisol levels: Hormonal changes can disrupt your body’s stress hormone regulation, primarily through the neurotransmitters above and also through the effect of hormone shifts on cortisol, your major stress hormone.  Cortisol and progesterone in particular have a complex relationship and imbalances in either can affect the other downstream.
• Testosterone levels: Though testosterone doesn’t follow a chaotic pattern like estrogen does in perimenopause, this estrogen chaos can affect testosterone levels in the body and high testosterone can contribute to anxiety.  PCOS can also contribute to high testosterone levels.

These hormone changes create a neurochemical environment where your brain becomes more reactive to stress, even if you’ve never experienced stress-related anxiety before.

Lifestyle Factors That Can Worsen Anxiety During This Transition

While hormones lay the groundwork, certain lifestyle factors can contribute to higher levels of perimenopause anxiety.  These include:

• Poor sleep caused by night sweats or insomnia
• Blood sugar imbalances from changing metabolism
• Overindulgence in caffeine (usually a result of the poor sleep so this can create a vicious cycle)
• Alcohol consumption (which affects hormones and sleep)
• Midlife stressors (caring for aging parents, teen children; relationship, work, or career stress)
• Weight gain affecting body image and self-esteem

Approaches to Supporting Anxiety in Perimenopause

The good news is that perimenopause anxiety can respond well to lifestyle changes, supplements, or even bioidentical hormone replacement therapy. Finding the right treatment often involves addressing both the hormonal and psychological aspects.

Therapy, Lifestyle Changes, and Nervous System Support

Non-hormone related evidence-based approaches can help manage perimenopause anxiety and aren’t to be underestimated in their ability to help.  These include:

• Cognitive behavioral therapy (CBT) helps reframe anxious thoughts.  We live in a time where many therapists are specializing in anxiety in women, and we have many resources available for therapy, including online options.
• Mindfulness-based stress reduction techniques, even using apps like Calm, Headspace, or Aura can make a big difference if you practice deep breathing, meditation, hypnosis, gratitude practices, and sleep support techniques daily (and these apps are full of all of the above, they truly are game changers if used consistently)
• Exercise, particularly calming, repetitive motion exercise, like walking or hiking outside, Pilates, yoga, and gentle strength training can greatly impact your stress levels and help you sleep better.
• An anti-inflammatory, nervous system supportive diet that is high in fruits and vegetables, low in processed carbs and added sugars, high in fiber, and has adequate levels of protein and hydration can also lower perimenopause anxiety.  For more about diet, check out this guide!
• Limiting caffeine to 1 cup of coffee per day or 2-3 cups of green tea
• Keeping alcohol to a minimum.  It’s best to avoid it all together or just have 1-2 per week or only on limited social occasions.

Coping Strategies for Managing Anxiety Day to Day

While medical interventions address the underlying causes, daily coping strategies help you navigate anxiety in the moment. Small, consistent actions can make a significant difference.

These practical approaches can help you reclaim your sense of calm and control during this transitional period.

The Role of Movement, Sleep, and Daily Rhythms

As noted above physical activity is one of the most effective natural anxiety remedies.

Regular exercise helps by:

• Releasing endorphins that combat anxiety
• Regulating cortisol levels
• Improving sleep quality
• Enhancing overall mood

Focus on movement that feels good rather than punishing workouts. Gentle yoga or Pilates, walking with a best friend, getting out into nature, and strength training can all help stabilize your nervous system.

Establishing consistent sleep patterns is equally important.

Try:

• Going to bed and waking at the same time daily- your hormones love routine times and schedules
• Creating a calming bedtime routine- gentle stretching or yoga, dim lighting, a relaxing bath, herbal tea routines can all really help
• Keeping your bedroom cool to minimize night sweats- 68F or around this temp is ideal
• Using breathwork or meditation (sleep stories found on the Calm or Aura apps can also help) when you wake with anxiety at night

Helpful Supplements and Nutrients for Perimenopause Anxiety

If you are still struggling with anxiety in perimenopause despite positive lifestyle changes nutrients and supplements can also be game changers.

The most helpful options include (but always discuss with your provider before starting any supplement):

• Magnesium Glycinate- This helpful mineral, particularly in glycinate form, can help restore depleted levels and sound sleep, as well as reduce anxiety.  Typical helpful doses are between 100-300 mg but some people need higher levels.  If you get loose bowels (which can happen with magnesium) go dow to the last tolerated dose you took
• L-theanine- This helpful amino acid, found in tea plants, can reduce anxiety and help your brain focus.  Helpful doses are between 100-200 mg and it can be taken a few times per day as needed.
• Magnolia Bark- This plant extract can be very helpful in relaxation, reducing cortisol, and improving your stress response.  It is most often combined with phellodendron bark extract and 250 mg  3 times a day has proven helpful in studies.
• Ashwagndha- A helpful, adaptogenic herb that can assist in regulating estrogen and progesterone levels, and a dose of 250-500 mg is often helpful.
• Vitex- Also known as chasteberry helps to restore healthy progesterone levels, and can help support estrogen too! It is best taken in the morning in doses of between 150-250 mg
• DIM- If your estrogen is high (estrogen dominance) this herb is super helpful for lowering it to healthier levels.  Typical dosing is 100 mg but can vary.

Blends I use quite often with my patients:

For estrogen dominance-

or for improved progesterone and estrogen levels overall-

Checkout my online supplement store and save 15% on the above blends and nutrients!

 

When Hormone Therapy May Play a Role

For many women, hormone therapy provides significant relief from perimenopausal symptoms including anxiety.  Current hormone replacement therapy (HRT) has evolved significantly from earlier formulations.

HRT (and I only recommend bioidentical HRT) works by stabilizing the fluctuating hormone levels that contribute to anxiety.  In early perimenopause this often looks like progesterone oral therapy, not necessarily estrogen, but every woman is different.

Before starting HRT, your healthcare provider should consider your:

• Medical history
• Risk factors for conditions like heart disease or osteoporosis
• Severity of symptoms
• Personal preferences for treatment
• Family History

Final Thoughts: Perimenopause and Anxiety

Perimenopause anxiety isn’t “just in your head” – it’s a legitimate response to significant biological changes. Understanding this can be incredibly validating when you’re in the thick of it.  Knowing you are not alone and you are not stuck can make a world of difference!

This challenging transitional period won’t last forever, and with the right support and strategies, many women find their anxiety improves as hormones stabilize.

Remember that seeking professional help isn’t a sign of weakness but of self-care. Whether that means talking to your doctor about hormone therapy, finding a therapist who understands midlife transitions, or joining a support group of women navigating similar waters, reaching out is the first step toward feeling better.  This is the time to act- don’t wait until you spiral.

You’ve weathered so many changes throughout your life, and with the right tools, you’ll get through this one too – perhaps even emerging with even greater wisdom, self-knowledge, and resilience than before!