The Perimenopause Symptom We Don’t Talk About Nearly Enough

If your mood fluctuations feel less like your usual stress and anxiety and more like the beginnings of a villain origin story (and you’re also experiencing symptoms like insomnia and feeling warmer than usual), it could be the beginning stages of perimenopause.

This is what doctors call the transition to menopause, which is the end of a person’s reproductive years and technically marked by 12 consecutive months without a period, with the full transition taking anywhere from two to eight years, according to the Office on Women’s Health (OWH).

Perimenopause usually begins after the age of 40 (though it can start earlier), the variabilities of which — both in ovarian function and hormone levels — can leave you feeling out of sorts.

“It’s generally a confusing time that catches many of us by surprise, in large part because of how wildly unpredictable symptoms of perimenopause can be,” Dr. Anna Barbieri, New York-based OB-GYN and founding physician at Elektra Health, told HuffPost. “Hormonal changes, and the way symptoms show up, are anything but linear.”

For some, periods can still be regular in the early stages of perimenopause, making it easy to brush off mood-related symptoms (anxiety, irritability, crying spells) as being caused by things like stress, sleep deprivation or burnout.

But start adding signs of cognitive decline to the mix — drawing a blank as to what someone just told you, forgetting what you walked into a room to do — and these ongoing mental blips can trigger understandable waves of panic and fear as to what exactly is going on with that mind of yours.

The possible links between perimenopause and mental health

In our 20s and 30s (pre-menopause), there’s a predictable ebb and flow to our hormones — ditto post-menopause, a time when our hormones are low, but steady.

The perimenopausal period is marked by one long hormonal fluctuation, with levels of estrogen and progesterone (typically referred to as “female” hormones) varying quite a bit. Testosterone — a “male” hormone that’s produced at lower levels in people assigned female at birth — takes a slow dip as well.

Bottom line: “Your hormones are a rollercoaster, and the rest of you is along for the ride,” Barbieri said.

These hormonal fluctuations can trigger worsening PMS symptoms (breast tenderness, acne flare-ups), irregular periods (heavier and more frequent or lighter and shorter or MIA), insomnia (especially during the two weeks before your period), hot flashes and night sweats, all at varying degrees and frequencies.

Also triggered? Mentally taxing symptoms, like depression, anxiety, irritability, brain fog and mood swings, with the estrogen fluctuations during perimenopause being one of the possible culprits.

It goes something like this: Different parts of the brain have various hormone receptors. These receptors receive instructions from our hormones and deliver them to the body’s cells using chemical messengers called neurotransmitters.

“There’s increasing evidence that estrogen — and estrogen-signaling pathways — are involved in a wide range of brain functions, including mood, cognition and memory,” Dr. Juliet Nevins, board-certified OB-GYN and clinical solutions medical director at CVS Health, told HuffPost.

If estrogen levels are on a downswing, it stands to reason the bodily processes that need estrogen to function optimally will be too, potentially impacting your mental health both directly (the brain) and indirectly (the body).

One of the most common indirect effects is how low estrogen can lead to sleep deprivation: It’s thought that estrogen droughts cause the hypothalamus (the body’s thermostat) to become sensitive to slight body temperature changes, triggering hot flashes and night sweats to cool the body down.

Night sweats are notorious for causing fragmented sleep, which then dominoes into an ongoing cascade of stress and inflammatory responses that can mess with your mental health in multiple ways, including executive function, emotional reactivity (anxiety, depression, crying spells, angry outbursts), memory formation, even decision-making.

Meanwhile, progesterone lows can cause a decrease in GABA activity (a neurotransmitter known for its calming effects), and a potential uptick in anxiety and sleep problems, like trouble falling asleep and staying asleep.

Testosterone may also play a big role beyond sexual and reproductive health: “When off-balance, testosterone levels can cause emotional fluctuations that result in depression and irritability,” Barbieri said, though more research needs to be done into the intricacies.

It’s hard to know how perimenopause might affect trans and gender-diverse (TGD) people differently — there’s not a lot of intel at the moment.

“TGD people have, in some ways, more ‘control’ over their hormones, since they are administered exogenously, so they might have more ‘choice’ in terms of if or how they want to simulate aging hormone production and levels,” Dr. Michelle Forcier, a clinician with Folx Health, told HuffPost.

Depending on when they started their gender-affirming hormone therapy, they might decide not to go through menopause, since they had to wait many years to have the right hormones for their body and identity.

“If our aging TGD patients don’t decrease their gender hormones and levels, do they become less or more at risk for some of the associated affects of aging? We don’t know yet,” Forcier said.

Thomas Barwick via Getty Images

Mild to moderate movement, including strength training, can help with cognitive symptoms of perimenopause.

How to relieve mental health symptoms during perimenopause

This, however, doesn’t mean perimenopause is the sole reason why you feel off. “It’s important to recognize there are also environmental contributors during this life phase that can lead to mental health concerns and sleep disruptions,” Nevins said.

These might include stressors stemming from your career, family or finances. You might have a chronic medical condition that requires a demanding level of maintenance or aspects of your lifestyle that might not be in the healthiest place, like your diet or drinking habits.

Perimenopause symptoms may also be exacerbated by pre-existing mental health conditions, such as depression, bipolar disorder and obsessive-compulsive disorder, according to the OWH.

Research suggests these factors can amplify the mental health symptoms that strike as a result of hormonal triggers — and that by assessing your situation as a whole, you can better pinpoint the medical and behavioral interventions necessary to reduce your distress.

Tracking your symptoms. The awareness gained by tracking and rating your perimenopause symptoms may lead to a one-two punch of improving communication between you and your doctor and strengthening your resolve to set and achieve treatment goals — ultimately leading to a reduction in symptom severity, according to a December 2021 review published in the journal Frontiers in Global Women’s Health.

Tweaking your diet. More research needs to be done to nail down the exact mechanisms behind why, but “the Mediterranean Diet has been linked to a reduction in hot flashes, symptoms of depression and cognitive decline,” Dr. Suzanne Fenske, New York-based board-certified gynecologist and founder of TārāMD, told HuffPost.

Because the Mediterranean Diet focuses on overall dietary patterns versus portion control and calculations, there aren’t specific guidelines for the diet available. Some of the broadly agreed upon highlights include: lots of vegetables, fruits, beans, lentils, nuts, whole grains and extra virgin olive oil, as well as moderate amounts of fish, dairy and red wine (but if you don’t drink, don’t start), and little-to-no red meat or high amounts of sugar.

Switching up your exercise routine. “Mild-to-moderate aerobic activities, such as power-walking and Tai Chi, are thought to increase brain volume and improve executive function,” Fenske said. (Bonus: Adding more strength training and yoga to your repertoire may help reduce hot flashes and night sweats.)

Avoiding hot flash triggers. Hot flash triggers to avoid include spicy foods, caffeine, alcohol, tight clothing and (spoiler alert) hot weather, according to the Cleveland Clinic. To help with hot flashes when they strike, dress in layers to quickly cool down and always have cold water handy.

Getting enough sleep. “Having a set sleep schedule, where you go to sleep and wake up at the same time every day trains your body and mind for sleep,” Fenske said. If you’re prone to night sweats, make sure to have temperature-controlling measures on standby, like light pajamas, a fan and a cooling mattress topper.

Looking into medication options. Medications can be a helpful adjunct to lifestyle changes — especially if specific perimenopause symptoms (depression, anxiety, insomnia) are showing no signs of improvement despite your efforts.

Selective serotonin reuptake inhibitors (SSRIs) are a type of antidepressant that may reduce hot flashes too, while gabapentin, a medication for treating seizures, can be helpful in reducing hot flashes in people who also have migraines.

Then there’s hormone therapies. “Estrogen — and progesterone if you have a uterus — has been shown to offer some potential relief and benefits in regard to brain health and hot flashes,” Forcier said. “Steadier hormone levels might also contribute to a decrease in mood and cognitive fluctuations.”

Even if you’re sure it’s perimenopause, see your doctor anyway

You might be certain the symptoms you’re experiencing point to perimenopause, but make sure a proper evaluation by your doctor is included in your journey.

“There are several common conditions, including thyroid abnormalities and even medication side effects, that can cause similar symptoms to perimenopause and should be ruled out as a precaution,” Barbieri said.

Finding a gender-affirming provider can be daunting, Forcier said, and ultimately impacted by a number of factors, including which part of the country you live in and the legislation and laws the state enforces regarding LGBTQIA+ medical and human rights.

Searching the World Professional Association for Transgender Health, LGBTQ+ Healthcare Directory and OutCare provider directories can be a helpful first step in successfully finding gender-affirming care for your perimenopause symptoms.

And if perimenopause is the culprit, your doctor can go over your specific symptoms, combined with your personal and family history, to help you piece together the most effective combination of treatments and lifestyle modifications to help ease them.