Perimenopause and Mental Health: Why You’re Not “Just Getting Older”

By Leah Tully, M.A. (Counselling Psychology),CCC, CT, RN, IBCLC · Tully Counselling Psychology · Edmonton, Alberta

She’s in her mid-forties. She’s slept well her whole life, but now she wakes at 3am with her heart racing and thoughts she can’t slow down. She finds herself crying in the car for no reason she can name. She snaps at her partner and then feels guilty about it for hours. She keeps forgetting words mid-sentence — words she’s always known. She doesn’t feel depressed exactly, but she doesn’t feel like herself either.

If this sounds familiar, it may not be stress, burnout, or “just getting older.” It may be perimenopause — and the changes it produces in the brain and nervous system are real, measurable, and increasingly well understood by science.

This article explains what perimenopause is, what it does to mood, cognition, and mental health, why so many women’s psychological symptoms go unrecognised, and what evidence-based support is available in Edmonton and across Alberta.

What Is Perimenopause?

Perimenopause is the transitional period leading up to menopause — typically beginning in the mid-to-late forties, though it can start earlier — during which the ovaries gradually produce less estrogen and progesterone. It ends one year after a woman’s final menstrual period, at which point she is considered to have reached menopause.

The perimenopause transition typically lasts between four and eight years, though its duration varies significantly between women. During this time, hormone levels do not decline steadily — they fluctuate unpredictably, sometimes dramatically from day to day. It is this variability, not simply the decline, that drives many of the psychological symptoms women experience (Di Florio et al., 2024).

By 2030, the World Health Organization projects there will be more than 1.2 billion menopausal women worldwide. In Canada, women in midlife represent one of the fastest-growing demographics — and their mental health needs during this transition remain significantly underserved.

What Perimenopause Does to the Brain

Estrogen is not only a reproductive hormone, it is a powerful neuromodulator — meaning it directly influences how the brain functions. Estrogen affects the serotonergic, noradrenergic, and dopaminergic systems, all of which regulate mood, motivation, sleep, and stress response (Deshpande & Rao, 2025). It also supports memory formation in the hippocampus, regulates the stress response via the hypothalamic-pituitary-adrenal axis, and plays a role in maintaining cognitive flexibility and attention.

When estrogen levels begin to fluctuate during perimenopause, these systems are disrupted. Neuroimaging research has documented measurable changes in brain metabolism, cortical volume, white matter integrity, and hippocampal structure across the menopausal transition (Metcalf & Duffy, 2023). A 2024 study using positron emission tomography found that perimenopausal and postmenopausal women showed significantly higher estrogen receptor density in cognitive and mood-regulating brain regions — interpreted as a compensatory response to declining estrogen availability (Weill Cornell Medicine, 2024).

In short: the changes women experience in perimenopause are not imagined, exaggerated, or a sign of weakness. They have a neurobiological basis that science is only beginning to fully characterise.

Perimenopause as a “Window of Vulnerability” for Mental Health

Research consistently identifies perimenopause as a period of heightened vulnerability for the onset or worsening of mood and anxiety disorders — even in women with no prior psychiatric history.

Perimenopausal women face a 2–4 fold increase in the risk of major depression compared to premenopausal women, with approximately 40% of perimenopausal women experiencing affective symptoms tied to estradiol fluctuations (NIH Clinical Trials, 2022). A landmark 2024 study using data from more than 128,000 women in the UK Biobank found that the perimenopausal transition was associated with a significant increase in first-time psychiatric diagnoses, including depression and anxiety disorders (Di Florio et al., 2024).

A global burden of disease analysis found that anxiety disorders in perimenopausal women have been rising since 1990, with projections suggesting the burden will increase by more than 40% by 2035 (PMC, 2025). This is not a niche concern — it is a growing public health issue that deserves dedicated clinical attention.

What Perimenopausal Mental Health Symptoms Actually Look Like

One reason perimenopausal psychological symptoms go unrecognised — by women themselves and by healthcare providers — is that they don’t always fit the textbook picture of depression or anxiety. Many women describe their experience as something more diffuse: not feeling like themselves, feeling reactive or on edge, feeling like something has quietly shifted without being able to name what.

Mood and Emotional Changes

• Anxiety, worry, or a low-level dread that’s new or worsening
• Irritability or anger that feels disproportionate
• Low mood, sadness, or emotional flatness
• Mood swings — feeling fine one moment, tearful or overwhelmed the next
• Emotional sensitivity or reactivity that feels unfamiliar
• Loss of joy in things that used to feel meaningful
• Feeling invisible, overlooked, or misunderstood
• Grief — for fertility, youth, roles, or a version of yourself

Cognitive Changes

• Brain fog — difficulty concentrating, feeling mentally “slow”
• Word-finding difficulties (losing words mid-sentence)
• Memory lapses — forgetting names, tasks, or where you put things
• Difficulty sustaining attention or following complex conversations

Research confirms that cognitive difficulties are among the most commonly reported and distressing symptoms during perimenopause, affecting an estimated 60% of women in the transition (Metcalf & Duffy, 2023). These changes are real and documentable, and they are not a sign of early dementia.

Sleep Disruption

Sleep disturbance is among the most prevalent and functionally impairing symptoms of perimenopause. Estrogen and progesterone both play roles in regulating sleep architecture, and their fluctuation disrupts slow-wave sleep and increases nighttime waking. The resulting sleep deprivation exacerbates every other psychological symptom — mood, cognition, stress tolerance, and emotional regulation (Maki et al., 2024).

Identity and Relational Changes

Beyond the biological, perimenopause often coincides with significant life transitions — children leaving home, career shifts, changes in relationship dynamics, ageing parents, and a broader reckoning with identity, purpose, and direction. For many women, this is as much an existential transition as a hormonal one. Therapy provides a space to hold both.

Why Perimenopausal Mental Health Is Often Missed

Despite the prevalence and severity of perimenopausal psychological symptoms, they are frequently underrecognised and undertreated. Research identifies several reasons for this:

• Symptom misattribution. Women are often told their symptoms are stress, burnout, or “just part of ageing” — and may internalise this, delaying help-seeking.
• Irregular presentation. Unlike the hot flush, which has a clear hormonal signature, mood and cognitive symptoms are less visible and easier to dismiss.
• Healthcare gaps. Menopause-specific mental health training is inconsistent across disciplines, meaning primary care providers may not be equipped to identify or address psychological symptoms in the context of hormonal transition.
• Stigma and silence. Cultural narratives around menopause are still largely negative or taboo, making it harder for women to speak openly about what they are experiencing.

A 2024 Australian study found that perimenopausal depression is “under recognised and poorly treated” even within specialist settings (Kulkarni et al., 2024). This is not an individual failing — it is a systemic gap that leaves many women suffering unnecessarily.

Evidence-Based Treatments for Perimenopausal Mental Health

The good news is that perimenopausal mental health symptoms are treatable, and there are well-researched options available.

Cognitive Behavioural Therapy (CBT)

CBT is now recommended as a first-line, non-pharmacological treatment for perimenopausal and menopausal symptoms by multiple international clinical bodies, including the British Menopause Society, the North American Menopause Society, and the UK’s National Institute for Health and Care Excellence (NICE, 2024). A systematic review of 16 studies involving 910 women found that CBT significantly improved health-related quality of life and reduced vasomotor, psychological, and sleep-related symptoms across perimenopausal and menopausal stages (PMC, 2025).

CBT for perimenopause addresses the cognitive patterns, beliefs, and coping strategies that influence how symptoms are experienced and managed. It helps women identify unhelpful thinking, build distress tolerance, improve sleep behaviours, and develop a more grounded relationship with the changes they are moving through.

Acceptance and Commitment Therapy (ACT)

ACT has emerging evidence for its effectiveness in perimenopausal mental health, particularly in helping women develop psychological flexibility — the ability to observe difficult experiences without being controlled by them. This can be especially valuable for the grief, identity shifts, and existential questioning that often accompany this transition.

Mindfulness-Based Approaches

Mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT) have been studied in menopausal populations with promising results for anxiety, mood, and sleep. A 2023 randomised study found that mindfulness-based interventions significantly reduced anxiety symptoms in menopausal women (Huang et al., 2023).

Hormone Therapy

For women with significant vasomotor or mood symptoms, menopausal hormone therapy (MHT) may be considered, often in combination with psychological therapy. This is a conversation best had with your physician or a menopause specialist, who can help you weigh the benefits and risks based on your individual health profile.

The Value of a Therapist with a Nursing Background

Perimenopause is one of those experiences that sits at the intersection of the physical and the psychological in ways that general mental health care doesn’t always capture well. A therapist who understands the biology — how fluctuating estrogen disrupts neurotransmitter systems, why sleep deprivation compounds mood dysregulation, how the nervous system is responding to hormonal withdrawal — can hold the whole picture in a way that purely psychological care sometimes cannot.

This integrated understanding is what Leah Tully brings to perimenopause and menopause counselling at Tully Counselling Psychology. As both a Registered Nurse and a Counselling Therapist, Leah works with the full picture of what women move through during this transition — not just the emotional surface, but the biological reality underneath it.

Getting Support in Edmonton and Across Alberta

Perimenopause and menopause counselling is available at Tully Counselling Psychology, in-person in Edmonton and virtually throughout Alberta. If you have been experiencing mood changes, anxiety, brain fog, sleep disruption, or a quiet sense of not feeling like yourself — and especially if these symptoms have been dismissed or minimised by others — you deserve knowledgeable, compassionate support.

You are not imagining it. You are not overreacting. And you are not “just getting older.” What you are moving through is real — and so is the possibility of feeling better.