# 15 | Is It Anxiety Or Is It Perimenopause?

For many women, the first signs of perimenopause have nothing to do with hot flushes. They show up as a low hum of anxiety that wasn't there before, sleep that starts fragmenting for no obvious reason, a short fuse that feels out of character or a creeping sense that something is just off. These symptoms are real, hormonal and are being missed in clinical settings at a rate that should concern all of us.

Perimenopause — the transitional phase leading up to the final menstrual period — can begin anywhere from the late thirties to the mid-forties and typically lasts between four and ten years. During this time, oestrogen and progesterone levels do not decline gradually and evenly. They fluctuate, sometimes dramatically, and it is this volatility rather than the eventual decline that drives so many of the neurological and psychological symptoms women experience.

What the Research Shows

Oestrogen has a well-established relationship with serotonin, dopamine and GABA — the neurotransmitters that regulate mood, calm and emotional resilience. When oestrogen levels become erratic, so does the signalling environment these neurotransmitters depend on. This is not a predisposition to anxiety or low mood. It is a physiological response to a changing hormonal landscape.

A 2025 qualitative study published in the British Journal of General Practice found that women presenting to their GPs with mental health symptoms during the perimenopausal years were frequently not asked about their hormonal status at all. GPs acknowledged gaps in their own training around perimenopause and many women either did not connect their symptoms to their hormonal transition or felt embarrassed to raise it. The result is a pattern that research has documented consistently: women in perimenopause being prescribed antidepressants when what they needed was a  conversation about their hormones.

This is important because the treatments are not equivalent. SSRIs, a class of antidepressants, can offer some relief for certain perimenopausal symptoms but they do not address the underlying hormonal driver and for women whose primary issue is oestrogen volatility rather than clinical depression, they are an incomplete answer at best.

Global data published in 2024 found that the burden of anxiety disorders in perimenopausal women increased by nearly 8% between 1990 and 2021, with projections suggesting a further 40% rise by 2035. These numbers point to a healthcare system that is still learning how to meet women at this stage of life.

What Perimenopause Can Actually Feel Like

The symptom profile is considerably wider than most women are told to expect. Alongside mood changes and sleep disruption, perimenopause is associated with brain fog and difficulty concentrating, heart palpitations, joint pain, changes in cycle length and flow, increased PMS severity, headaches and heightened sensitivity to stress. Many women describe feeling unlike themselves, which, given the neurological effects of fluctuating oestrogen, makes complete physiological sense.

The challenge is that no two women experience the transition in the same way and symptoms can precede any obvious menstrual changes by several years. This makes self-recognition difficult, and it makes clinical recognition even harder without a practitioner who is actively looking for it.

What You Can Do

If you are in your late thirties or forties and experiencing any combination of these symptoms — particularly if they seem to track with your cycle or have appeared without an obvious life stressor to explain them — perimenopause is worth considering. Tracking your symptoms across several cycles, including their timing and severity, gives you something concrete to bring to a clinical conversation.

When you do seek support, it is entirely reasonable to ask your GP or gynaecologist to consider your hormonal status as part of the picture. NICE guidelines updated in 2023 support the diagnosis of perimenopause based on symptoms alone in women over 45, without requiring blood tests, which can be unreliable given the hormonal fluctuation of this phase.

Perimenopause is still under-taught in medical training and under-discussed in consulting rooms. That is not a reflection of how real your experience is but a gap in the system and one worth knowing about when you are navigating it. The good news? Things are changing and doctors are catching up.

References:

1.    Burgin J. et al. (2025). Mental health consultations during the perimenopausal age range. British Journal of General Practice.

2.    NICE. (2023). Menopause: diagnosis and management. Guideline NG23. nice.org.uk

3.    Santoro N. et al. (2021). Perimenopause: From research to practice. Journal of Women's Health.

4.    Li Y. et al. (2024). Global burden of anxiety disorders during perimenopause 1990–2021. PMC / Frontiers in Psychiatry.

5.    Brinton R.D. et al. (2015). Perimenopause as a neurological transition state. Nature Reviews Endocrinology.

6.    Freeman E.W. & Sherif K. (2007). Prevalence of hot flushes and night sweats around the world. Climacteric.

Medical Disclaimer: This article is intended for informational and educational purposes only and does not constitute medical advice. Always consult a qualified healthcare professional regarding any symptoms or treatment decisions. HER is not a medical provider.