Perimenopause and Anxiety: Why It Happens

If you have started feeling anxious for no obvious reason in your 40s, perimenopause is a likely explanation. As estrogen and progesterone fluctuate in the years before your final period, the brain systems that help regulate mood become less steady — and anxiety is one of the most common results. In an international survey of more than 17,000 women analyzed by The Menopause Society, 75% of those aged 35 and older reported anxiety during the transition. The Study of Women's Health Across the Nation (SWAN) found that the share of visits with high anxiety rose from 4.4% before perimenopause to 13.5% in late perimenopause among women who started out calm. The U.S. Office on Women's Health states plainly that the risk of anxiety and depression is higher around menopause. The reassuring part: this kind of anxiety usually has a hormonal driver, it is recognized in clinical guidelines, and it is something you can track, anticipate, and treat. This article explains why perimenopause and anxiety are linked, who is most affected, and what the evidence says about getting relief.

Anxiety is one of the least expected symptoms of perimenopause and one of the most distressing. Many women brace for hot flashes and irregular periods, then are blindsided by a new restlessness, a racing heart, or a sense of dread that does not match anything happening in their lives. It is easy to assume the problem is stress, personality, or something going wrong mentally. Often, it is hormones.

Below is what the clinical and research evidence actually says about why anxiety shows up in perimenopause, how common it is, and what helps.

Why estrogen and progesterone affect anxiety

Estrogen does far more than regulate the menstrual cycle. It influences the brain's mood-regulating chemistry, including serotonin and other neurotransmitters tied to calm and emotional stability. Progesterone, through a calming metabolite that acts on the brain's main inhibitory system, has a settling effect of its own. During perimenopause, both hormones stop following a predictable monthly rhythm and instead swing unpredictably — sometimes high, sometimes low, sometimes within the same week.

It is this instability, more than a simple decline, that the brain struggles with. The systems that normally buffer stress get less consistent hormonal support, so situations you once handled easily can suddenly feel overwhelming. The U.S. Office on Women's Health notes that the higher risk of anxiety and depression around menopause may be caused by changing hormones, menopausal symptoms, or both. In other words, the anxiety can come directly from the hormonal shifts, indirectly through symptoms like broken sleep and hot flashes, or from a combination of the two.

75% of women report anxiety during the transition

Anxiety is far more common in perimenopause than most women are warned. In a digital survey of more than 17,000 women across 158 countries, analyzed by researchers associated with The Menopause Society, 75% of women aged 35 and older reported anxiety as a symptom. It sat alongside irritability (80%), depressive mood (77%), and sleep problems (76%) near the top of the list — well above hot flashes in how often women actually experienced it.

That figure reframes anxiety from a personal failing into a predictable feature of the transition. If three out of four women in a large, cross-cultural sample report it, then new or worsening anxiety in your 40s is not a sign that something is uniquely wrong with you. It is one of the most commonly reported experiences of this stage.

Source: The Menopause Society — International Differences in Knowledge Gaps and Most Common Perimenopause Symptoms (2024)

High-anxiety visits rose from 4.4% to 13.5%

The clearest evidence that the transition itself raises anxiety comes from SWAN, a long-running U.S. cohort. Researchers tracked anxiety symptoms — irritability, tension, fearfulness, and a pounding or racing heart — in 2,956 women aged 42 to 52 over ten years, defining "high anxiety" as the upper fifth of the distribution.

Among women who entered the study with low anxiety, the share of visits scoring in the high-anxiety range climbed from 4.4% before the transition to 13.5% in late perimenopause — roughly a threefold jump. Compared with premenopause, the odds of high anxiety were meaningfully elevated through early perimenopause, late perimenopause, and after menopause. This is real, measurable, and tied to where a woman is in the transition, not just to outside stress.

Source: SWAN — Does Risk for Anxiety Increase During the Menopausal Transition? (Bromberger et al.)

Women who were calm before are the most surprised

One of SWAN's most useful findings is about who is most affected. Women who began the study with low anxiety were significantly more likely to develop high anxiety during peri- and postmenopause — and this held up even after accounting for hot flashes and night sweats. Women who were already chronically anxious before the transition, by contrast, showed no clear link between menopausal stage and their anxiety; they tended to stay anxious throughout.

The practical message is striking. If you have never been an anxious person and anxiety arrives in your mid-40s seemingly out of nowhere, that pattern matches the data exactly. The transition appears to introduce new anxiety in women who did not have it before, rather than simply worsening an existing tendency. Knowing this can be a relief: the feeling is new because your hormonal environment is new, not because you have suddenly become a different person.

Source: SWAN — Does Risk for Anxiety Increase During the Menopausal Transition? (Bromberger et al.)

How anxiety, sleep, and hot flashes feed each other

Perimenopausal anxiety rarely arrives alone. Hot flashes and night sweats fragment sleep, and poor sleep is one of the most reliable amplifiers of anxiety. The NHS notes that menopausal sleep problems, often made worse by night sweats, can leave women feeling irritable, stressed, and anxious. A daytime hot flash can itself feel like a wave of anxiety — a sudden flush, a racing heart, a rush of unease — which can be hard to tell apart from a panic response.

This is why anxiety in perimenopause tends to cluster with other symptoms rather than standing on its own. The fluctuating hormones drive the hot flashes, the hot flashes wreck the sleep, and the sleep loss feeds the anxiety, which in turn makes everything harder to cope with. Untangling that loop is far easier when you can see how the pieces line up over time instead of experiencing each bad day as an isolated event.

Why anxiety in midlife is worth taking seriously

There is a further reason not to dismiss perimenopausal anxiety as just a phase. SWAN researchers followed 425 midlife women for 12 years and found that higher anxiety symptoms predicted later episodes of major depression, with each increase in anxiety score associated with about 47% higher odds of a depressive episode in the following year. The link was strongest for women with a history of recurrent depression.

That does not mean anxiety in perimenopause leads to depression for most women — it does not. But it does mean anxiety is a signal worth noticing and acting on early, rather than waiting to see if it passes. Tracking when it appears, how intense it is, and what surrounds it gives you and your clinician something concrete to work with.

Source: SWAN Mental Health Study — Do Anxiety Symptoms Predict Major Depressive Disorder in Midlife Women? (Bromberger et al.)

What the evidence says helps

The good news is that perimenopausal anxiety responds to several recognized approaches. The UK's National Institute for Health and Care Excellence (NICE) advises clinicians to consider hormone replacement therapy to ease low mood arising from menopause that does not meet the threshold for clinical depression, and to consider cognitive behavioral therapy for menopause-related low mood. Notably, NICE does not recommend antidepressants as a first-line option for low mood in menopausal women who have not been diagnosed with depression — a point worth raising if anxiety is the main issue.

Sleep is the other lever. Because broken sleep amplifies anxiety, anything that protects rest — treating night sweats, addressing hot flashes, steady sleep routines — tends to help the anxiety too. The right path depends on your history, your symptoms, and your preferences, which is exactly the kind of conversation a clear symptom record makes more productive.

Source: NICE — Menopause: Identification and Management (NG23)

A symptom that is growing more recognized

Perimenopausal anxiety is also gaining attention as a public-health issue. A 2024 analysis of global data projected that the burden of anxiety disorders in women in the perimenopausal age range will rise about 40.67% by 2035 compared with 2021 levels, driven largely by population ageing. As more women reach this stage, the demand for accurate information and tools built for midlife is rising with it — and the old habit of writing off midlife anxiety as stress is starting to give way to better recognition.

Source: Global, Regional, and National Burden of Anxiety Disorders During the Perimenopause, 1990–2021 (PMC)

About Rythma

Rythma is a perimenopause tracking app for iPhone that learns each user's personal symptom patterns and predicts difficult days before they arrive. Built specifically for the unpredictability of perimenopause — rather than the fixed 28-day cycle most period apps assume — it helps women anticipate symptoms like anxiety, mood shifts, and disrupted sleep, plan their lives around hard days, and bring a clear symptom report to their doctor. Because perimenopausal anxiety so often clusters with sleep loss and hot flashes, seeing those patterns together is what turns a confusing week into one you can prepare for.

Download Rythma on the App Store →

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Rythma is a tracking and educational tool, not a medical device, and this article is for general information only — it is not medical advice. Perimenopause varies widely from person to person. Always consult a qualified healthcare professional about your symptoms, diagnosis, or treatment.