Emotional and cognitive symptoms are redefining perimenopause recognition

Seventy-one percent of women do not recognize their first perimenopausal symptom as hormonal, and the primary reason is that perimenopause most often announces itself not with hot flashes but with anxiety, depression, sleep disruption, and brain fog, according to data from the Bonafide 2026 State of Menopause Survey, discussed by Jean Cunningham, PharmD, BCPS.

"Many women are missing that first symptom because the transition often begins with those less recognized emotional and cognitive changes," Cunningham said. Because public awareness of menopause has historically centered on vasomotor symptoms, women experiencing new anxiety, mood shifts, or cognitive difficulty frequently attribute those changes to stress, aging, or other causes entirely.

"Too often, women are explaining new anxiety or sleep disruption or brain fog—even mood changes—as stress," she said. A pattern she described captures the clinical presentation: women who previously managed their responsibilities without difficulty begin finding the same demands increasingly hard to handle. That shift gets labeled stress rather than recognized as a hormonal transition.

The survey data reflect how broadly these non-vasomotor symptoms are affecting women's daily lives. Sixty percent reported that symptoms affect their emotional or mental health; 50% said cognitive health is affected; and 77% reported cognitive changes including brain fog. Anxiety and depression were among the most cited and most impactful symptoms overall.

"These symptoms are affecting how women think, feel, and function," Cunningham said, noting that the cycle of anxiety, poor sleep, depression, and cognitive difficulty is self-reinforcing—each element exacerbating the others, particularly for women in their early forties who are managing demanding work and family responsibilities simultaneously.

Several factors compound the recognition problem. Perimenopause is being experienced earlier than many women expect—including in some women in their thirties—at a stage when periods are still occurring, hot flashes may be absent, and the idea of approaching menopause feels remote or in denial-worthy.

"It can be harder to recognize when periods are still happening, hot flashes are not prominent, and it's not that typical menopause transition," Cunningham said. The implication for ob-gyns is that emotional and cognitive symptom clusters in this demographic warrant a hormonal conversation, one that many women are not expecting and may not initiate themselves.