Perimenopause and mental health: Beyond hormonal vs psychological

Anxiety, brain fog, and mood changes in midlife patients warranted validation and a structured evaluation that considered perimenopause as a possible contributor, according to Jean Cunningham, PharmD, BCPS. Many patients were searching for an explanation for these symptoms, and clinicians should weigh whether they reflected the hormonal transition rather than defaulting to stress or normal aging as the cause.

Cunningham recommended starting with timing, specifically whether anxiety, mood changes, or concentration problems followed a pattern. Sleep disruption, hot flashes and other vasomotor symptoms, and menstrual changes should be assessed alongside medical history, medications, and life stressors. Prior mental health history was an important consideration entering the transition, and research continued to support its relevance.¹

Not every mood or cognitive symptom should be attributed to hormones, however. Screening for depression and anxiety, and assessing safety when indicated, remained essential, Cunningham said. She cautioned against framing symptoms as either hormonal or psychological, noting meaningful overlap between the 2, and said clinicians evaluating new symptoms should keep the patient's age in mind and consider what else could be contributing.

Treating symptoms in isolation risked missing the underlying driver.

"When anxiety, sleep disruption, or those cognitive changes are emerging during a period of hormonal instability, treating those symptoms in isolation can lead clinicians to use tools that are only partially addressing the problem," Cunningham said. Selective serotonin reuptake inhibitors may be appropriate for some patients, but when declining or fluctuating hormones contributed to mood and cognitive changes, the care plan should also consider whether improving hormonal health could address the broader symptom pattern. Newer perimenopause assessment tools currently undergoing validation may help clinicians recognize this context, validate the patient's experience, and discuss the full range of options. This approach considered perimenopause alongside other diagnoses rather than in place of them and supported individualized care.

For patients in their late 30s and 40s, earlier recognition may come from routine questioning as part of preventive care. Useful questions addressed menstrual predictability, including whether cycles had become closer together, farther apart, heavier, lighter, or different in duration.² Sleep questions should cover nighttime waking, ruminating thoughts, sweating, and feeling unrefreshed during the day. Mood assessment should capture new anxiety or irritability, low mood, reduced resilience, difficulty concentrating or finding words, and trouble keeping up with established routines. Additional symptoms to ask about included episodes of heat, night sweats, palpitations, headaches, joint aches and pains such as frozen shoulder, changes in libido, vaginal discomfort or dryness, and urinary symptoms.

Clinicians should also establish when changes began and whether they tracked with cycles or other patterns. Asking about work, relationships, and daily functioning may help patients recognize the external impact of what they were experiencing internally. History of depression, anxiety, and migraines should be reviewed, thyroid and other conditions evaluated, and bone health and fracture history assessed, given the potential for unrecognized changes during a hormonally unstable period.

"So overall, normalize the conversation and look for a pattern across menstrual, physical, sleep, and emotional symptoms," Cunningham said.

References

1. Maki PM, Kornstein SG, Joffe H, et al. Guidelines for the evaluation and treatment of perimenopausal depression: summary and recommendations. Menopause. 2018;25(10):1069-1085. https://journals.lww.com/menopausejournal/Citation/2018/10000/Guidelines_for_the_evaluation_and_treatment_of.5.aspx
2. Harlow SD, Gass M, Hall JE, et al. Executive summary of the Stages of Reproductive Aging Workshop + 10: addressing the unfinished agenda of staging reproductive aging. Menopause. 2012;19(4):387-395. https://pmc.ncbi.nlm.nih.gov/articles/PMC3340903