The list of potential reasons for anxiety during midlife is long: You’re taking on more responsibility at work, your kids are in their angsty teenage phase, and you need to be in a million places at once. On top of that, studies suggest anxiety could be linked to the menopause transition (1).
You might press for the obvious anxiety solve: anti-anxiety meds. But that isn’t your only option. In fact, The Menopause Society guidelines say these medications shouldn’t be the first-line treatment for menopause-related mood issues. Hormone replacement therapy (HRT) might help but is often under-prescribed (2).
Research shows that HRT stabilizes hormone levels and can alleviate both physical and emotional symptoms, including anxiety (3, 4). Many women report significant relief from menopause-related anxiety when using hormone replacement therapy (HRT).
But to figure out the best approach to manage anxiety, it’s first crucial to pinpoint the cause. Whether it’s triggered by physical menopause symptoms, low estrogen-induced anxiety, hormone changes impacting neurotransmitters, or midlife stress can help determine the best course of treatment.
About the Experts
Susan B. Trachman, M.D. is a board-certified psychiatrist with a special interest in reproductive psychiatry. She regularly sees women for premenstrual dysphoric disorder (PMDD), pregnancy-related mood disorders, and postpartum disorders.
medical director at Rockwell Centers for Sexual Medicine & Wellness in Manhattan, the Philadelphia area, and Allentown, PA.
How HRT Can Help With Anxiety
HRT is primarily used to address the physical symptoms of menopause, like hot flashes, night sweats, and vaginal dryness. But it can also play a role in managing menopause anxiety. By balancing estrogen and progesterone levels, HRT helps stabilize mood and alleviate anxiety, providing some women with much-needed emotional relief during the menopause transition.
Stabilizes hormones
One of the key ways HRT alleviates anxiety is by stabilizing fluctuating hormones. “Decreasing levels of estrogen in the years leading up to menopause can cause an increase in anxiety,” explains Trachman. That’s because estrogen acts as a natural mood stabilizer and helps reduce anxiety. HRT replenishes estrogen levels, which helps balance hormones and, by extension, may alleviate anxiety.
Supports serotonin production
“Hormone fluctuations can influence the neurotransmitters (like serotonin) in the brain that make us happy, sad, or anxious,” explains urologist Paul Gittens, M.D. Restoring estrogen can boost serotonin levels, which influence mood and endorphin production, stabilizing emotions and reducing anxiety.
Relieves menopause symptoms
HRT can indirectly reduce anxiety by addressing uncomfortable menopause symptoms like hot flashes and night sweats. These symptoms can disrupt sleep, exacerbating any feelings of anxiety or stress, says Gittens.
Types of HRT for Anxiety
There are several types of HRT that may help with anxiety during perimenopause. The best option depends on your individual needs.
Estrogen and Estradiol
Estrogen-based therapies, such as estradiol patches, are often recommended for women experiencing anxiety during perimenopause. Studies suggest that for those with low estrogen, estrogen therapy could be a game-changer since it’s been linked to serotonin production and mood (5).
Progesterone
While estrogen often takes center stage in most discussions about women’s sexual health, progesterone plays a vital role in managing anxiety (6). Progesterone stimulates GABA (a neurotransmitter that promotes calmness and relaxation) production in the brain. However, some women may experience progesterone intolerance (7). So, if you’re considering progesterone as part of your HRT regimen, work with your doctor to determine whether it’s right for you and the correct dose for your individual needs (8).
Testosterone
While testosterone’s role in managing anxiety is still under study, it could be an option for women when other treatments don’t provide relief. Early research suggests that low-dose testosterone might help ease symptoms of depression and anxiety in midlife, says Gittens (9). “It can be helpful in some cases for mood, energy, and libido.”
HRT is not prescribed solely for anxiety, but rather when other menopause symptoms accompany anxiety, notes Gittens. “It just depends on the patient. Some women with baseline anxiety may not see improvement with just hormone therapy, while others who experience anxiety as part of their menopausal symptoms may benefit greatly.”
HRT isn’t suitable for everyone. “You also have to look at lifestyle factors and see how they contribute to overall anxiety,” adds Gittens. With that in mind, it’s best to carefully consider the pros and cons of HRT with the help of a healthcare provider to determine if it’s right for you.
Other Ways to Treat Menopause Anxiety
HRT isn’t the only way to tackle anxiety during perimenopause. Several different lifestyle changes and treatments can also help manage symptoms and improve overall well-being.
Exercise
Gittens emphasizes the importance of physical activity as a standalone treatment or complementary tool to HRT. “Exercise has been shown to increase dopamine, self-confidence, and well-being,” he says.
Regular physical activity, especially somatic exercise like yoga or pilates that involves the body and mind, can help manage anxiety during perimenopause. Aim for at least 150 minutes of moderate-intensity aerobic activity and strength training twice a week (10).
Diet
A healthy diet supports overall hormone balance. Trachman recommends her patients eat a Mediterranean diet, which has been found to reduce menopause symptoms (11). Specifically, eating more legumes was linked to less severe overall symptoms, while higher consumption of extra-virgin olive oil was associated with fewer psychological symptoms.
Reducing alcohol and caffeine can also help. Both can disrupt sleep, which is often already affected during the menopause transition, and may exacerbate anxiety (12, 13). Limiting your intake can make it easier to manage sleep issues and feel more at ease.
Seek mental health support
For women experiencing anxiety, counseling (particularly cognitive-behavioral therapy) can be beneficial (14). Gittens points out that both life circumstances and hormone changes can cause anxiety, so working with a therapist to address both aspects is key.
How do you know when to seek help? Changes in behavior lasting over seven to 10 days, such as poor sleep, anxiety, irritability, or loss of interest in usual activities, are signs that you should be evaluated by a mental health professional, says Trachman.
Prioritize sleep
Sleep disturbances during menopause are common and can exacerbate anxiety. “Sleep patterns change, especially with changing hormones. Lack of sleep can lead to more anxiety and brain fog,” explains Gittens. To get better sleep:
Turn off electronic devices at least 30 minutes before bed (15).
Practice relaxing activities, like yoga or meditation, before bedtime.
Get blackout curtains and remove other sources of light from your bedroom.
Use earplugs or a white noise machine to block out ambient noise.
Wake up and go to bed at the same time every day.
Reduce stress
Not all anxiety during menopause is directly tied to hormone changes. The timing of this natural transition often coincides with other everyday midlife stressors. “Anxiety could stem from life stress, like marital issues, kids leaving the house, or work pressures. It’s important to identify those triggers,” says Gittens.
Getting stress under control can go a long way. “Stress management techniques like meditation and mindfulness can improve mood and decrease anxiety,” says Trachman. They can help reduce stress and build resilience to help you weather the storm (not to mention the ups and downs) of menopause.
The Bottom Line
HRT may help relieve anxiety during menopause. It can potentially provide emotional relief by stabilizing hormones, boosting serotonin, and improving uncomfortable menopause symptoms. However, not all anxiety is hormone-related, and other treatments such as exercise, diet, and mental health support can also help. Work closely with your doctor to create a treatment plan tailored to your specific needs.
Meredith Bethune is a freelance journalist covering health, wellness, food, travel, and the outdoors for publications like New York Times, Outside, Wine Enthusiast, National Geographic, Travel + Leisure, Condé Nast Traveler, CNN, Vogue, and Eater. An avid hiker and adventurer, Bethune holds a degree in history from Tulane University in New Orleans, Louisiana.
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