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Managing Anxiety in Perimenopause and Menopause

Racing thoughts, sleepless nights—menopause anxiety is no joke. Take control with these expert tips.

Anxiety is no joke, but anxiety during perimenopause and menopause is an entirely different beast. As with most things during this time, you can blame your rapidly changing hormones. Both estrogen and progesterone levels randomly fluctuate during your cycles and can trigger feelings of anxiety.

”When progesterone is declining at a fast rate, it can leave you feeling overstimulated, overwhelmed, agitated, short-fused, and anxious,” says women’s hormone expert Natalie Kunsman, M.D. Plus, the symptoms that go hand in hand during this time in life, such as poor sleep, brain fog, and irregular periods, can pile on even more anxiety.
It’s more than just mental strain.

Research suggests that anxiety affects from 15 to 50 percent of women during menopause. If left untreated, it puts you at nearly 2 times the increased risk of dying before the age of 57 (1). Thankfully, there are effective ways to manage this all-too-common menopause symptom and regain your sense of calm.


About the Experts

Natalie Kunsman, M.D., is a functional medicine physician with Broad Health, Hone’s affiliated medical practice. She specializes in menopause care, anti-aging, and regenerative medicine.

Jess Kovler, PhD, MA, is an award-winning psychologist who specializes in evidence-based approaches to mental health care.


What Is Anxiety in Menopause?

Anxiety during menopause can come in several forms. For some, it hits like a ton of bricks. For others, it creeps in slowly over time. It can ebb and flow, leading to waves of dread or fear. 

The effects aren’t just mental. Menopause anxiety can come with physical symptoms, including:

  • Dizziness
  • Heart palpitations
  • Sweating
  • Nausea
  • Fast breathing
  • Muscle tension 

Why Does Menopause Cause Anxiety?

During menopause, a perfect storm of factors happening all at the same time can contribute to anxiety. Those raging hormones you keep hearing about play are the primary culprit. Much of the anxiety during perimenopause and menopause is linked to drops in estrogen and progesterone—two hormones that play critical roles in regulating mood. 

Menopause anxiety can present in several different ways, including:

  • Brain fog. This can look like forgetting an appointment, why you walked into a room, or searching for the right words when talking to someone (2).
  • Panic attacks. Examples include an increased heart rate, sweating, or an unexplained sense of impending doom (2).
  • Mood swings. Best defined as abrupt changes in your mood, from happy to sad, without explanation (2).

Progesterone helps regulate gamma-aminobutyric acid (GABA), a neurotransmitter that calms down hyperactive nerve cells in the hippocampus, hypothalamus, and amygdala. These parts of the brain regulate mood anxiety (3). Estrogen is tied to the production and activity of other mood-regulating hormones, including serotonin and cortisol (low levels of the “stress hormone”), which promotes relaxation (4). When estrogen levels dip, these hormones are thrown out of balance, making it harder to cope with stress. 

Then there’s the stress and anxiety caused by menopause symptoms themselves. Waking up in the middle of the night drenched in sweat or dealing with persistent muscle aches can leave you frazzled. 

Hot flashes, in particular, can exacerbate anxiety, according to the Menopause Society. The fear of them striking at inopportune moments can be embarrassing and stressful. And ironically, anxious thoughts can trigger more hot flashes (5). 

“Women also experience anxiety around the physical changes that happen in menopause, which can contribute to overall health anxiety,” says registered psychologist Jess Kovler, Ph.D. It’s an endless cycle.

If you’ve experienced anxiety, severe or otherwise, in the past, it might resurface or worsen as you go through the menopause transition. “People with a lifelong history of anxiety, depression, or hormonal challenges have a higher incidence of mood symptoms, including anxiety, during this phase,” says Kovler.

Estrogen levels in flux

The anxious feelings you experience during perimenopause and menopause are connected to hormone changes. During your childbearing years, your ovaries produce most of your body’s estrogen. As you age, the fixed number of eggs you’re born with begins to run out. Fewer follicles make it difficult for your body to produce estrogen and progesterone, marking the start of perimenopause.

Estrogen doesn’t drop as quickly. Instead, it fluctuates—rising and falling unpredictably for up to 10 years before finally plummeting to almost nothing. Sometimes, this can last up to 10 years. When you finally achieve menopause (one full year without a period), your estrogen levels will have dropped by nearly 90 percent (6). 

With only 10 percent of your previous estrogen circulating throughout your body, anxiety can start to increase. “Estrogen modulates several neurotransmitters or brain chemicals,” says Kunsman. These include GABA (which is calming), norepinephrine (which helps with blood pressure and mood), serotonin (the “feel good” hormone), and dopamine (associated with pleasure). When estrogen levels are erratic or low, the production of these other hormones drops, leading to anxiety.

Sleep problems 

Waking up hot and sweaty in the middle of the night or being unable to fall asleep are common menopause woes. Even if you drift off, you may develop sleep apnea, a breathing condition that keeps you awake (7). Approximately 60 percent of women in postmenopause develop the condition (8).

Sleep disturbances should be taken seriously,  says Kunsman. “Low-quality sleep can exacerbate emotional instability, brain fog, and mental fatigue, leading to increased emotional sensitivity,” she says. In other words, sleep issues can make your anxiety worse, and worry about sleeping can intensify your anxiety. 

Some of the menopause sleep symptoms linked to anxiety include:

  • Hot flashes: These episodes of intense heat last two to four minutes and can be accompanied by profuse sweating and feelings of anxiety. When the hot flashes happen during sleep, they’re called “night sweats,” and they can wake you up. Disrupted sleep may raise cortisol levels, exacerbating anxiety (9). 
  • Insomnia:  Difficulty falling and staying asleep becomes more common during menopause. Insomnia can make night sweats feel even more noticeable and contribute to anxious feelings (10).
  • Sleep apnea: Midlife weight gain and hormone changes can obstruct airways, causing breathing to become shallow or stop briefly at night. Again, disrupted sleep may raise cortisol levels and increase anxious feelings (9).

Midlife stress

Life pressures are often most intense during your 40s and 50s. You may juggle a demanding job, growing children, and caring for aging parents—all simultaneously (11). The relentless stress can amplify the mental health challenges that accompany perimenopause and menopause and ramp up fatigue and anxiety.

How Long Does Menopause Anxiety Last?

Just as no two women experience menopause the same way, there is no set timeline for how long the anxiety will last. Overall health, stress levels, and lifestyle play a role. So does your history of mental health struggles.

What to Take for Menopause Anxiety

Fortunately, there are several ways to manage anxiety during menopause, from hormone treatments and anti-depressants to holistic approaches.

HRT

Hormone replacement therapy (HRT), also known as menopausal hormone therapy (MHT), treats a range of symptoms, including vaginal dryness, hot flashes, insomnia, and more. By targeting the underlying causes of menopause anxiety—the drop in estrogen and progesterone—some women have seen their anxiety decrease once they begin HRT therapy.

A 2024 study in the journal Menopause showed that three months of HRT improved symptoms of depression, which tends to go hand-in-hand with anxiety (12). 

“This is the functional medicine preferred approach,” says Kunsman. “Optimize hormones first, and if other medications are still needed to control symptoms, they can be added,” she says. 

HRT reintroduces estrogen and progesterone back into the body. Several FDA-approved and compounded options are available, including progesterone capsules, creams, and patches. Talk to your doctor about the proper dosage and delivery method.

Anti-anxiety meds

Serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are also popular treatment options for menopause anxiety. They boost serotonin in the brain, helping to regulate mood. 

A  2015 meta-analysis of 234 trials confirmed that anti-anxiety medications are effective (13). They are invaluable for women with pre-existing anxiety whose symptoms have increased during menopause, says Kunsman. “There are many patients who may require medication because the condition is big enough to need more support,” she says. 

There is some concern that antidepressants are over-prescribed to treat menopause anxiety. The Menopause Society advises that anti-anxiety medications shouldn’t be the first line of defense for mood issues in women during menopause (14).  

Supplements and vitamins

A 2017 study found half of participants with depression and anxiety had a vitamin B12 deficiency. But, their average age was under 60, which is a population that usually has only a 4 percent deficiency rate (15). Researchers have also noted a connection between anxiety and vitamin D, but more studies are needed (16).

Herbal remedies and supplements that may help with anxious feelings during menopause include:

  • Ashwagandha: An herb used in traditional Ayurvedic medicine, ashwagandha may increase estrogen and reduce anxiety, according to some studies (17, 18).
  • Magnesium: This essential mineral can lower cortisol levels and reduce nervous tension (19). “Magnesium is a wonderful chill pill!” says Kunsman.
  • Black cohosh:  Research on this popular menopause supplement is mixed. A review in the Journal of The Menopause Society found black cohosh significantly reduced reports of anxiety, but another, more recent review questioned its actual impact (20).  

Natural Remedies for Menopause Anxiety

Lifestyle changes can have a significant impact on managing anxiety during menopause. Eating a healthy diet, staying active, improving sleep habits, and finding emotional support are all proven strategies.

Exercise

Overall, regular exercise will help you manage menopause anxiety by increasing the amount of anxiety-relieving chemicals in your brain. Regular exercise boosts mood-regulating brain chemicals, making it a powerful tool against anxiety. Try these types of exercises:

  • Pilates: One study found that an eight-week program improved hot flashes and mood in postmenopausal women (21). 
  • Walking: Research suggests daily strolls can reduce menopause anxiety and depression (22).
  • Strength Training: A 2023 review showed that strength training benefits menopausal women  by improving heart rate, bone density, blood pressure, and lean muscle mass and may also reduce anxiety (23). 

Diet

A diet emphasizing whole foods, fiber, and healthy proteins can lessen anxiety. ” A low-inflammatory diet is helpful,” says Kunsman. “Think of the Mediterranean Diet, Paleo diet, and other low-carbohydrate, whole-food plans that rely on real food.” 

Additionally, certain nutrients may reduce anxiety (24):

  • Magnesium: Found in leafy greens, nuts, and seeds (25)
  • Zinc: Found in beef, egg yolks, and cashews. (26)

Get good sleep

For many women in menopause, getting the recommended 7 to 9 hours feels almost impossible due to night sweats and insomnia. “When we don’t sleep, we don’t feel our best, so implementing sleep hygiene is important,” says Kovler.  Fortunately, improving sleep hygiene can increase your odds of scoring a full eight hours (27):

  • Go to bed and wake up  at the same time each day
  • Skip caffeine (found in coffee, teas, and chocolate) late in the day
  • Keep your bedroom dark, quiet, and at a comfortable temperature
  • Don’t use  a phone, tablet, or TV in bed
  • Avoid large meals close to bedtime
  • Exercise each day, but ideally not in the evening

Start with one habit, and once you master it, add another. As you incorporate each new habit into your routine, you’ll be on track to get 8 hours of sleep each night.

Find support

Emotional support is key to managing menopause anxiety. You can talk to a trusted friend or family or work with a professional therapist. Cognitive behavioral therapy (CBT) helps you identify and reframe negative thought patterns around anxiety, creating new neuropathways and fostering neuroplasticity (28). Talk to your doctor about finding a psychotherapist or counselor that is right for you.

The Bottom Line

Menopause anxiety is a common but manageable challenge caused by fluctuating hormone levels, midlife stressors, and physical symptoms like sleep disturbances. Treatments range from hormone replacement therapy, which addresses the decline of estrogen and progesterone, to anti-anxiety medications, supplements, and natural remedies like diet, exercise, and improved sleep hygiene. Seeking support from friends, family, or a therapist can also help you navigate this transition with greater ease.

About the author

Karen Robock is a journalist who has contributed to dozens of magazines, newspapers and digital brands and teaches journalism at Centennial College. Her work regularly appears in Reader’s Digest, Canadian Living, and The Toronto Star.