Managing Anxiety in Perimenopause and Menopause
Racing thoughts, sleepless nights—menopause anxiety is no joke. Take control with these expert tips.

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