Anxiety and mood in perimenopause: it is not the drop, it is the swings
You cry over something tiny and you do not recognize yourself. The reversal almost nobody makes: it is not low estrogen that destabilizes mood in perimenopause, it is its variability. In French with English subtitles.
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What you will understand
You cried this week over something tiny: a remark that meant nothing, a traffic jam, a photograph. Or you slammed a door, you heard yourself speak in a tone you did not recognize, and then came the shame, then the exhaustion. This video will not tell you to breathe, to do yoga and to put things in perspective. It explains what is really happening in the brain between forty-two and fifty-two, and it offers a reversal of reasoning that almost nobody makes.
We always imagine that the mood problems of perimenopause come from a lack of estrogen: the level goes down, mood goes down with it. That is intuitive, and it is not what the data show. It is not the low level that destabilizes mood, it is the instability itself, the variability from one cycle to the next. In perimenopause, estrogen does not come down on a gentle slope: it sometimes climbs higher than before, collapses, then climbs again. It is that amplitude that was associated with the appearance of a depressed mood in a cohort where hormones were measured repeatedly (PMID 16585466). It is not the bottom of the well that hurts, it is the journey.
This distinction is not theoretical: it explains why you can feel very well for three weeks then very unwell for four days without anything having happened in your life, why it is not linear, and why you find no trigger. If there is no external trigger, it may simply be that there was none: it was internal, biological and invisible. It is also why, seen from the outside, it looks like inconstancy, and why so many women have been told they were moody, a word that describes an accurate observation with a completely false explanation.
Now the figures, with what they say and what they do not say. A Harvard study followed women aged thirty-six to forty-five who had never had depression in their lives: those who entered perimenopause had about twice the risk of developing significant depressive symptoms compared with those who remained premenopausal (PMID 16585467). The denominator matters: this is not all women, but women with no history at all, compared with each other, and it is an increased risk, not a fate. A large American multiethnic cohort finds the same thing for major depression, and the result holds even after taking hot flashes and difficult life events into account (PMID 21306662). Anxiety, which is systematically forgotten, was studied separately in the same cohort: its risk also increases during the transition, including in women who were not particularly anxious before (PMID 23615639). It is often physical: the heart racing, a tightness in the chest, that four in the morning awakening with the body on alert. These are observational studies: they show a strong and consistent association, not on their own a cause and effect link.
Why the brain? Because estrogen does not act only on the uterus and the ovaries: it takes part in the functioning of several neurotransmitters, including serotonin, the very one targeted by the most widely prescribed antidepressants. When its concentration becomes unstable, that regulation system becomes unstable with it. A second element, found in the same study on variability: women who had gone through stressful life events in the preceding months were more vulnerable to that instability. So it is not hormones versus circumstances, it is both, multiplying each other. In practice, the same difficult week does not cost the same at thirty-five and at forty-eight. You have not become more fragile: your biological shock absorber is less regular than it used to be. A third factor deserves to be named, a family history of depression, alongside a depression already experienced, a marked premenstrual syndrome, a postpartum depression or significant hot flashes.
Finally comes a study of another kind. In 2018, an American team published a randomized placebo-controlled trial in women aged forty-five to sixty who were doing well as far as mood was concerned, in perimenopause or in early postmenopause: twelve months of an estradiol patch with intermittent progesterone, or a placebo. In the placebo group, 32.3% of the women developed significant depressive symptoms during the year, versus 17.3% in the treated group, that is a risk about two and a half times higher on placebo (PMID 29322164). The condition that comes with this result is the most useful part of the study: the benefit was clear in early transition, and it was found neither in late transition, nor in women already postmenopausal. It was also all the more marked when the women had gone through more stressful events in the preceding six months. That does not make hormone therapy a treatment for mood, and nothing is decided on your own. Expert recommendations on perimenopausal depression set out a simple principle: there is no single answer but several avenues, psychotherapy, antidepressants, hormones depending on the profile, and the choice is made with a professional (PMID 30179986). Added to that is physical activity, whose effect on the depressive and anxiety symptoms of women in transition was confirmed in a recent review (PMID 39856668), and sleep, the most underestimated lever: if night sweats wake you three times a night, no therapy will make up for months of broken nights.
The key points to remember
- It is not the lack of estrogen that destabilizes mood in perimenopause, it is its instability, its variability from one cycle to the next.
- That instability explains why it is unpredictable and why you find no trigger: the trigger was internal, biological and invisible.
- In women aged 36 to 45 with no history of depression at all, entering perimenopause was associated with about twice the risk of significant depressive symptoms (PMID 16585467). An increased risk is not a fate: the majority of these women did not develop depression.
- The excess risk of major depression persists even after taking hot flashes and difficult life events into account (PMID 21306662). Something remains once all of that has been removed.
- Anxiety also increases during the transition, including in women who were not particularly anxious before, and it is often physical rather than mental (PMID 23615639).
- In the 2018 randomized trial: 32.3% of depressive symptoms on placebo versus 17.3% on transdermal estradiol and progesterone, but the benefit existed only in early transition (PMID 29322164). It is not a treatment for mood, and it is never decided on your own.
- Physical activity is the only avenue you can start this week without a prescription (PMID 39856668), and treating what breaks your nights is often the most rewarding lever.
Video chapters
- 0:00 It is not stress, and it is not in your head
- 1:37 The reversal: not the lack of estrogen, its instability
- 2:24 Why it is unpredictable and has no trigger
- 3:34 The figures: a risk about doubled, even with no history
- 5:06 Anxiety, the one we systematically forget
- 5:56 The brain, serotonin and the effect of stress
- 7:13 Family history and other vulnerability factors
- 8:03 The 2018 randomized trial and the condition that comes with it
- 9:39 What really helps, sleep included
- 10:51 What must not wait + recap
The scientific sources cited
Every claim in this video rests on a verified reference. Here is the complete list, with the PubMed links.
- Cohen LS, Soares CN, Vitonis AF, Otto MW, Harlow BL. Risk for new onset of depression during the menopausal transition: the Harvard Study of Moods and Cycles. Archives of General Psychiatry. 2006;63(4):385-390. PubMed 16585467
- Bromberger JT, Kravitz HM, Chang YF, Cyranowski JM, Brown C, Matthews KA. Major depression during and after the menopausal transition: Study of Women's Health Across the Nation (SWAN). Psychological Medicine. 2011;41(9):1879-1888. PubMed 21306662
- Bromberger JT, Kravitz HM, Chang Y, et al. Does risk for anxiety increase during the menopausal transition? Study of Women's Health Across the Nation. Menopause. 2013;20(5):488-495. PubMed 23615639
- Gordon JL, Rubinow DR, Eisenlohr-Moul TA, Xia K, Schmidt PJ, Girdler SS. Efficacy of Transdermal Estradiol and Micronized Progesterone in the Prevention of Depressive Symptoms in the Menopause Transition: A Randomized Clinical Trial. JAMA Psychiatry. 2018;75(2):149-157. PubMed 29322164
- 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. PubMed 30179986
- Yue H, Yang Y, Xie F, et al. Effects of physical activity on depressive and anxiety symptoms of women in the menopausal transition and menopause: a comprehensive systematic review and meta-analysis of randomized controlled trials. International Journal of Behavioral Nutrition and Physical Activity. 2025;22(1):11. PubMed 39856668
- Freeman EW, Sammel MD, Lin H, Nelson DB. Associations of hormones and menopausal status with depressed mood in women with no history of depression. Archives of General Psychiatry. 2006;63(4):375-382. PubMed 16585466
- Colvin A, et al. The role of family history of depression and the menopausal transition in the development of major depression in midlife women (SWAN MHS). Depress Anxiety 2017. PubMed 28489293
- Joffe H, et al. Impact of Estradiol Variability and Progesterone on Mood in Perimenopausal Women With Depressive Symptoms. J Clin Endocrinol Metab 2020. PubMed 31693131
- Gordon JL, et al. Estradiol variability, stressful life events, and the emergence of depressive symptomatology during the menopausal transition. Menopause 2016. PubMed 26529616
Frequently asked questions
Why do I find no trigger for my bad days?
Because there may not have been one. You look for an event, a cause, a reason, you find none, and you end up concluding that the problem comes from you, from your resilience, from your character. Yet what triggers it here is internal: a rapid, invisible hormonal variation that gives no warning. That is what explains how you can feel very well for three weeks then very unwell for four days without anything having changed in your life.
I am told it is stress, work, the teenagers, the ageing parents. Is that false?
No, and that is precisely what makes the explanation a trap: all of that is true too, this period of life is objectively loaded. But a piece is missing, and it is neither psychological nor circumstantial. In the large American cohort, the excess risk of depression during and after the transition persists even after taking hot flashes and difficult life events into account (PMID 21306662). In other words, it is not only because you sleep badly, and it is not only because your life is complicated right now.
I have never had depression in my life. Am I concerned all the same?
Yes, and that is exactly what the Harvard study measured: it followed women aged 36 to 45 with no history at all, no episode, and those who entered perimenopause had about twice the risk of developing significant depressive symptoms compared with those who remained premenopausal (PMID 16585467). This figure has to be read with its denominator: it is an increased risk, not a fate, and the majority of these women did not develop depression.
And anxiety, why is it never talked about?
Because as soon as mood and menopause are put together, everyone talks about depression. Anxiety is nonetheless a distinct phenomenon, studied separately in the same large cohort, where its risk also increases during the transition, including in women who were not particularly anxious beforehand (PMID 23615639). It does not always look like what you would imagine either: it is not necessarily a worry about a specific subject, it is often a physical sensation, the heart racing for no reason, a tightness in the chest, that four in the morning awakening with the body on alert while nothing at all is happening.
Can hormone therapy prevent perimenopausal depression?
A 2018 randomized trial tested prevention, and not only treatment: in women aged 45 to 60 who were doing well as far as mood was concerned, twelve months of an estradiol patch with intermittent progesterone were compared with a placebo. Result: 32.3% of significant depressive symptoms on placebo versus 17.3% on treatment (PMID 29322164). But the condition matters as much as the result: the benefit was clear in early transition, and it was found neither in late transition, nor in women already postmenopausal. That does not mean hormone therapy is a treatment for mood, nor that it should be taken to prevent a depression. It is a shared medical decision, which depends on your age, your history and your complete profile.
What can I start without waiting for an appointment?
Two things. Physical activity first: its effect on the depressive and anxiety symptoms of women in transition was confirmed in a recent review (PMID 39856668), and it is the only intervention you can start this week, without a prescription. Sleep next: if night sweats wake you three times a night, your mood will pay for it, and no therapy will make up for months of broken nights. Treating what breaks your nights is often the most rewarding lever, because it acts on several things at once. Finally, if you make an appointment, write down for four to six weeks the days when things are not going well, the intensity, where you are in your cycle if you still have one, and how you slept: that record makes visible what is hardest to put into words, the irregularity.
What if I have dark thoughts? What are the right numbers to call?
This is a matter neither of patience nor of willpower: seek help without waiting. In France, 15 or 112 in case of a life-threatening emergency, and 3114, the national suicide prevention number. In Quebec and in Canada, 911 in case of a life-threatening emergency, and 988, the suicide crisis helpline. One important clarification: the video mistakenly announces 888 as the suicide prevention line. That is an error, corrected in the video description. Remember 988 in Canada and 3114 in France. There is no shame in calling, and there is no threshold to reach in order to be entitled to it.