Perimenopause and Mental Health: The Emotional Changes Nobody Warned You About

Key takeaways

Perimenopause is not just hot flushes—it can cause anxiety, low mood, rage, brain fog, and a profound sense of losing yourself, often years before periods stop
Fluctuating oestrogen directly affects brain chemistry, including serotonin and dopamine, which is why you may feel like a completely different person
If you have ADHD or autism, perimenopause can intensify your symptoms significantly—and this connection is only now being understood
What you're experiencing is physiological, not a personal failing, and it doesn't mean you're "going mad"
Counselling can help you process the emotional upheaval, navigate identity changes, and find your footing during a transition that gets far too little recognition

I want to start with something a lot of my clients have said to me, in almost exactly these words: "I feel like I'm going mad, and nobody will take me seriously."

They're usually in their late 30s or 40s. Successful, capable women who've managed demanding lives for years. And suddenly—or what feels like suddenly—everything is different. The anxiety that was always manageable has become overwhelming. The patience they prided themselves on has evaporated. They're forgetting words. Crying at things that wouldn't have bothered them six months ago. Lying awake at 3am with a racing heart, convinced something is terribly wrong.

They've been to the GP. Maybe they were offered antidepressants. Maybe they were told it's stress. Maybe nobody mentioned perimenopause at all—because they're "too young," or because the symptoms don't look like the hot flushes and night sweats that most people associate with menopause.

If this sounds like you, you're not going mad. You're not weak. And you're very much not alone.

What perimenopause actually is

Perimenopause is the transitional phase before menopause—the years during which your body gradually produces less oestrogen and progesterone. It typically begins in your early-to-mid 40s, but can start in your late 30s. It can last anywhere from a few years to over a decade.

Menopause itself is a single point—the day that marks 12 months since your last period. Everything before that is perimenopause. Everything after is postmenopause. But the term most people casually use—"menopause"—usually refers to the whole transition, and perimenopause is where most of the upheaval happens.

Here's the key thing: oestrogen isn't just a reproductive hormone. It plays a significant role in brain function. It influences serotonin (mood regulation), dopamine (motivation and reward), GABA (calm and relaxation), and acetylcholine (memory and cognitive function). When oestrogen fluctuates—and during perimenopause it doesn't decline neatly, it swings wildly—these brain systems are directly affected.

This is why the mental health symptoms often arrive first, long before the more "recognisable" physical symptoms. And it's why so many women spend months or years being treated for depression, anxiety, or burnout when what's actually happening is hormonal.

The emotional symptoms nobody warned you about

The cultural image of menopause is hot flushes and the end of periods. The reality—particularly in the perimenopausal phase—is far more complex, and the emotional and cognitive changes are often the most distressing.

Anxiety that appears from nowhere

This is one of the most common symptoms I see, and one of the most disorienting. You may have never been an anxious person, and suddenly you're having panic attacks. Or your existing anxiety, which you'd managed perfectly well for years, has escalated beyond recognition.

The anxiety of perimenopause often has a particular quality: it feels physical and overwhelming, it may not attach to specific worries, and it can spike at certain points in your cycle. It responds poorly to the coping strategies that used to work. This is because it's being driven, at least in part, by neurochemistry rather than psychology—though of course the two interact.

Mood changes that feel extreme

Rage that surprises you with its intensity. Tearfulness over nothing. Irritability that makes you snap at the people you love. A flatness or sadness that descends without cause and lifts without explanation.

These are oestrogen fluctuations affecting your serotonin system. They are not character flaws. But they can be deeply unsettling—particularly if you're someone who has always prided yourself on being calm, patient, and emotionally steady.

The gap between who you feel like now and who you've always been can be genuinely frightening.

Brain fog and cognitive changes

Forgetting what you walked into a room for. Losing your train of thought mid-sentence. Struggling to find words that used to come easily. Difficulty concentrating on tasks that were previously routine.

These cognitive changes are real—they're linked to fluctuating oestrogen's effect on acetylcholine and hippocampal function. Research shows that cognitive function typically recovers after the menopause transition, but that's cold comfort when you're in the middle of it and wondering whether you're developing early dementia.

Several of my clients have arrived deeply worried about their cognitive decline, only to realise—with considerable relief—that perimenopause was the most likely explanation.

Loss of confidence and identity

This one is harder to pin on a hormone, but it's enormously common. A creeping sense that you don't know who you are anymore. That the person you've been for decades is dissolving. That you've lost your edge, your competence, your spark.

Part of this is the direct effect of hormonal changes on mood and cognition. Part of it is the accumulated impact of months of feeling unlike yourself. And part of it is the cultural invisibility of midlife women—the sense that you're moving into a phase of life that society doesn't value or even particularly see.

Sleep disruption

Difficulty falling asleep. Waking at 3am or 4am and being unable to get back to sleep. Night sweats that wreck your rest. Sleep that no longer feels restorative even when you get enough hours.

Poor sleep affects everything—mood, anxiety, cognitive function, resilience, pain tolerance. It's both a symptom and a multiplier. When I'm working with perimenopausal clients, sleep is often one of the first things we address.

Perimenopause and neurodivergence

This is an area I'm particularly interested in, and one where the research is finally starting to catch up with what clinicians have been observing for years.

ADHD and perimenopause

Oestrogen is involved in dopamine regulation. This is significant if you have ADHD, because ADHD is fundamentally a condition of dopamine regulation.

What many women with ADHD—diagnosed or not—report during perimenopause is that their symptoms dramatically worsen. The executive function that was already a struggle becomes near-impossible. Focus deteriorates further. Emotional dysregulation intensifies. Medication that was working may become less effective.

For women with undiagnosed ADHD, perimenopause can be the point at which everything falls apart. The compensatory strategies that held things together for decades stop working because the underlying neurochemistry has shifted. I've worked with several clients who received their ADHD diagnosis during perimenopause, after years of being told their difficulties were anxiety or depression.

Autism and perimenopause

The research here is newer and sparser, but the clinical picture is consistent: autistic women frequently report that perimenopause intensifies sensory sensitivities, reduces tolerance for masking, increases meltdowns and shutdowns, and generally makes the autistic experience more pronounced.

If you've spent your life managing autism through careful routines and energy management, the hormonal disruption of perimenopause can blow those systems apart. Things that were tolerable become intolerable. Capacity shrinks. And because autistic burnout and perimenopausal symptoms overlap considerably, it can be very difficult to unpick what's causing what.

The diagnostic gap

The overlap between perimenopausal symptoms and neurodivergent symptoms creates a diagnostic problem. Brain fog could be perimenopause, ADHD, or autistic burnout. Emotional dysregulation could be any of the three. Anxiety could be driven by hormones, by neurodivergence, or by both interacting.

What's needed is a holistic view—someone willing to look at the whole picture rather than treating each symptom in isolation. This is something I try to do in my practice, and it's one of the reasons I think counselling during perimenopause can be valuable alongside medical support.

The medical side (briefly)

This is a counselling guide, not a medical one, and I'd always encourage you to discuss hormonal symptoms with your GP. But a few things are worth knowing:

HRT (Hormone Replacement Therapy)

HRT is the most effective treatment for perimenopausal symptoms, including the psychological ones. Modern HRT is considered safe for most women and can make a significant difference. If your GP isn't helpful, you can ask to see a menopause specialist or seek a referral to an NHS menopause clinic.

Antidepressants

These are sometimes offered for perimenopausal mood symptoms. They can help—particularly SSRIs, which affect serotonin—but they don't address the hormonal cause. Some women benefit from both HRT and an antidepressant. Others find that HRT alone resolves the mood symptoms.

What the NICE guidelines say

HRT should be offered as first-line treatment for perimenopausal symptoms, including anxiety and low mood, before antidepressants are considered. If you've been offered antidepressants without any discussion of hormones, it's worth going back and asking.

What I'd gently suggest is this: medical treatment and counselling aren't competing approaches. They address different aspects of the same experience. HRT can stabilise the neurochemistry. Counselling can help you process the emotional fallout, the identity shifts, and the relational changes that hormones alone don't resolve.

What counselling can offer during perimenopause

The women who come to me during perimenopause aren't looking for someone to explain hormones to them—most of them have already done extensive research. What they need is somewhere to process what this transition is actually doing to their lives.

A space to be honest

About the rage. About the grief. About how frightened you are by the changes in your mind and body. About the strain on your relationship. About the sense of losing yourself. Most of my perimenopausal clients are holding all of this while continuing to work, parent, and function—because what's the alternative?

Making sense of the emotional upheaval

Is this hormones? Is this something deeper? Often it's both. Perimenopause has a way of surfacing things that were buried—unresolved grief, dissatisfaction with a relationship, a career that no longer fits, needs that have been pushed aside for decades. The hormonal shifts crack open whatever you've been sitting on. Counselling can help you sort through what emerges.

Working with identity

Midlife is a transition in its own right, regardless of hormones. But perimenopause accelerates it. The body you knew is changing. The roles you've occupied—mother of young children, career-driven professional, the reliable one—may be shifting. Who are you on the other side of this? That's a question worth exploring with support.

Navigating the impact on relationships

Perimenopause affects partnerships, often significantly. Changes in libido, mood, patience, and energy can strain even solid relationships. And if the relationship wasn't solid to begin with, perimenopause tends to bring that into sharp focus. We can work with this—not to fix the relationship (that's couples work) but to help you understand what you need and how to communicate it.

Addressing the neurodivergent dimension

If you have or suspect ADHD or autism, and perimenopause is making everything harder, we can look at the whole picture together. Understanding the interaction between hormonal changes and neurodivergence can be genuinely relieving—it explains what's happening and opens up different avenues for support.

You're not imagining this

If there's one thing I want you to take from this guide, it's that what you're experiencing is real. It has a physiological basis. It's not a sign that you're failing, losing your mind, or falling apart as a person.

The fact that it's poorly understood, under-researched, and frequently dismissed by the healthcare system doesn't mean it isn't significant. It means the system is behind—and you deserve better than what it's currently offering most women.

If you're struggling and want someone to talk to about what's happening—someone who understands that this is bigger than "just hormones" and more complex than a prescription can solve—I'm here.

About the author

Nadia Wilkinson is a BACP registered counsellor (Member No. 394901) and HCPC registered Educational Psychologist specialising in supporting adults with anxiety, ADHD, autism, and emotional wellbeing during major life transitions. She offers online counselling across the UK.

References:

NHS: Menopause
NICE Guidelines: Menopause: diagnosis and management (NG23)
Newson Health Research and Education: newsonhealth.co.uk
Shanmugan, S. & Epperson, C.N. (2014). "Estrogen and the prefrontal cortex" — Hormones and Behavior
Women and ADHD: ADHD UK