Can Perimenopause Cause Anxiety? Palpitations, Insomnia and What Helps

Can perimenopause cause anxiety? Yes. In a 10-year study of nearly 3,000 midlife women, those who had little anxiety before the transition had about 1.6 times the odds of high anxiety once perimenopause began. Swinging estrogen and progesterone, night sweats and broken sleep all feed it. Palpitations, insomnia, low mood and forgetfulness often arrive in the same years.

Can perimenopause cause anxiety, or is it just a stressful age?

Both things are true, and the research has managed to pull them apart better than you might expect. The Study of Women’s Health Across the Nation (SWAN) followed 2,956 women aged 42 to 52 for 10 years. Anxiety was scored on four symptoms: irritability, nervousness or tension, feeling fearful for no reason, and a pounding or racing heart. According to a Contemporary OB/GYN summary of the 2013 paper in Menopause, women who started the study with low anxiety had 1.56 to 1.61 times the odds of high anxiety during or after the transition compared with before it.

That held after the researchers accounted for upsetting life events, money strain, poor health and hot flashes. So it is not only the teenagers, the aging parents and the job.

The other half of the finding is less comforting. Women who were already highly anxious at the start stayed that way through every stage. Perimenopause did not make their anxiety worse on average, and it did not make it better either.

Why would hormones do this? During perimenopause the ovaries produce hormones erratically and ovulate less often, as The Menopause Society describes it. Estrogen does not glide down. It rises and drops unpredictably, and progesterone, which is made after ovulation, goes missing in cycles where no egg is released. Cleveland Clinic puts the mood effect down to these swings acting on brain chemistry, plus the obvious multiplier: lost sleep and hot flashes.

Hot flashes and anxiety also chase each other. The Menopause Society’s mental health page notes that hot flashes can worsen anxiety because they are unpredictable and embarrassing, and that anxious thoughts can set off a hot flash. If you have ever felt dread arrive a few seconds before the heat, that is the loop.

Here is the part we would push on. New anxiety in a woman of 44 who has never had it deserves a question about her cycle and her sleep before it gets a label and a prescription. Sometimes the label is right. It should still come second. Our post on perimenopause symptoms worth investigating covers the lookalikes, such as thyroid problems and iron deficiency, that belong on the list too.

Can menopause cause heart palpitations?

It can, and palpitations are one of the most frightening symptoms of the transition because they feel cardiac. The Menopause Society says some women feel a rapid heartbeat during a hot flash. Outside of hot flashes, the evidence is thinner than you would think for something so common.

A 2021 systematic review by Carpenter and colleagues found only five usable studies from five countries, published between 1974 and 2011. Reported rates ran from 20.1 to 40.2 percent in perimenopausal women and 15.7 to 54.1 percent in postmenopausal women. Three of the five studies found palpitations were more common in perimenopausal and surgically menopausal women than in premenopausal women. The authors call the evidence limited and say the way palpitations are measured needs to be standardized.

Translation: palpitations in your late 40s are common, probably partly hormonal, and still worth taking seriously.

Menopause is only one cause. The NHS palpitations page lists stress and anxiety, lack of sleep, caffeine, alcohol, nicotine, some medicines, iron deficiency anemia, an overactive thyroid, heart rhythm problems and heart valve disease. Several of those cluster in exactly the same years. A racing heart at 2 a.m. after two glasses of wine and a night sweat is a different problem from a racing heart while you sit still at your desk.

See a clinician if palpitations keep coming back, are getting more frequent, last longer than a few minutes, or you have a heart condition or a family history of one. Call 911 if palpitations come with chest pain, shortness of breath, or feeling faint or fainting. Those are not perimenopause symptoms until a heart workup says otherwise.

Can menopause cause insomnia?

Yes, and sleep is probably the hinge that the other symptoms swing on. In SWAN’s large screening survey, Kravitz and colleagues (Menopause, 2003) asked 12,603 women aged 40 to 55 across seven US sites about the previous two weeks. Overall, 38 percent reported sleep difficulty. The rate was highest in late perimenopause, at 45.4 percent, and in women who had a surgical menopause, at 47.6 percent.

Night sweats are the obvious culprit. The Menopause Society describes them simply as hot flashes that happen during sleep. But plenty of women wake at 3 a.m. with no sweat at all, wide awake and running through tomorrow’s list, and that pattern overlaps heavily with anxiety.

The treatment with the best non-drug evidence is cognitive behavioral therapy for insomnia, usually shortened to CBT-I. In a 2016 trial in JAMA Internal Medicine led by Susan McCurry at the University of Washington, a little over 100 Seattle-area women aged 40 to 65 with moderate insomnia and at least two hot flashes a day got six short phone sessions over eight weeks. Compared with a menopause education group, the CBT-I group slept meaningfully better and the improvement lasted. Their hot flashes did not become less frequent. They bothered them less.

CBT-I fixes the sleep, not the hormones. That is all it promises.

One caution. Loud snoring, gasping or morning headaches can point toward sleep apnea, which needs its own workup and is not solved by sleep hygiene tips.

Can menopause cause depression?

Perimenopause raises the risk of depression, including in women who have never been depressed. The Penn Ovarian Aging Study followed 231 women aged 35 to 47 with no history of depression for eight years. During the menopausal transition, they were more than four times as likely to score high on a depression symptom scale and more than twice as likely to be diagnosed with a depressive disorder as when they were premenopausal. Fluctuating FSH, LH and estradiol levels tracked with the symptoms.

The Menopause Society says women have double the rates of depression in these years, and that the women at highest risk are those with depressed mood earlier in life.

In 2018, The North American Menopause Society and the National Network of Depression Centers published the first guidelines for perimenopausal depression. The main points are practical. Antidepressants and talk therapy remain first-line treatment for a major depressive episode. Estrogen is not effective for depressive disorders after menopause, though hormone therapy can be considered when hot flashes and broken sleep are driving the low mood. Evidence is not strong enough to recommend botanical or alternative remedies for perimenopausal depression. The guideline’s co-lead, Pauline Maki, called perimenopause “a window of vulnerability.”

If you are having thoughts of suicide or self-harm, call or text 988 to reach the 988 Suicide and Crisis Lifeline, any time. In an emergency, call 911.

Does menopause cause memory loss?

It can cause real, measurable memory slips. It does not appear to cause lasting memory loss. That distinction comes from one of the most reassuring studies in this field. Gail Greendale’s SWAN team at UCLA gave 2,362 women aged 42 to 52 repeated memory and processing-speed tests over four years (published in Neurology, 2009). Normally people score better each time they repeat a test. In late perimenopause, that improvement in verbal memory was only 7 percent as large as it was in premenopause. After menopause, learning returned to premenopausal levels.

Greendale’s summary was blunt: “The good news is that the effect of perimenopause on learning seems to be temporary.”

Dementia worries are common at this stage and almost always misplaced. The Menopause Society notes that an Alzheimer diagnosis is very rare before 60. The more likely story is a brain short on sleep, running on anxiety, in a body whose hormones are unstable for a few years.

Can menopause cause brain fog?

Yes. According to The Menopause Society, 40 to 60 percent of midlife women report cognitive symptoms such as forgetfulness during the transition, and “brain fog” is the name most of them use.

Brain fog rarely travels alone. Sleep loss, low mood and hot flashes each blunt concentration, and The Menopause Society lists sleep changes and mood among the factors that shape midlife thinking. That is why treating the insomnia or the anxiety often clears the fog more than anything aimed at memory directly. The Society also says hormone therapy is not recommended to improve cognition in women who go through natural menopause.

What we cannot tell you is why one woman sails through these years with clear thinking and calm sleep while her sister, with similar hormone levels, struggles for five. Sensitivity to hormone swings seems to vary from person to person. Nobody can measure it in advance yet.

What helps perimenopause anxiety, sleep and mood

There is no single fix, and anyone selling one is overselling. What works is matching the treatment to the symptom that is driving the others.

• If night sweats are waking you, treating the hot flashes often improves sleep and mood together. The Menopause Society calls hormone therapy the most effective treatment for bothersome hot flashes, and it is not suitable for everyone, including women with a history of breast cancer, blood clots or cardiovascular disease. Non-hormonal options exist for women who cannot or prefer not to use it.
• If you lie awake with no sweats, CBT-I has the best evidence and does not depend on hormones.
• If low mood has lasted two weeks or more, antidepressants and talk therapy are first-line under the 2018 guidelines.
• If anxiety is the main problem, therapy, regular exercise and cutting back on alcohol and caffeine are reasonable starting points, and Cleveland Clinic notes growing evidence that hormone therapy can help emotional symptoms, though not severe mental health conditions on its own.

Keep a simple journal for six to eight weeks: cycle days, sleep, hot flashes, anxiety spikes and palpitations. It turns “I feel off” into a pattern a clinician can act on. Many women hesitate about hormone therapy because they are afraid of gaining weight, and we looked at whether HRT causes weight gain in a separate post. The short version is that the trials are more reassuring than the rumor.

Frequently asked questions

At what age does perimenopause anxiety usually start?

Usually in the 40s, as cycles start to change. The 2018 perimenopausal depression guidelines define perimenopause as roughly the three to four years before the final period plus the first year after it. In the SWAN anxiety study, women in early perimenopause were among those more likely to have high anxiety. Anxiety that starts before 40 alongside cycle changes is worth a medical check.

Can perimenopause cause panic attacks?

It can contribute to them. Cleveland Clinic notes that people prone to anxiety, or with a history of postpartum depression, may be more likely to develop panic disorder around menopause, though anyone can. Panic symptoms such as sweating and a racing heart overlap with hot flashes, which makes panic easy to miss. A clinician can help sort out which is which and treat both.

Does perimenopause anxiety go away after menopause?

For many women it eases, but not for everyone. In SWAN, women who first developed high anxiety during the transition still had higher odds of it after menopause than before. Women who were anxious long before perimenopause tended to stay anxious throughout. Waiting it out is a gamble, so it is worth treating anxiety that affects your work, sleep or relationships now.

Can hormone therapy help perimenopause anxiety?

Possibly, especially when hot flashes and night sweats are behind the anxiety and lost sleep. Cleveland Clinic describes growing evidence that hormone therapy can help emotional symptoms, but says it is not enough on its own for more severe conditions. The 2018 guidelines keep antidepressants and therapy as first-line for major depression. The right choice depends on your symptoms and health history.

When should I worry about palpitations in perimenopause?

Call 911 if palpitations come with chest pain, shortness of breath, fainting or feeling faint. See a clinician soon if they keep coming back, are becoming more frequent, last more than a few minutes, or you have a heart condition or a family history of one. Ask whether thyroid problems, anemia or a heart rhythm problem have been ruled out before assuming the cause is hormonal.

If perimenopause has brought anxiety, 3 a.m. wake-ups or a racing heart you cannot explain, it helps to talk it through with someone who looks at the whole picture. Dr. Drew Collins, ND, at Proactive Choice reviews your history, cycle and sleep, orders labs such as estrogen, progesterone and FSH, and talks through hormonal and non-hormonal options. Learn more about our menopause specialist in Bend, or book a free 15-minute call at +1 (858) 333-5196.

Sources

• The Menopause Society. Perimenopause.
• The Menopause Society. Mental Health.
• The Menopause Society. Hormone Therapy.
• Contemporary OB/GYN. Are menopausal women more anxious? (summary of Bromberger JT, et al., Study of Women’s Health Across the Nation, Menopause, 2013).
• Carpenter JS, et al. A systematic review of palpitations prevalence by menopausal status. Current Obstetrics and Gynecology Reports, 2021.
• NHS. Heart palpitations.
• Kravitz HM, et al. Sleep difficulty in women at midlife: a community survey of sleep and the menopausal transition. Menopause, 2003.
• ScienceDaily. Telephone-based CBT for insomnia in menopausal women, 2016 (McCurry SM, et al., JAMA Internal Medicine, 2016).
• American Family Physician. Tips from other journals (summary of Freeman EW, et al., Penn Ovarian Aging Study, Archives of General Psychiatry, 2006).
• ScienceDaily. Guidelines for the evaluation and treatment of perimenopausal depression, 2018 (Maki PM, Kornstein SG, et al., Menopause and Journal of Women’s Health).
• UCLA Health. Menopause transition may cause trouble learning (Greendale GA, et al., Neurology, 2009).
• Cleveland Clinic. Can menopause cause anxiety?
• 988 Suicide and Crisis Lifeline.

Medically reviewed content from Proactive Choice. This article is for education and is not a diagnosis. Talk with a licensed clinician about your own symptoms and treatment options.

Want to talk this through for your own health? Book a visit with Dr. Drew Collins, ND at 601 NW Harmon Blvd in Bend, or call (858) 333-5196.