Menopause and Your Mood: How Shifting Hormones Influence Mental Health

If your once sunny—or at least steady—mood is darker and less predictable lately, don’t simply chalk it up to stress, pandemic burnout, or a world full of annoying people. All those things and plenty more may contribute to rollercoaster emotions, and midlife can be a relentlessly busy and complicated time (we won’t argue with you on that). But feeling downright gloomy or consistently “off” compared to your norm could mean there’s something more at play.

It’s always important to look for the root cause of mood swings, irritability, depression, and anxiety—and what many women don’t realize is that the hormonal changes that occur during perimenopause and menopause can contribute to all of these symptoms (plus dozens of others, some truly unexpected). As many as 70 percent of menopausal women deal with mood fluctuations, from feeling a little weepy to full-blown rage, and understanding the role of hormones is the first step to getting help and regaining your emotional balance.

Below, we cover the relationship between hormones and mood, plus the ways Midi practitioners take a full-body approach to treating common midlife issues like depression and anxiety.

How Fluctuating Hormones Mess With Your Mood

Hormones fluctuate significantly during perimenopause—the transition phase leading up to menopause—which typically kicks off in a woman’s mid-40s. At the start of this phase, estrogen and progesterone levels start relatively high and gradually taper off, with sometimes dramatic peaks and dips along the way, until they reach their lowest point at menopause. Along with triggering irregular menstrual periods (before your period eventually stops altogether), these hormonal ups and downs may also cause mood swings and make it harder to cope with pressures that once felt perfectly manageable. 

To understand the impact of hormonal changes on mood, it’s important to understand how hormones work in the body. Among other things, estrogen interacts with the central nervous system to help stimulate the production of “feel good” brain chemicals and increase their effects.  Called neurotransmitters, these chemicals include norepinephrine and serotonin, which play a key role in mood stabilization and concentration. In fact, low levels of neurotransmitters have been associated with depressed mood. 

What’s the connection? Fluctuating and declining estrogen during the menopause transition may interfere with the normal output of serotonin and norepinephrine—potentially decreasing levels of these hormones in the brain. Less estrogen also means fewer serotonin receptors are produced, dimming its mood-boosting benefits. Together, these factors bring on mood changes for many women during this period. 

To be clear, not all hormone-induced mood changes qualify as full-blown depressive or anxiety disorders, which are characterized by a specific set of symptoms that last for a minimum period of time and truly disrupt your normal day-to-day functioning. More commonly, women notice less severe, but still disconcerting, symptoms that come and go.  You might relate to a few of these: crying at the drop of a hat (over everything from spilled whatever to a friend’s casual teasing), blowing up at your partner or kids over little irritations, or struggling to manage deadlines at work. 

Perimenopause and menopause also come with a host of additional symptoms—also driven by hormonal shifts—that may impact mental health. For example, hot flashes affect up to 80% of women and can be associated with heart palpitations, fatigue, and anxiety. It’s not surprising that daily life might seem like an emotional minefield to women dealing with uncontrolled temperature spikes that sometimes come with a racing heart, anxious thoughts, and what some women call feelings of dread. Night sweats—the nocturnal form of hot flashes—can also reduce sleep quality, sometimes dramatically. You probably know from experience how just one night of poor sleep can make it hard to feel upbeat or regulate your emotions (even with a hefty dose of caffeine), so it follows that consistently wrecked sleep over time has been associated with a lower overall quality of life and can double the risk for depression. Throw in the grab-bag of other challenges that may pop up in perimenopause and menopause—from brain fog and painful sex to thinning hair and drier, older-looking skin—and it’s little wonder so many women feel far from their “normal” selves.

Of course, some contibutors to mood changes have nothing to do with menopausal hormone changes. That’s why, at Midi, we take a comprehensive look at other biological markers that affect mental wellbeing such as thyroid hormones and levels of key nutrients such as vitamin D and vitamin B12, to help you take personalized steps to support your mood.

Depression: How it Feels & What Can Help

Depression affects a huge number of women at midlife, and research suggests the hormonal shifts of menopause are a driving factor. A woman is up to three times more likely to experience a depressed mood during the menopausal transition than during perimenopause. To appreciate the scale of the problem, just look at the number of women who are medicated for depression: 20% of women between the ages of 40 and 59 and 25% of women over age 60 took antidepressants within the past 30 days, per a recent national survey. These are double the rates for men of the same age.

As mentioned earlier, estrogen helps to support the production and function of neurotransmitters, like serotonin, which help keep mood stable. When estrogen fluctuates and declines, those neurotransmitter levels are thrown off along with it, potentially contributing to depression. Understanding this hormonal component of depression is incredibly beneficial — not only does it make you realize you’re not alone and that your symptoms may have a concrete and natural cause, it can also help guide optimal treatment. 

A history of depression factors into your risk, too. In a study published by the Journal of The North American Menopause Society, resercher Ellen W. Freeman, PhD, explains: “Women with a history of depression are nearly five times more likely to have a diagnosis of major depression in the menopausal transition, whereas women with no history of depression are two to four times more likely to report depressed mood compared with premenopausal women.”

What does depression feel like?

The answer to that question is different for every woman. We associate depression with sadness, but it may also show up as feeling unmotivated, or unworthy of anything positive in your life (be it a relationship, a job, or positive feedback). Daily activities that helped you feel upbeat before might barely measure on the pleasure scale. Unlike typical sadness, though, depression often feels hopeless and all-consuming. Imagine a sense of being stuck in emotional quicksand that’s gradually sapping you of your life force and happiness, where even the smallest amount of forward progress feels impossible. It can also be a true mind/body experience, with symptoms including exhaustion and excessive sleeping, aches and pains with no clear cause, or changes in eating and sleeping patterns. 

Just as depression comes with a variety-pack of feelings, it also spans a spectrum of severity (the official terms are subclinical, mild, moderate, moderately severe, or severe). Determining where you fall on that spectrum helps to pinpoint the best treatment. Midi incorporates the PHQ-9 depression screening tool into every patient’s health questionnaire to guide clinicians in making an accurate diagnosis and tailoring your Care Plan. Someone with subclinical or mild depression, for example, may have depressive symptoms that respond well to psychotherapy, exercise, and botanical supplements, while symptoms of moderate to severe depression may require prescription medication combined with those and other therapies.

A whole-body approach to depression treatment

There’s comfort in this: Depression related to menopausal hormone shifts doesn’t usually follow you very far beyond menopause. But for many women, the menopause transition lasts a decade or more—far too long to wait if you’re depressed. So it’s important to explore the range of treatments that can help. Midi considers all of the below, and combines them in a Care Plan that’s personalized for each patient. 

• Lifestyle changes: Daily habit changes can have a hugely positive impact on mood, which is why Midi practitioners often start with lifestyle coaching. That involves collaborating with each patient to identify helpful (and realistic) changes to her sleep, exercise, eating, and stress management routines. Regular exercise, for example, has been shown to help alleviate even treatment-resistant depression, while yoga and mindfulness meditation are also beneficial as a stand-alone solution, or added to other therapies. Research suggests that scaling back on added sugars and refined carbohydrates in favor of more whole and minimally processed foods (the basics—fruits, veggies, nuts, whole grains, lean meats, fish) may also curb depression risk by keeping blood sugar stable. The thinking: When you eat lots of sugar, your blood glucose levels initially spike and then drop off significantly. This drop may then cause a temporary shortage of glucose in the brain, leading to poor mood and fatigue. To compensate, your body pumps out hormones like cortisol and adrenaline, which can trigger anxiety and irritability. But, with a balanced diet, you can avoid this blood sugar rollercoaster.
• Wellness therapies: A variety of wellness (aka integrative therapies) can support a balanced mood, including cognitive behavioral therapy (CBT), acupuncture, and light therapy. In one study on women suffering from hot flashes and night sweats, CBT—a form of psychotherapy that involves challenging negative thought patterns—effectively improved these symptoms along with mood, quality of life, and emotional functioning. Light or lightbox therapy, which mimics the mood-boosting effect of sunlight and helps balance circadian rhythms, and weekly acupuncture, are also effective for depression when layered on with other treatments. (Midi’s care coordination team can help with referrals to appropriate practitioners for these therapies.)
• Botanicals and supplements: Evidence suggests several botanicals and nutritional supplements may improve depressive symptoms, including the amino acid SAM-e , omega-3 fatty acids, and St. John’s Wort. St. John’s Wort, for example, contains active compounds (hyperforin and hypericin) that modulate the neurotransmitters dopamine, serotonin, and norepinephrine, and some studies suggest it has similar effects to conventional SSRI antidepressant medications (more about those below) for mild to moderate depression. These are valid options to consider, particularly if you’ve had a poor response to prescription medication, or want to avoid it.  
• Prescription medications: Natural approaches are always worth exploring, but sometimes prescription treatments are necessary—and Midi practitioners can help you safely explore your options. SSRIs (selective serotonin reuptake inhibitors) are the most commonly prescribed antidepressants for moderate to severe depression. They work by blocking the reabsorption of serotonin into neurons, which increases levels of mood-stabilizing serotonin in the brain. While SSRIs are a valuable tool, some experts feel that they’re prescribed too quickly, before trying other options. Given the strong connection between women’s midlife hormone shifts and depression, hormone replacement therapy (HRT) could be a more effective way to address the root cause. The research suggests HRT alleviates menopause-related depressive symptoms, and a combination of SSRIs and HRT may move the needle for severe depression.  

Anxiety: How it Feels & What Can Help

Anxiety is another common problem during the menopause transition—as many as 51% of women experience symptoms. As with depression, fluctuating estrogen is a likely suspect when looking for a root cause, especially for women experiencing anxiety for the first time in their lives. When estrogen see-saws and declines, serotonin—the neurotransmitter responsible for stabilizing mood—declines with it, and the brain has fewer chemical tools to cope with stressors, which can result in anxiety. Additionally, hot flashes can kick off or worsen anxious thinking. 

What does anxiety feel like?

Anxiety is a general term that refers to a variety of disorders with different symptoms, such as generalized anxiety (excessive and uncontrollable worry, irritability, difficulty sleeping), panic disorder (suddenly feeling fearful for no reason), social anxiety (fear of social or performance situations), and obsessive compulsive disorder (unwanted, repetitive thoughts). Often, anxiety is used to describe unrelenting nervousness and worry, but it can also cause physical symptoms such as shaking, heavy breathing, and heart palpitations. 

While it can manifest a bit differently for everyone, some women describe anxiety as being stuck under a rain cloud of negative thoughts and self-judgment wherever they go, sometimes coupled with full-body tension, stabbing sensations or tightness in the chest, and feelings of restlessness or wanting to jump out of their skin. Others say it’s almost like an imposter has taken over their body, rendering them incapable of functioning as their “normal,” steady, and relatively social self. During perimenopause, anxiety can also cause hot flashes — which, in turn, can trigger even more restlessness and irritability, creating a vicious cycle. 

At Midi, our practitioners incorporate the GAD-7 anxiety screening tool into every patient’s health questionnaire to help make a diagnosis and identify severity to better tailor your treatment plan.

A whole-body approach to anxiety treatment

There are a variety of effective ways to help you feel less frazzled or on-edge, depending on the severity of your anxiety. You’ll notice many similarities to the strategies for depression.

• Lifestyle changes: As with depression, lifestyle interventions can make a huge difference for anxiety—and Midi practitioners work with you on doable changes to your habits around exercise, mindfulness, healthy sleep, and a balanced diet. One key recommendation: Moderate your caffeine and alcohol intake, both of which can trigger anxiety. While alcohol can temporarily ease social anxiety, it can increase anxious feelings and irritability hours later or even the next day. Eating mostly whole and minimally processed foods is also a smart preventative step, since fluctuating blood sugar from a diet heavy on sugar or refined carbohydrates can drive hot flashes, which often go hand in hand with anxiety. Another biggie: Getting enough exercise (particularly aerobic exercise), which fights anxiety on multiple fronts. Moving your body, whether it’s a basic power-walk or a full-on workout, decreases muscle tension, distracts from anxious thoughts, boosts levels of anxiety-busting brain chemicals such as serotonin and  gamma aminobutyric acid (GABA), and promotes quality sleep, all while benefiting nearly every other aspect of your health. 
• Wellness therapies: CBT (again, that’s a form of psychotherapy that involves challenging negative thought patterns) has been found effective for a range of anxiety disorders, including generalized anxiety disorder, panic disorder, and social anxiety. It’s also associated with improvements in quality of life for anxious patients. Light or lightbox therapy and acupuncture can also help elevate mood and calm anxiety. Additionally, research suggests CBT, hypnosis, and acupuncture are all effective for reducing symptoms of hot flashes, which may, in turn, reduce anxiety symptoms. Midi’s care coordinator team can help with referrals to appropriate practitioners for these therapies.
• Botanicals and supplements: Evidence suggests several botanicals and nutritional supplements may alleviate anxiety symptoms, including magnesium glycinate, L-theanine, ashwagandha, and lavender—all solutions Midi practitioners recommend, when appropriate. Magnesium and L-theanine, for example, both help promote relaxation and quality sleep. Ashwagandha is an adaptogen, or, essentially an herb that supports the body's ability to deal with stress, and lavender can be used as a form of aromatherapy or taken in capsule form to calm your nerves. 
• Prescription medications: Research suggests HRT is a good option for mild anxiety symptoms. Additionally, HRT is the most effective treatment for the menopausal vasomotor symptoms, or hot flashes, that often drive anxiety. Depending on the severity of your symptoms, SSRIs such as escitalopram (or Lexapro) may also be appropriate. While SSRIs are the most commonly prescribed class of medication for anxiety, a variety of alternatives—gabapentin, hydroxyzine, and buspirone (or Xanax)—can also offer relief when given in relatively low doses.‍

Mood problems in midlife are complex, clearly, so seek care from Midi or another provider who understands the hormonal forces at work in your emotional wellbeing at midlife, and looks at the whole you—including your diet, sleep, exercise habits, and your personal situation. You don’t have to tough out mood symptoms. You deserve to feel better, and with expert care, you can. 

Note of warning: If you are suffering from severe depression or anxiety, or are having any thoughts about harming yourself or others, get care immediately. You can call the National Suicide Prevention Lifeline: 988. Additional information can be found here.