What are mood changes?
We believe there are mood changes unique to perimenopause. These include:
- Feelings of anxiety, more nervous, worrying more, easily startled
- Feeling easily overwhelmed, less able to cope
- Volatile mood, irritability, or sudden anger
- Depressive symptoms like low feelings or tearfulness and crying spells
The mood changes were surprising until I realized that it was likely associated with perimenopause, I was wondering where it was coming from. I was anxious, which interfered with sleep; I had episodes where my irritability went from 0 to 60 in a matter of seconds, and I became easier to cry. It really helps to know that there is an explanation for why this is happening and that it is temporary and will pass.WLB Community Member
4 things to know about mood changes in perimenopause
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Perimenopause is a time of vulnerability for depression, particularly for those who have had a previous depressive episode. The risk of new-onset and recurrence of major depression goes away after the final menstrual period.
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Many people describe a change in their “ability to cope” or “fight or flight sensitivity” during perimenopause which we believe is distinct from general anxiety. Research demonstrates these symptoms are associated with estrogen fluctuations and changes in estradiol levels.
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Those with a history of adverse childhood events (ACEs), are more likely to experience mood changes in the years leading to menopause.
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The many roles we take on in midlife as caregivers, employees, partners, and volunteers can be a source of stress. But, the hormonal fluctuations of perimenopause are another cause of mood changes. It’s important to recognize both biological changes and life contexts as contributors to mood changes.
MOOD SYMPTOMS
Symptoms included in the 2020 Women Living Better survey
Anxiety/vigilance
- Feelings of anxiety, more nervous
- Waking in the middle of the night feeling panic, anxious, or worried
- Heart palpitations
- Easily overwhelmed, less able to cope
- Worrying more
- Panic attacks
- Can’t calm down on the inside, jumpy, startle easily
Volatile mood
- Irritability (e.g. short-tempered, grumpy, impatient with others)
- Sudden anger (e.g. raging feelings, fly off the handle)
- Sudden mood changes
Depressive symptoms
- Low feelings (e.g. sad, blue, depressed, down, blah)
- Tearfulness, crying spells
WLB 2020 SURVEY RESULTS
These data are from the Women Living Better Survey. LRS stands for the late reproductive stage and MT for the Menopause Transition. These are two stages on the path to menopause (the final menstrual period).
New feelings of anxiety, more nervous
% of respondents reporting symptoms
Overall Sample
0%
With Regular Periods
0%
Skipping Periods
0%
Easily Overwhelmed, Less Able to Cope
% of respondents reporting symptoms
Overall Sample
0%
With Regular Periods
0%
Skipping Periods
0%
New Irritability
% of respondents reporting symptoms
Overall Sample
0%
With Regular Periods
0%
Skipping Periods
0%
Low feelings
% of respondents reporting symptoms
Overall Sample
0%
With Regular Periods
0%
Skipping Periods
0%
Worry more
% of respondents reporting symptoms
Overall Sample
0%
With Regular Periods
0%
Skipping Periods
0%
New feelings of anxiety, more nervous
% of respondents reporting symptoms
Overall Sample
0%
With Regular Periods
0%
Skipping Periods
0%
Heart palpitations
% of respondents reporting symptoms
Overall Sample
0%
With Regular Periods
0%
Skipping Periods
0%
Wake at night, panic/anxious
% of respondents reporting symptoms
Overall Sample
0%
With Regular Periods
0%
Skipping Periods
0%
Sudden anger, rage
% of respondents reporting symptoms
Overall Sample
0%
With Regular Periods
0%
Skipping Periods
0%
Mood swings
% of respondents reporting symptoms
Overall Sample
0%
With Regular Periods
0%
Skipping Periods
0%
Can't calm down, startle easily
% of respondents reporting symptoms
Overall Sample
0%
With Regular Periods
0%
Skipping Periods
0%
Panic attacks/feeling panicky
% of respondents reporting symptoms
Overall Sample
0%
With Regular Periods
0%
Skipping Periods
0%
The best data comes from longitudinal studies
These findings come from lots of women over time, and show just how common mood changes are during perimenopause.
The Penn Ovarian Aging Study (POAS) showed the likelihood of anxiety was similar to that of depression in the menopause transition, and together with irritability and mood swings, anxiety peaked early in the transition.
In the Melbourne Midlife Health Study, 30% of women reported depression and “nervous tension” experiences in the last two weeks of their cycle.
The Study of Women’s Health Across the Nation (SWAN) reported that women with low anxiety prior to menopause may be susceptible to higher anxiety during and after the menopausal transition.
FEATURED RESEARCH
A paper combining results from 12 studies found that 45-68% of perimenopausal women report increased depressive symptoms as compared to 28-31% in premenopause.
Maki PM, et al. Guidelines for the Evaluation and Treatment of Perimenopausal Depression: Summary and Recommendations.
When the speaker asked the room of menopause health care providers, “How many of you see patients presenting with just anxiety?” a huge percentage of hands went up.Observation from the Menopause 101 Course, Chicago IL, September 2019
I am so much more irritable lately — and not just in the week before my period. I’m cranky for 2-3 weeks of the month! I really don’t feel like myself.WLB Community Member
FEATURED POLL
Mood Changes
RESEARCH HIGHLIGHT
Anxiety in menopause is a different type of anxiety.
In Dr. Bremer’s research, the anxiety experiences described were not consistent with Generalized Anxiety Disorder.
A focus group with 20 women yielded these findings:
- The anxiety experiences described were not consistent with Generalized Anxiety Disorder as defined in the DSM Manual.
- The anxiety symptoms might occur randomly or in response to a stressful event.
- Some anxiety experiences were short-lived (minutes to hours) and others felt a more ongoing, mild sense of unease.
- Many participants reported waking up frequently and once awake becoming aware of mind racing and experiencing an “unnerving feeling” unable to put a finger on the cause.
Anxiety and panic attacks [are new]. I just recently started to get panic attacks and I documented when they are occurring and it only occurs when ovulating but not necessarily every month.WLB Community Member
Remedies to Consider
NOTE: Most of these data are studied in the adult population at large and not specifically studied in perimenopausal populations. It’s noted where there is research specific to perimenopause.
BEHAVIORAL OPTIONS
Cognitive Behavioral Therapy (CBT) for anxiety
A 2012 review of meta-analyses (106 meta-analysis) of the effectiveness of CBT for a variety of conditions concluded that the base of evidence was strong. Specifically, the review found that the strongest support was for anxiety disorders, somatoform disorders, bulimia, anger control problems, and general stress.
Cognitive Behavioral Therapy (CBT) for depression
A very large 2023 meta-analysis that included 409 trials concluded that CBT was as effective as medication in the short-term but more effective in the longer term for depression.
Psychotherapy
Psychotherapy is an effective option for both depression and anxiety.
Breath work for anxiety and stress
A study that looked at the impact of breathwork on mood, anxiety and physiological arousal — defined by respiratory rate, heart rate, and heart rate variability — outcomes, found that 5 minutes a day had benefit. We wrote this post explaining this research in more detail.
Exercise for anxiety
Both aerobic exercise and resistance training have been shown to be effective for anxiety in randomized controlled trials and a meta-analysis.
Exercise for depression
A 2022 systematic review and meta-analysis concluded that there were significant mental health benefits from being physically active with respect to depression. Further, the authors noted this was true at physical activity levels below public health recommendations.
Qi Gong for stress and anxiety
In a meta-analysis that included 7 studies qi gong exercise was found to reduce stress and relieve anxiety.
MANY MODALITIES WORK
A 5-week trial in 76 people compared physical activity, mindfulness meditation, and heart rate variability biofeedback. All three modalities showed benefits in stress reduction, improvement in anxiety and depressive symptoms, and enhanced psychological well-being and sleep quality.
THERAPEUTIC (PRESCRIPTION) OPTIONS
Prescriptions for anxiety
Anti-depressants (SSRIs, SNRIs)
Anti-anxiety medications, benzodiazepines
Options for depression
Anti-depressants (SSRIs, SNRIs)
Studies show estrogen can benefit perimenopausal depression, but estrogen does not benefit women who are postmenopausal. Estrogen is not approved by the FDA to treat depression.
Oral contraceptives or an estradiol patch with a progestin IUD are sometimes used in perimenopausal women with vasomotor symptoms. Neither has been studied with respect to depression.
FEATURED RESOURCES
Interesting Findings: Small Studies
Higher estrogen can lead to a heightened stress response. A study took two groups of college-aged men and asked them to perform stressful tasks — public speaking and math. One group was given estrogen before performing the tasks, and the other a placebo. In the estrogen group, stress response as measured by cortisol levels, ACTH, and epinephrine increased versus placebo.12 So, if you are feeling like you can’t cope as well as you used to, or generally feel more fragile, the erratic levels of estrogen during perimenopause could be the culprit!
Carbs improve mood in days before your period (luteal phase). A small study at MIT found that “consumption of a carbohydrate-rich, protein-poor evening test meal during the late luteal phase of the menstrual cycle improved depression, tension, anger, confusion, sadness, fatigue, alertness, and calmness scores (p < 0.01) among patients with premenstrual syndrome”. So, if you experience dysphoria (altered mood) and crave carbs right before your period, there is a biological basis for it.14
Estrogen and Progesterone Play a Role. A 2020 study found that fluctuations in estrogen and low levels of progesterone resulting from anovulation (not ovulating) were associated with more severe depressive symptoms in those whose cycles had begun to noticeably change in length.
Our data suggest that exercise is effective in improving anxiety symptoms in people with a current diagnosis of anxiety and/ or stress-related disorders. Taken together with the wider benefits of exercise on wellbeing and cardiovascular health, these findings reinforce exercise as an important treatment option in people with anxiety/stress disorders.Stubbs B, et al. An examination of the anxiolytic effects of exercise for people with anxiety and stress-related disorders: A meta-analysis.
REFERENCES
- Freeman EW, Sammel MD, Lin H, et al. Associations of hormones and menopausal status with depressed mood in women with no history of depression. Arch Gen Psychiatry. 2006;63:375–382.
- Dennerstein L, Dudley EC, Hopper JL, Guthrie JR, Burger HG. A prospective population-based study of menopausal symptoms. Obstet Gynecol. 2000 Sep;96(3):351-8.
- Joyce T. Bromberger, Ph.D.Howard M. Kravitz, D.O., M.P.H. Yuefang Chang, Ph.D. John F. Randolph, Jr., M.D., Nancy E. Avis, Ph.D., Ellen B. Gold, Ph.D. and Karen A. Matthews, Ph.D. Does Risk for Anxiety Increase During the Menopausal Transition? Study of Women’s Health Across the Nation (SWAN) Menopause. 2013 May; 20(5): 488–495.
- Freeman EW, Sammel MD, Lin H, et al. Symptoms in the menopausal transition: hormone and behavioral correlates. Obstet Gynecol 2008;111(1):127–36.
- Joffe, H, de Wit, A, Coborn, J, et al. Impact of Estradiol Variability and Progesterone on Mood in Perimenopausal Women With Depressive Symptoms. J Clin Endocrinol Metab, March 2020, 105(3):e642–e650
- Breymeyer, Kara L. et al. “Subjective Mood and Energy Levels of Healthy Weight and Overweight/Obese Healthy Adults on High-and Low-Glycemic Load Experimental Diets.” Appetite 107 (2016): 253–259. PMC. Web. 15 Sept. 2018.
- Ulka Agarwal, MD, Suruchi Mishra, PhD, Jia Xu, PhD, Susan Levin, MS, RD, Joseph Gonzales, RD, and Neal D. Barnard, MD. A Multicenter Randomized Controlled Trial of a Nutrition Intervention Program in a Multiethnic Adult Population in the Corporate Setting Reduces Depression and Anxiety and Improves Quality of Life: The GEICO Study. American Journal of Health Promotion. Vol 29, Issue 4, pp. 245 – 254. First Published March 1, 2015.
- Stefan G. Hofmann, Ph.D., Anu Asnaani, M.A., Imke J.J. Vonk, M.A., Alice T. Sawyer, M.A., and Angela Fang, M.A. The Efficacy of Cognitive Behavioral Therapy: A Review of Meta- analyses. Boston University, Boston, MA Cognit Ther Res. 2012 October 1; 36(5): 427–440. doi:10.1007/s10608-012-9476-1.
- Crush EA, Frith E, Loprinzi PD. Experimental effects of acute exercise duration and exercise recovery on mood state. J Affect Disord. 2018 Mar 15; 229:282-287. doi: 10.1016/j.jad.2017.12.092. Epub 2018 Jan 3.
- Slyepchenko A, Carvalho AF, Cha DS, Kasper S, McIntyre RS. Gut emotions – mechanisms of action of probiotics as novel therapeutic targets for depression and anxiety disorders. CNS Neurol Disord Drug Targets. 2014;13(10):1770-86.
- Park C, Brietzke E, Rosenblat JD, Musial N, Zuckerman H, Ragguett RM, Pan Z, Rong C, Fus D, McIntyre RS. Probiotics for the treatment of depressive symptoms: An anti-inflammatory mechanism? Brain Behav Immun. 2018 Oct;73:115-124. doi: 10.1016/j.bbi.2018.07.006. Epub 2018 Jul 18.
- Woelk H, Schläfke S. A multi-center, double-blind, randomised study of the Lavender oil preparation Silexan in comparison to Lorazepam for generalized anxiety disorder. Phytomedicine. 2010 Feb;17(2):94-9.
- Kirschbaum, C. et al. Short-term estradiol treatment enhances pituitary-adrenal axis and sympathetic responses to psychosocial stress in healthy young men. J Clin Endocrinol Metab. 1996 Oct; 81(10):3639-43.
- Wurtman, Judith J. et al. Effect of nutrient intake on premenstrual depression. American Journal of Obstetrics & Gynecology , Volume 161 , Issue 5 , 1228 – 1234
- Borrow AP, Handa RJ. Estrogen Receptors Modulation of Anxiety-Like Behavior. Vitam Horm. 2017;103:27-52. doi: 10.1016/bs.vh.2016.08.004. Epub 2016 Oct 13. PMID: 28061972; PMCID: PMC5815294.
- Stubbs B, Vancampfort D, Rosenbaum S, Firth J, Cosco T, Veronese N, Salum GA, Schuch FB. An examination of the anxiolytic effects of exercise for people with anxiety and stress-related disorders: A meta-analysis. Psychiatry Res. 2017 Mar;249:102-108. doi: 10.1016/j.psychres.2016.12.020. Epub 2017 Jan 6. PMID: 28088704.
- Vancampfort D, Heissel A, Waclawovsky A, Stubbs B, Firth J, McGrath RL, Van Damme T, Schuch FB. Precision-based exercise in people with anxiety and stress related disorders: Are there interindividual differences in anxiolytic effects? An ancillary meta-analysis of randomized controlled trials. Psychiatry Res. 2022 Nov;317:114803. doi: 10.1016/j.psychres.2022.114803. Epub 2022 Aug 20. PMID: 36027821.
- Wang CW, Chan CH, Ho RT, Chan JS, Ng SM, Chan CL. Managing stress and anxiety through qigong exercise in healthy adults: a systematic review and meta-analysis of randomized controlled trials. BMC Complement Altern Med. 2014 Jan 9;14:8. doi: 10.1186/1472-6882-14-8. PMID: 24400778; PMCID: PMC3893407.
- Balban MY, Neri E, Kogon MM, Weed L, Nouriani B, Jo B, Holl G, Zeitzer JM, Spiegel D, Huberman AD. Brief structured respiration practices enhance mood and reduce physiological arousal. Cell Rep Med. 2023 Jan 17;4(1):100895. doi: 10.1016/j.xcrm.2022.100895. Epub 2023 Jan 10. PMID: 36630953; PMCID: PMC9873947.
- Pearce M, Garcia L, Abbas A, Strain T, Schuch FB, Golubic R, Kelly P, Khan S, Utukuri M, Laird Y, Mok A, Smith A, Tainio M, Brage S, Woodcock J. Association Between Physical Activity and Risk of Depression: A Systematic Review and Meta-analysis. JAMA Psychiatry. 2022 Jun 1;79(6):550-559. doi: 10.1001/jamapsychiatry.2022.0609. PMID: 35416941; PMCID: PMC9008579.
- Cuijpers P, Miguel C, Harrer M, Plessen CY, Ciharova M, Ebert D, Karyotaki E. Cognitive behavior therapy vs. control conditions, other psychotherapies, pharmacotherapies and combined treatment for depression: a comprehensive meta-analysis including 409 trials with 52,702 patients. World Psychiatry. 2023 Feb;22(1):105-115. doi: 10.1002/wps.21069. PMID: 36640411; PMCID: PMC9840507.
- Lee DY, Andreescu C, Aizenstein H, Karim H, Mizuno A, Kolobaric A, Yoon S, Kim Y, Lim J, Hwang EJ, Ouh YT, Kim HH, Son SJ, Park RW. Impact of symptomatic menopausal transition on the occurrence of depression, anxiety, and sleep disorders: A real-world multi-site study. Eur Psychiatry. 2023 Sep 12;66(1):e80. doi: 10.1192/j.eurpsy.2023.2439. PMID: 37697662; PMCID: PMC10594314.
- Kornstein SG, Jiang Q, Reddy S, Musgnung JJ, Guico-Pabia CJ. Short-term efficacy and safety of desvenlafaxine in a randomized, placebo-controlled study of perimenopausal and postmenopausal women with major depressive disorder. J Clin Psychiatry. 2010;71(8):1088–1096. doi: 10.4088/JCP.10m06018blu.
- Hofmann SG, Asnaani A, Vonk IJ, Sawyer AT, Fang A. The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-analyses. Cognit Ther Res. 2012 Oct 1;36(5):427-440. doi: 10.1007/s10608-012-9476-1. Epub 2012 Jul 31. PMID: 23459093; PMCID: PMC3584580.
- Eleanor Bremer, Nancy Jallo, Beth Rodgers, Patricia Kinser, Natalie Dautovich, Anxiety in Menopause: A Distinctly Different Syndrome?, The Journal for Nurse Practitioners, Volume 15, Issue 5, 2019, Pages 374-378, ISSN 1555-4155, https://doi.org/10.1016/j.nurpra.2019.01.018.