Perimenopause and mental health: Anxiety, mood, sleep and brain fog

If you are in your 40s or early 50s and feel more anxious, flat, irritable or foggy than you used to, and your sleep is unravelling, perimenopause may be part of the explanation. It may not be all of it, because midlife mood changes usually have more than one cause.

This guide is for women and anyone else going through the menopause transition, including trans and gender-diverse people. Most research describes its participants as women, so we use that word when reporting studies.

It covers what is common, why emotional symptoms are easily missed, how expected changes differ from depression or an anxiety disorder, which treatments have evidence, and when to get help.

What perimenopause is, and why mood is part of it

Jean Hailes for Women’s Health describes perimenopause as the time from when your periods start changing, or menopausal symptoms begin, until one year after your final period.⁶ In Australia it usually starts at around 47 and lasts four to six years on average.⁶

Besides hot flushes and night sweats, menopause can affect sleep, mental health, memory and concentration.⁶ In the Jean Hailes National Women’s Health Survey, more than 1 in 2 women in Australia who had menopausal symptoms in the previous five years said their mental and emotional wellbeing had been affected.⁶

The Australasian Menopause Society (AMS) notes that the risk of mood changes and symptoms of depression and anxiety is higher during perimenopause, even in women with no history of major depression, and that unstable oestrogen levels can affect the brain.¹ In one eight-year study of women with no history of depression, high depressive symptom scores were more than four times as likely during the transition as before it, and a diagnosed depressive disorder two and a half times as likely (Freeman et al., 2006).⁴

Common emotional and thinking changes

• Mood: mood swings, or feeling more irritable, angry or sad than usual.⁶
• Anxiety: worry, feeling on edge, and for some people panic attacks.
• Energy: lower motivation and self-esteem.
• Sleep: trouble getting to sleep, staying asleep or waking too early. Jean Hailes estimates this affects around 1 in 2 women during perimenopause and after menopause.⁶
• Brain fog: poor concentration, forgetfulness, losing your train of thought, struggling to find words or slower thinking.⁶

These feed each other. Night sweats break up sleep, poor sleep has been linked with mood problems, and stress and anxiety can influence hot flushes.⁶ Reassuringly, Jean Hailes notes that for most women emotional wellbeing improves closer to the final period and after menopause.⁶

Why it can be missed or misread

• The symptoms overlap. Tiredness, poor concentration, broken sleep and irritability can come from menopausal changes, depression, anxiety or a mix. The AMS notes that hot flushes, sleep disturbance and brain fog overlap with mental health symptoms.¹
• Midlife is busy. Caring roles, work and relationship changes, illness and a changing body all affect mood, so it is easy to blame stress.
• The first signs can be psychological. Evidence to the Senate inquiry into menopause and perimenopause noted that brain fog and mental health changes can be among the first signs of menopause.⁸
• It is still under-discussed. The committee’s September 2024 report found that menopause is rarely discussed and is stigmatised, and heard that uncertainty about which symptoms come from menopause is a major barrier to diagnosis and care.⁸

Misreading goes both ways. Depression or an anxiety disorder can be waved away as “just hormones”, or anxiety treated without anyone asking about perimenopause. As Jean Hailes puts it, menopause might be responsible for some, all or none of the changes.⁶

Expected changes, or depression or an anxiety disorder?

No simple test separates these, and they can happen together. Ask how long it has lasted, how much it gets in the way of daily life, and whether it lifts on easier days.

Changes that are common in the transition

• Moods that shift more than they used to, often worse after a bad night.
• Worry that comes and goes without taking over your days.
• Forgetfulness that is frustrating but does not stop you managing work or home.
• Still enjoying things and feeling close to people, even if it takes more effort.

Signs it may be depression

The AMS describes how some women have more severe depressive symptoms, including thoughts of suicide, lasting at least two weeks. This is a major depressive episode, and it is more likely in women who have had major depression before.¹ Watch for low mood or loss of interest most days for two weeks or more, feeling hopeless or worthless, withdrawing from people, or thoughts of not wanting to be alive. Our article on depression versus sadness explains more.

Signs it may be an anxiety disorder

Worry that is hard to switch off most days, panic attacks or dread of the next one, avoiding situations such as driving or social events, and needing constant reassurance all deserve attention, whether or not hormones are involved. Both anxiety treatment and depression treatment focus on what you are living with now.

If you have a past history of anxiety, depression or premenstrual syndrome (PMS), or your menopause followed surgery or came early, it is worth watching for these signs.¹⁶

Psychological approaches with evidence

The AMS notes that treatments shown to help in the wider population, including psychological therapy, also suit menopause-related mental health symptoms, alongside basics such as physical activity, protecting sleep, easing stress and limiting alcohol.¹ Two forms of cognitive behavioural therapy have been tested specifically around menopause.

CBT for menopausal symptoms

CBT looks at the links between thoughts, behaviour, body sensations and mood. Versions adapted for menopause, such as CBT-Meno, add information about the transition and strategies for hot flushes, mood, anxiety, sleep and sexual concerns.⁵

• In the MENOS 2 trial of 140 women with troublesome hot flushes and night sweats, both group CBT and guided self-help CBT reduced how problematic these felt compared with no treatment at 6 and 26 weeks, and mood and quality of life improved at 6 weeks (Ayers et al., 2012).²
• In a trial of 71 women, CBT-Meno led to greater improvement than a waitlist in hot flush interference, depressive symptoms, sleep difficulties and sexual concerns, with gains holding three months later; the effect on anxiety was less clear (Green et al., 2019).⁵

These trials are modest in size, and CBT aims to ease the impact of symptoms rather than remove them.

CBT for insomnia (CBT-I)

CBT-I targets the habits and thoughts that keep insomnia going. In a trial of 106 women aged 40 to 65 with insomnia and daily hot flushes, six telephone sessions over eight weeks, including sleep restriction, stimulus control and cognitive strategies, improved insomnia more than menopause education did, and the difference lasted to 24 weeks.⁷ Hot flushes were no less frequent, but women who had CBT-I said they interfered less with daily life (McCurry et al., 2016).⁷ Read more about sleep and mental health and treatment for insomnia.

The GP’s role: medical assessment and options

A GP is usually the first stop. The AMS suggests an individual assessment covering your stage of perimenopause, physical and thinking symptoms, past and current mental health, sleep and exercise, and pressures such as caring roles, work and illness.¹ Your GP can also look for other contributors, such as low iron if heavy periods leave you very tired, or sleep apnoea and restless legs if sleep is poor.⁶

Options may include lifestyle changes, psychological therapy and medicines such as menopausal hormone therapy (MHT) or antidepressants.¹ Whether any medicine suits you is a medical decision made with your doctor, based on your symptoms, health history and preferences. Psychologists do not prescribe, and therapy can run alongside whatever medical plan you choose.

A few weeks of notes on sleep, mood, hot flushes and periods can help, and Jean Hailes has a symptom checklist you can take along.⁶

When and how to get help

Jean Hailes suggests seeing your doctor if symptoms are interfering with work, relationships or daily life, or if you are worried about your emotional or mental health.⁶ Also book in if:

• low mood, worry or irritability has been there most days for two weeks or more;
• you are having panic attacks or avoiding things because of anxiety;
• familiar signs of past depression or anxiety are returning;
• poor sleep has gone on for weeks and is wearing you down.

If you have thoughts of suicide or feel unsafe, get help the same day. Our urgent help page lists where to go.

Your GP can talk with you about a Mental Health Treatment Plan (often called a mental health care plan) for Medicare rebates on psychology sessions. Since 1 November 2025, the plan generally needs to come from your MyMedicare registered practice or your usual doctor (Department of Health, Disability and Ageing, 2025).³

At Mind Health we see people in Parramatta and by telehealth for anxiety, low mood and sleep difficulties, including around menopause; you can read about individual therapy.

Frequently asked questions

Can perimenopause cause anxiety if I have never had it before?

It can. The Australasian Menopause Society notes that the risk of mood changes and symptoms of depression and anxiety rises during perimenopause, even in women with no past history of major depression. New anxiety in midlife is still worth discussing with a GP, as sleep, health and life pressures can contribute.

Is brain fog a real perimenopause symptom?

Yes. Many women describe trouble concentrating, forgetfulness, losing their train of thought or struggling to find words. Poor sleep and low mood can affect thinking too. If memory changes are marked, getting worse or worrying you, see your GP so other causes can be checked.

How can I tell if it is depression or just perimenopause?

The two overlap and can happen together. Low mood or loss of interest lasting two weeks or more, hopelessness, withdrawing from people, struggling to manage daily life, or thoughts of suicide all point towards depression. A GP or psychologist can help you work out what is going on.

Should I see my GP or a psychologist first?

A GP is usually a sensible first step. They can look at your stage of perimenopause, check for other causes, talk through medical options and, where appropriate, prepare a Mental Health Treatment Plan for Medicare rebates on psychology sessions. Many people see both.

Where does menopausal hormone therapy fit in?

Menopausal hormone therapy is a medical treatment, and whether it suits you is a decision to make with your doctor after an individual assessment. Australian menopause guidance lists it among possible options alongside lifestyle changes, psychological therapy and antidepressants. Psychological support can run alongside any medical plan.

References

1. Australasian Menopause Society (2023). Menopause and mental health: fact sheet. Australasian Menopause Society. https://www.menopause.org.au/health-info/fact-sheets/menopause-and-mental-health
2. Ayers, B., Smith, M., Hellier, J., Mann, E., & Hunter, M. S. (2012). Effectiveness of group and self-help cognitive behavior therapy in reducing problematic menopausal hot flushes and night sweats (MENOS 2): a randomized controlled trial. Menopause, 19(7), 749-759. https://doi.org/10.1097/gme.0b013e31823fe835
3. Department of Health, Disability and Ageing (2025). Better Access redesign from 1 November 2025. Australian Government. https://www.health.gov.au/sites/default/files/2025-10/better-access-redesign-from-1-november-2025_0.pdf
4. Freeman, E. W., Sammel, M. D., Lin, H., & Nelson, D. B. (2006). Associations of hormones and menopausal status with depressed mood in women with no history of depression. Archives of General Psychiatry, 63(4), 375-382. https://doi.org/10.1001/archpsyc.63.4.375
5. Green, S. M., Donegan, E., Frey, B. N., Fedorkow, D. M., Key, B. L., Streiner, D. L., & McCabe, R. E. (2019). Cognitive behavior therapy for menopausal symptoms (CBT-Meno): a randomized controlled trial. Menopause, 26(9), 972-980. https://doi.org/10.1097/GME.0000000000001363
6. Jean Hailes for Women’s Health (2026). Menopause. Jean Hailes for Women’s Health. https://www.jeanhailes.org.au/health-topics/menopause/
7. McCurry, S. M., Guthrie, K. A., Morin, C. M., Woods, N. F., Landis, C. A., Ensrud, K. E., Larson, J. C., Joffe, H., Cohen, L. S., Hunt, J. R., Newton, K. M., Otte, J. L., Reed, S. D., Sternfeld, B., Tinker, L. F., & LaCroix, A. Z. (2016). Telephone-based cognitive behavioral therapy for insomnia in perimenopausal and postmenopausal women with vasomotor symptoms: a MsFLASH randomized clinical trial. JAMA Internal Medicine, 176(7), 913-920. https://doi.org/10.1001/jamainternmed.2016.1795
8. Senate Community Affairs References Committee (2024). Issues related to menopause and perimenopause. Parliament of Australia. https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/Menopause/Report/Chapter_1_-_Introduction

Related reading

• How To Sleep Better
• The Anxiety Toolkit
• What Actually Happens in a Psychology Session

This article is general information only and is not a substitute for personal advice from a qualified health professional. If you are concerned about your mental health, please speak with your GP or a psychologist.

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