Many of the women I see in their forties and early fifties arrive saying some version of "I do not feel like myself". Often they have been turning this over for a year or two before coming. The work is going well, the family is in motion, life looks fine from the outside, and yet there is a quiet unsteadiness underneath. Sleep has shifted. Mood has shifted. A short fuse has appeared where there used to be patience. The familiar coping has stopped quite working.
Frequently — not always, but frequently — the shift turns out to be at least partly hormonal. Perimenopause has been quietly underway, and no one has flagged it.
This is a gentle look at how perimenopause can land on mental health, why it so often goes missed, and how therapy can sit alongside the medical care that may be helpful too.
What perimenopause actually is
Perimenopause is the years — sometimes four to ten of them — leading up to menopause, in which the ovaries gradually wind down hormone production. Oestrogen and progesterone fluctuate before they decline, and the fluctuation itself, rather than the decline, is often what causes the most disruption.
It can begin in the late thirties for some women, more usually in the early to mid forties, and the average age of menopause in the UK is 51. By the time periods become noticeably irregular, the underlying hormonal shifts have often been happening for years.
The physical symptoms are familiar to most people — hot flushes, night sweats, irregular periods, vaginal dryness, joint aches, weight changes. The psychological symptoms are less often named, and they include anxiety, low mood, irritability, brain fog, loss of confidence, sleep disturbance, and what many women describe as a quiet stranger-ness to their own self.
How perimenopause lands on mental health
Oestrogen is involved in serotonin regulation, in the stress response, in sleep architecture and in cognitive function. When it fluctuates, all of those can wobble. Many women describe the experience as follows.
Sleep changes first for some. Waking at three in the morning, with a feeling of low-grade dread, and finding it difficult to fall back asleep. Sometimes the waking is accompanied by night sweats, sometimes it is not.
Anxiety, often a new kind. Not the same anxiety they may have had earlier in life, but a more bodily, less rational kind — a sense of being keyed up without a story to attach it to. Some women experience panic for the first time in their forties.
Low mood that does not respond to the things that used to help. The walks, the time with friends, the things that used to lift the mood, are doing less.
Irritability, often with people they love. A short fuse with partners and teenage children. A sense of being more easily overwhelmed by ordinary demands.
Brain fog. Word-finding difficulty, lost car keys, missed appointments, a sense of being a few steps behind their own thinking.
Loss of confidence. Saying yes to fewer things. Feeling more exposed at work. A quiet retreat that does not match how they have always felt.
A particular kind of grief that is hard to name. A sense of something ending without quite knowing what.
Why it so often gets missed
Perimenopause is poorly taught at medical school, and women in their early forties presenting with anxiety, low mood or sleep disturbance often have those symptoms taken at face value rather than considered in the context of hormonal change. Antidepressants are sometimes prescribed where HRT might also be useful. The blood tests for menopause are unreliable in perimenopause, which can make diagnosis feel slippery.
There is also a cultural piece. Perimenopause has only recently begun to be talked about openly. Many women in their forties grew up in a culture that did not name it, and so when it arrives they have no template for what they are experiencing.
And the symptoms overlap with the things that genuinely are stressful at this life stage — teenage children, ageing parents, busy careers, the weight of being the person who holds the household together. It is easy to attribute the difficulty to circumstances and miss the underlying shift.
What helps medically
HRT (hormone replacement therapy) is, for many women, transformative. Modern HRT is body-identical, available on the NHS, and considered safe for most women. It is not the same as the HRT that was the subject of older studies, and the risk-benefit picture has shifted significantly in its favour. The British Menopause Society and the NHS both have clear, evidence-based guidance.
If you suspect perimenopause and your symptoms are affecting you, your GP is the first port of call. If they are not knowledgeable or are dismissive, ask to see another GP at the practice, or look for one with a special interest in menopause. The British Menopause Society maintains a register of menopause specialists at thebms.org.uk.
HRT is not the right choice for everyone, and not everyone wants it. The decision is yours, and a good GP will help you weigh it.
Where therapy fits
Therapy does not adjust your oestrogen. What it can do is help you make sense of what is happening, hold the disruption with less self-blame, and tend to the deeper currents that perimenopause often surfaces.
Many women find that perimenopause brings up earlier material. The hormonal volatility loosens something. Old griefs, old anger, old relational patterns that had been managed for years can surface in this period in a way that asks to be attended to. This is often described as confronting — "I do not know who this person is" — and is, in fact, a piece of psychological work that the timing has made possible.
Therapy in perimenopause is often as much about identity as about symptoms. Who am I becoming. What do I actually want now. What have I been doing because it was expected, and what do I want to keep doing for my own reasons. What does the next twenty or thirty years of my life look like, and on whose terms.
This can be quietly transformative. Many women look back on the perimenopausal years, with the right support, as the years in which they came back to themselves.
Lifestyle pieces that earn their place
None of these are a substitute for medical care if it is needed. All of them earn a place in supporting how perimenopause feels.
Sleep. Anything that protects sleep is worth protecting. Limiting alcohol in the evenings, cooling the bedroom, gentle wind-down routines, addressing night sweats if they are present.
Movement. Regular weight-bearing exercise has both physical and mood-related benefits. Walking the Surrey commons, swimming, yoga, strength training — whatever you will actually do, regularly.
Connection. Perimenopause is a time when other women are often the most useful source of perspective. Talking to friends, joining a perimenopause group, listening to one of the many good UK podcasts on the topic.
Slowing the load. Many women in perimenopause are running on a schedule that was set by an earlier version of themselves, with less margin than they now have. Quietly reducing demands tends to help.
A few questions worth turning over
"Is this just menopause, or is this depression?" — It can be both. Tending to one often makes the other easier to see. A good GP and a good therapist between them can help you work out what is what.
"Why am I so angry?" — Anger that arrives in perimenopause is often anger that has been held quietly for years and is now harder to suppress. It is not always pleasant, but it is often pointing at something useful.
"Will I ever feel like myself again?" — Most women do, and many feel meaningfully more themselves on the other side, particularly with appropriate support. The version of you who comes through is not the same version who went in, and that is not necessarily a loss.
And finally
If you have been quietly carrying changes in mood, anxiety, sleep or sense of self in your forties or early fifties, you are not failing. The body is shifting. The psyche is shifting with it. There is good help available, both medical and psychological.
You do not have to manage this alone.
If you would like to talk
If something here has resonated and you would like to talk it through, you can arrange an introductory call by emailing me at FelicityJaggar@gmail.com or leaving a message on 07923 319800. The introductory call is free, lasts fifteen to twenty minutes, and carries no obligation to take anything further.