Of the many ways that the menopause transition makes itself known, some symptoms are more immediately apparent—and more, well, visceral—than others. Hot flashes, super-soaker periods that show up whenever they please, and puzzling weight gain are pretty dramatic physical signs that things are changing, and they can be hard to ignore. Physical symptoms get a lot of coverage in the current conversations about menopause, which is a good thing, since it means more women have the information they need to seek help and relief.
But alongside the uncomfortable physical symptoms, perimenopause can also stir up new or worsening mental health concerns, like anxiety, depression, brain fog, mood swings, even unexpected rage. In our fast-paced culture packed with distractions, stressors, and endless obligations, it may not occur to some women that these symptoms might be connected to the menopause transition, or that they can get help for them. Add to this the fact that menopause and mental health remain somewhat taboo topics and that many women have their mental health concerns dismissed, and it’s clear we need to be having more conversations about the psychological and emotional symptoms to be aware of during perimenopause.
Take this one, for instance: Some women notice a hard-to-put-your-finger-on-it sense of “blahness” or numbness, most profoundly marked by a loss of interest in things they used to enjoy, and a loss of pleasure from things that used to provide it, including food, hobbies, creative pastimes, sex, and social connections.
The term for this is anhedonia, and if it’s not already on your radar, it might be difficult to recognize or articulate at first. Anhedonia doesn’t necessarily rise to the top of the list of conversations about mental health in general, since it’s often considered a hallmark of depression and the neurobiological mechanisms behind it aren’t especially well understood yet.
We think it’s important to spotlight anhedonia in its own right, however, since mental health concerns can vary so widely between individuals during perimenopause, and we’re all about digging into the sometimes uncomfortable and underdiscussed topics you need to know about during this transition.
If you can relate to what we describe here, please consider bringing it up with a healthcare provider or mental health professional, especially one well-versed in menopause. Mental health concerns during menopause can be complex, distressing, and have multiple root causes, but getting help is worth it.
What is anhedonia?
The word anhedonia is derived from the Greek words “an-” meaning “without” and “hedone,” meaning pleasure. It was first used by the French psychologist Théodule Ribot in the late 1800s, and while the definition has expanded over time (especially in the context of clinical depression), you’re still most likely to see it used to describe a lack of interest in formerly enjoyable activities, and/or a lack of pleasure in those activities while doing them.
How is anhedonia different from depression and anxiety?
To understand where anhedonia fits in among other mental health symptoms, it might help to imagine them along a sort of spectrum. Where depression might generally present as a low-energy condition, marked by feelings of sadness, hopelessness, despair, and disinterest in normal activities, and anxiety might present as a higher energy condition, characterized by racing thoughts (and heartbeat!), worry, rumination, and even panic attacks, typical descriptions of anhedonia place it closer to depression. It’s possible to have anhedonia as the sole sign of a mental health disorder (ie, you can experience episodes of anhedonia as a variant of depression without other symptoms), but it is also one of the diagnostic criteria for major depressive disorder (MDD), and several other psychological and neurological disorders, including Parkinson’s disease.
Essentially, anhedonia is responsible for the “disinterest and apathy” symptoms that can accompany depression and other disorders. It’s not associated with having strong negative emotions so much as it is a lack of emotions; it’s waking up feeling “meh,” “blah,” or “take it or leave it,” in the most passive sense, about activities you would ordinarily look forward to and enjoy.
Do we know what causes anhedonia?
Researchers believe that anhedonia presents when there is dysfunction in the brain’s motivation and reward centers. However, as with so many mental health disorders, it’s hard to narrow down a singular cause or predict what might trigger an episode in any given person, especially since it can be co-present with other conditions.
It’s thought that there may be a genetic component partially contributing to whether an individual is prone to anhedonia. It has also been linked to inflammation in the brain, which interferes with the function of neurotransmitters, such as the “feel-good hormone” dopamine, that play important roles in mood regulation, pleasure, and motivation.
Other contributors to anhedonia can include trauma and PTSD; burnout; substance use disorders; even chronic illness like Long Covid; this raises the question whether it’s driven by something biochemical, circumstantial, or both, in ways science doesn’t fully understand.
Anhedonia during perimenopause
As for what spurs episodes of anhedonia during perimenopause, it’s difficult to say with certainty, but plummeting estrogen levels are likely partially responsible. During the menopause transition, we’re at the whims of fluctuating hormones, often for years. These wild hormone swings can bring about not just irritability but other serious mental health concerns, like depression, as we lose the (sometimes) mood-balancing effects of progesterone, and declining estrogen and progesterone interfere with dopamine function.
All these hormonal shifts can result in mood and mental health changes during midlife, and the severity can vary from person to person. Some research suggests that women who experienced depression before beginning menopause may be more prone to depressive symptoms (especially those severe enough to meet the criteria for major depressive disorder) during and after menopause, but mental health struggles can arise for all kinds of reasons, including situational ones, during this time.
Transitions during midlife involve so much more than just hormones: it’s a time when our relationships, body image, sense of identity, roles at home and at work can all go through destabilizing shifts too, sometimes with no predictable end in sight. It’s not unreasonable, then, that stress, burnout, overwhelm, anxiety, depression, and anhedonia can set in and prompt a need for more support.
What does anhedonia feel like?
We all have experiences we don’t enjoy sometimes, right? And is it so bad to lose interest in certain things, especially as you grow and change and adjust to new life phases throughout the years? Does moving on from former activities, hobbies, or social groups always mean you’re dealing with anhedonia?
Of course not—that’s just having preferences! Anhedonia isn’t simply disliking an activity or not being interested in a pastime because it’s not your cup of tea or you’ve found something new to try. It’s better described as a sense of apathy or indifference that extends into multiple areas of your life, or a pervasive numbness that leaves you not caring about much of anything, which doesn’t lift even after your favorite pick-me-ups—anything that used to reliably buoy you through a bad mood.
So how does this show up?
Women responding to discussions about anhedonia during perimenopause in various online forums use phrases like:
“faking my way through life”
“I don’t care about anything”
“everything is boring”
“life just feels gray”
“wouldn’t really care if I never saw my friends again”
“going through the motions”
“no sense of urgency”
“can’t find motivation, even for the fun stuff”
“trying to figure out how to want to want something again”
“nothing calls to me”
“I’m just existing”
“I would feel this in my bones…if I could feel feelings”
They describe abandoning hobbies and businesses, withdrawing from social and family obligations, not looking forward to plans, putting off basic tasks, and doing the bare minimum to get through the day, not because their to-do list feels challenging but because they simply can’t work up the motivation to care about following through.
It’s also not uncommon for people experiencing anhedonia to lose interest in, or fail to get satisfaction from, things they used to find enjoyable like food, sex, or engaging with music and art. Particularly with food, this can lead to changes in appetite and eating habits—some people may struggle to eat enough, while others might seek out highly palatable and less nutrient-dense foods, like salty or sweet snacks, in the hopes of finally tasting something satisfying.
Is anhedonia treatable?
If anhedonia saps your motivation, interest, and sense of satisfaction or joy, it’s fair to say that it isn’t compatible with nurturing your well-being, relationships, or self-image—particularly not during menopause, which can bring forth new challenges on these fronts anyway. Wanting relief from anhedonia is as understandable as wanting relief from hot flashes, and just as important for your menopausal quality of life.
Because it’s so often linked to other conditions and we’re still learning about what can cause it, anhedonia on its own can be difficult to treat. There are no treatments designed specifically for anhedonia yet, outside of those meant to address the other disorders it often accompanies, and frustratingly, it’s not always responsive to some of the go-to medications often used to treat depression, like SSRIs.
To offer some hope, though, it seems that anhedonia isn’t always a persistent state for all who experience it. Depending on the factors involved, its severity can ebb and flow over time, and various mental health interventions can help bring about relief for some people. Though there’s no one remedy that’s a proven anhedonia-buster, a combination of approaches may help.
These include:
Cognitive behavioral therapy
- Cognitive behavioral therapy, or CBT, is a psychotherapy approach focused on helping patients identify negative thoughts and learn new problem-solving skills to change behavior patterns. It’s used to treat depression and anxiety, sometimes in combination with medications or other therapeutic techniques, and is widely considered effective for those conditions. Because anhedonia can be a pervasive symptom with depression, CBT can provide patients with tools to address negative thought patterns and lack of motivation or interest in activities, but some research has found that CBT is only partially effective at alleviating anhedonia compared to other depressive symptoms, though it does still offer some benefit.
- CBT is still a valuable therapeutic technique for navigating menopause challenges, so don’t count it out entirely! It’s been found to be particularly effective at helping women manage anxiety, stress, and vasomotor symptoms like hot flashes and night sweats. It’s also recommended by the American Academy of Sleep Medicine as a first-line treatment for insomnia (called CBT-I), which can be a common and unpleasant symptom for many women during perimenopause.
Atypical antidepressants
- A number of atypical antidepressant drugs including Wellbutrin and trazodone, are approved to treat depression, and several have been shown to be more effective against anhedonia than traditional antidepressants such as SSRIs. As with any new-to-you pharmaceutical treatment, talk with a healthcare provider to decide if an atypical antidepressant makes sense for your needs—it can take time to find the right course of medication in order to find relief and avoid side effects or drug interactions.
Menopause hormone therapy
- Hormone fluctuations, especially changes in progesterone and estrogen, can lead to an increase in mental health and mood disruption during perimenopause. Anxiety and depression can arise for the first time for some or worsen for others, and it’s thought that this is partially due to the relationship between estrogen and neurotransmitters that help control our moods and how we experience pleasure.
- Anecdotally, many women in online menopause forums report that starting hormones helped regulate their moods and ease mental health symptoms as well as their physical symptoms. The Menopause Society also reports encouraging research that hormone therapy, especially alongside an antidepressant, may help patients with depression during menopause. As for anhedonia specifically, there is slight evidence that supplemental estrogen therapy might help reduce anhedonia associated with perimenopause, though the study notes more research is needed. Menopause hormone therapy is safe and effective for many women but before getting started, talk it over with your doctor, who can advise about dosage, formulation, and whether hormones are suitable for you.
Mental health support during menopause
Without a better understanding of what really causes anhedonia during perimenopause (and in other circumstances), and better data pointing toward effective treatment options, it can be challenging to treat and frustrating when it affects important aspects of your life, especially during a time of such intense change. But this doesn’t mean there’s nothing to be done. If you’re struggling during menopause—with anhedonia, depression, anxiety, or any combination of these—we encourage you to communicate it to a healthcare provider who listens to your concerns and can support you with the right combination of treatments, lifestyle changes, and other mental health interventions for your needs. You and your well-being are worth it.
If you feel you or someone you care about may be suffering from depression, there is help. You can start finding your way back from depression by talking to a doctor or mental health provider, or contacting the 988 Lifeline for immediate, 24/7 support. Gennev’s clinicians can support you through the unique physical and emotional challenges of menopause with personalized treatment plans; book an appointment to get started.