Waking up to anxiety: it's a common experience for women in the perimenopause years. For women who have dealt with it before, it can come roaring back. For women who've never experienced it, it can show up for the first time. From annoying to downright debilitating, anxiety can persist for months or years. But anxiety can be treated and managed so you don't have to live with the swirling brain, pounding heart, and interrupted sleep.

According to Batya Swift Yasgur in Psychiatry Advisor, studies show more than half of women aged 40 to 55 report occasional anxiety (or “nervousness”) and as much as a quarter of women report frequent anxiety.

Researchers haven’t spent much time looking at the relationship between anxiety and perimenopause and menopause, because depression, which can come on the heels of many age-related conditions, has absorbed the lion’s share of time and funds.

Dr Swapna VaidyaHowever, with such a large number of people in the perimenopause > menopause transition suffering from disruptive anxiety, we thought it was time to talk with an expert. We asked psychiatrist Swapna Vaidya, MD and Executive Medical Director in the MultiCare Health System, for some answers on hormones, anxiety, and how to stay mentally healthy in a difficult time.

Why does anxiety happen or get worse in perimenopause and menopause?

Dr. Vaidya: Anxiety can occur due to the estrogen and progesterone imbalance that occurs during  perimenopause/menopause. When this hormonal system gets out of balance, symptoms of anxiety, depression, irritability, mood swings, foggy brain, tense muscles, and sleep disturbances can all occur. In the brain, reproductive hormones such as estrogen act via steroid receptors. They also have an effect on different neurotransmitters such as serotonin (a mood regulator), dopamine (active in pleasure and reward centers of the brain), etc. Additionally, studies show estrogen can influence brain areas that regulate mood, behavior, and cognitive abilities. So when estrogen declines, we lose its regulating effect on our brain and central nervous system (CNS).

Who is at the most risk of having more anxiety at perimenopause and menopause?

According to Dr. Vaidya, women with a history of depression or premenstrual dysphoric disorder (PMDD), women with significant care taking responsibilities, those who experience loss or who have chronic fatigue or other health problems are at a greater risk of anxiety. However, even women without risk factors may develop anxiety during this time of hormonal disruption and fluctuation.

Those who already experience anxiety or have a previous experience with anxiety, depression, PTSD, or panic disorder are also at greater risk of developing more severe symptoms of anxiety during the perimenopause to menopause transition.

What does this sort of anxiety feel like? What signs can tell me it’s probably hormonal (at least in part)?

Says Dr. Vaidya, if you’re experiencing hot flashes followed by sweating and panic, body aches, sexual changes, and/or memory issues as well, your anxiety is likely more a sign of hormonal imbalance than a new case of anxiety or panic disorder.

If menopause symptoms are disrupting your life, get help from a menopause-expert physician, from the comfort of your own home. 

Will anxiety get worse?

It may for a while, says Dr. Vaidya: Studies of mood and anxiety during menopause have generally revealed an increased risk of depression during perimenopause with a decrease in risk during postmenopausal years. The Penn Ovarian Aging Study, a cohort study, showed depressive symptoms increased during the menopausal transition and decreased after menopause. (“Cohort” studies follow a group of individuals who share a common characteristic over time.)

My anxiety is worst in the mornings – is that normal? Why does it work that way?

Early morning anxiety is typically seen in the perimenopause-to-menopause period, says Dr. Vaidya. Estrogen helps regulate cortisol production; cortisol is your body’s main stress hormone, responsible for your “fight or flight” response. Decreases in estrogen can cause increases in cortisol levels which can stimulate the nervous system — leading to early morning anxiety.

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How do I explain to my partner, children, colleagues, boss, etc., what’s happening to me?

Telling people you’re dealing with perimenopause or menopause symptoms can be really tough in our society, and telling people you’re dealing with mental and emotional symptoms as a result risks a double stigma. Hopefully, as menopause and women’s health issues generally become more normalized, we’ll be able to talk more openly and easily.

As Dr. Vaidya says, “Communication and being transparent with your colleagues and loved ones about the experience of menopause and change, whether physical or emotional, would be the first step.” Telling those around you that your responses may sometimes be influenced by unruly hormones may help them have greater understanding and prompt them to do more to accommodate and support you.

What can others do to help?

It’s a tricky question: those who aren’t going through it (and perhaps never will) often struggle to figure out ways to be supportive and helpful. Dr. Vaidya suggests, “One of the best things loved ones can do for you is to listen and to be empathetic. Often people around you may try to give well-meaning but unsolicited advice, but this can come across as pedantic or judgmental.” Discussing a game plan when you’re not currently dealing with anxiety can be helpful, since in the moment, it can be challenging to think and communicate clearly. Now, when you’re clear and calm, is perhaps a better moment to have the discussion.

What are the solutions? Lifestyle choices, naturopathic solutions, medical interventions, apps?

Dr. Vaidya: There are several modalities, interventions, lifestyle changes, and diets that are available out there; however, the most important thing is to create a program that is easy to use and adapt. We know from studies that lifestyle changes such as having a balanced diet and getting good exercise can have real benefits. Cognitive behavioral therapy as well as mindfulness and relaxation techniques have demonstrated significant improvement in symptoms of anxiety. Supportive groups, whether online or in person, are helpful as well; however, it is important not to overwhelm yourself. Approach treatment at your own pace.

When is it bad enough that I should get some sort of help or intervention? What are the red flags that this is likely beyond my control?

If you’re experiencing anxiety or panic that may be hormonal, it may help to talk with a menopause specialist. Remember, hormonal fluctuations can cause symptoms that mimic panic or anxiety disorder, and treatment may depend on the cause of your symptoms. However, regardless of what causes your anxiety, persistent panic attacks and debilitating anxiety that cause significant impairment in functioning or lead to suicidal thoughts or concerns should be addressed immediately. 

I know a lot of younger women; should I talk with them about anxiety?

Thanks to continuing social stigma around women’s bodies, many of “Generation X” and older women entered perimenopause with no real understanding of what was happening or what was to come. Moving to normalize perimenopause and menopause can make it so much easier for younger generations of women to have a smoother, healthier transition.

As Dr. Vaidya says, “It's important to talk about the natural change of life with women in your group. Very often menopause is culturally viewed as an ‘end of reproductive ability or desirability.’ However, opening dialogue and sharing the challenges and treatments would help transform the way menopause is viewed. This can help dissipate fear as well about a normal change in life.” Our anxiety, says Dr. Vaidya, is made worse when we keep menopause a mystery, so talking and educating ourselves and one another is good for us all.

 Have you dealt with hormonal anxiety? How did you manage it? We'd love to know more about it. Join the conversation in Gennev's community forums.