When Anxiety Spikes in Perimenopause: What’s Going On & How Therapy Can Help

If your anxiety has suddenly dialed up—or you’re feeling waves of panic you’ve never had before—while your periods are getting irregular, you are not imagining it. Perimenopause (the transitional years before menopause) is a biologically and psychologically sensitive window where anxiety can newly emerge or intensify. Research is catching up with what so many women report in real life: this phase can be a “window of vulnerability” for mood and anxiety symptoms. ScienceDirect

Below, I’ll walk through what we know from peer-reviewed studies, why this happens, and practical, therapy-forward strategies you can use right now. If you’d like support, individual and group therapy can give you tools, community, and a plan tailored to your nervous system.

First, the science: yes, anxiety really can rise in perimenopause

Large, well-designed studies have tracked women across the midlife transition and found a meaningful shift in anxiety risk:

• In the multi-site SWAN study (nearly 3,000 women followed for ~10 years), women who had low anxiety before perimenopause became more likely to report high anxiety during and after the transition. In other words, perimenopause itself was linked to new or higher anxiety for many previously low-anxiety women. PMC

• Global analyses and systematic reviews increasingly connect the menopausal transition with higher burden of anxiety disorders, suggesting biological changes plus life stressors drive risk worldwide. BioMed CentralPMC

Woman engages in virtual therapy session. Help is only a dm, text or call away. Dr. Tera sees clients from 43 states.

Importantly, not every woman will develop an anxiety disorder—but it’s common to notice more worry, restlessness, irritability, or panic sensations during this time.

Why now? Hormone fluctuations meet a sensitive stress system

We often picture hormones sliding steadily downward, but the story is messier: estradiol levels swing and spike unpredictably in perimenopause. Those fluctuations (more than the final decline) can sensitize the brain’s stress circuitry. Experimental and longitudinal work shows that greater estradiol variability is linked to increased emotional reactivity to social stress and mood symptoms. PMCOxford AcademicFrontiers

That biological sensitivity then collides with real-life midlife stressors—career load, caregiving for kids and/or aging parents, relationship shifts, sleep disruption from night sweats—and it’s easy to see why anxiety can surge.  I have worked with so many women who share new onset or changing patterns of anxiety during this life transition.  For example, folks that describe a history of rumination or worry about many different things suddenly feel paralyzed to drive or have new-onset health focused anxiety.

What makes anxiety more or less likely? (The social + psychological picture)

A recent narrative review in Maturitas mapped out protective and harmful factors tied to mood and anxiety during perimenopause:

• Protective factors: strong social support, a sense of well-being, and resilience traits (flexible coping, optimism) were linked to fewer symptoms. ScienceDirect

• Risk factors: prior mental health history, trait anxiety/neuroticism, chronic stress, adverse childhood experiences, and current stressful life events were associated with higher risk of anxiety and depressive symptoms. PubMed

This framework matters in therapy: we can build protective factors and buffer the risks—regardless of hormone levels.

What anxiety looks like in perimenopause

Common patterns I hear (and studies echo):

• A new baseline of edginess or “wired-and-tired” feelings

• Panic spikes, often on waking (cortisol is naturally higher in the morning)

• Catastrophic thinking around health, work, or relationships

• Sleep disruption, which then amplifies next-day anxiety

• Sensitivity to heat or heart palpitations, which can themselves trigger panic

If that sounds familiar, you’re not alone and you’re not “overreacting.” Your body and brain are processing real, layered change and it feels terrible sometimes.

Evidence-based ways to feel better

You deserve a plan that addresses both biology and psychology. These are approaches with supportive evidence and strong clinical track records:

1) Skills-based psychotherapy (individual and/or group)

• Acceptance & Commitment Therapy (ACT) teaches skills to unhook from anxious thoughts and orient toward values-based actions, even when symptoms show up. It helps you identify and shift worry cycles, reduce avoidance, and retrain your nervous system’s response to bodily sensations (interoceptive exposure can be especially helpful for panic-like symptoms).

• Mindfulness-based strategies calm reactivity, work to train the parasympathetic nervous system response and improve sleep.

Group formats can add peer support, which the research above highlights as protective. ScienceDirect

2) Sleep first, then everything gets easier

Sleep disruption is both a symptom and an amplifier of anxiety. Targeted therapy techniques, including sleep hygiene work including consistent wake time, circadian-friendly light exposure in the morning, and stimulus control for the bed can reduce nighttime overarousal and thus daytime worry. 

3) Address vasomotor symptoms (hot flashes, night sweats)

When hot flashes and night sweats improve, anxiety often eases. Hormone replacement therapy (HRT) is the most effective treatment for vasomotor symptoms for eligible women; improving sleep and physical comfort can indirectly calm anxiety. Decisions about HRT are individualized and should be made with your medical provider using current guidelines. Lippincott JournalsThe Menopause Society

4) Medication options for anxiety

Some women benefit from SSRIs/SNRIs or other medications—either short-term while learning therapy skills or longer-term if symptoms are moderate to severe. Work with your prescriber; therapy and medication often pair well.

5) Lifestyle levers that truly move the needle

• Regular aerobic activity lowers baseline anxiety and improves sleep.

• Reduce alcohol intake (it fragments sleep and can worsen next-day anxiety).

• Nervous-system regulation strategies you can do in minutes: paced breathing (e.g., 4-6 breaths/minute), grounding (5-4-3-2-1 senses), or a brief cold face splash to activate the dive reflex.  Dr. Tera also teaches biofeedback skills. 

How therapy specifically supports you in this season

Therapy in perimenopause isn’t just generic anxiety care. We tailor tools to hormone linked symptom cycles, body sensations (palpitations, heat), and the context of midlife. We also work on the social-psychological factors that shape outcomes:

• Build protective factors: strengthen social support, cultivate resilience skills, and increase perceived well-being. ScienceDirect

• Buffer risk factors: map your stress load, process earlier adverse experiences safely, and reduce all-ostatic (wear-and-tear) stress on your system. PubMed

If you’ve never had anxiety before, it can feel disorienting. Remember the SWAN finding: many previously low-anxiety women experience new-onset high anxiety because of this transition. Your experience is valid—and treatable. PMC

When to reach out

Consider professional support if you notice:

• Panic attacks, persistent worry, or avoidance that limits your life

• Sleep that’s broken more nights than not

• Anxiety that’s new for you or worse/different than before

• Intrusive health fears, heart-race episodes, or “I don’t feel like myself”

Therapy can help you feel steady again while your body navigates change.

A compassionate next step

Dr Tera at Mindful Path Psychological Services offers individual and group therapy for women in perimenopause focused on anxiety, mood, sleep, sexual health, menorage, and resilience skills. We’ll create a plan that’s science-informed and human-centered—so you can reclaim calm, restore sleep, and feel like you again.

If you’re ready, reach out and we’ll get you scheduled for a complementary discovery call. You don’t have to bear this challenging time alone, and it’s actually better for your overall health if you don’t.

References (peer-reviewed & key guidelines)

• McElhany K, et al. Protective and harmful social and psychological factors associated with mood and anxiety disorders in perimenopausal women: A narrative review. Maturitas. 2024. (Protective role of social support/resilience; risk from trait anxiety, ACEs, stressors.) ScienceDirectPubMedmaturitas.org

• Bromberger JT, et al. Does Risk for Anxiety Increase During the Menopausal Transition? Menopause. SWAN cohort. 2013. (Higher risk of high anxiety during/after transition among women with low premenopausal anxiety.) Open-access full text. PMC

• BMC Women’s Health (2025). Global, regional, and national burden of anxiety disorders during the menopausal transition. (Links transition with elevated anxiety burden across regions.) BioMed Central

• Systematic Review (2025). Anxiety and depressive symptoms among women with vasomotor symptoms and fatigue.(Synthesizes associations between VMS and anxiety.) PMC

• Gordon JL, et al. Estradiol variability, stressful life events and the emergence of depressive symptoms in perimenopause. (Evidence that estradiol fluctuation heightens stress sensitivity; relevant for anxiety reactivity.) PMC

• The Menopause Society / NAMS (2022). Hormone therapy position statement. (MHT is the most effective treatment for vasomotor symptoms; decisions should be individualized.) Lippincott JournalsThe Menopause Society

Note: Research on anxiety in perimenopause is evolving; the studies above represent current, peer-reviewed evidence across cohort, experimental, and review designs. Chat GPT was utilized as a writing aid.