Menopause and Anxiety: Why It Happens and What Can Genuinely Help

Article Summary

Anxiety during perimenopause and menopause can be influenced by fluctuating hormones, sleep disturbance, physical symptoms, previous anxiety, accumulated stress and the demands of midlife. This article explains these interacting influences and offers evidence based psychological, physiological, medical and lifestyle strategies that can be adapted to the individual.

When Anxiety Feels Different During Menopause

Anxiety during perimenopause does not always resemble the anxiety a person may have experienced earlier in life. It can appear as persistent worry, irritability, emotional overwhelm or an inability to switch off, but it may also arrive as a sudden wave of dread or unease when nothing obviously threatening is happening.

Some people describe a sensation rising through the stomach or chest, a sudden feeling of “Oh no, something is wrong,” or an urgent need to escape and return somewhere familiar. Others experience heart palpitations, sweating, shakiness, nausea, dizziness, breathlessness, disrupted concentration or a fear that they may faint or lose control.

These experiences are real. They are not a sign of weakness, attention seeking or an inability to cope. Anxiety involves measurable changes within the brain, nervous system and body.

Why Can Anxiety Increase During Perimenopause?

Perimenopause is characterised by fluctuations in oestrogen and progesterone rather than a simple, steady reduction. These hormones interact with systems involved in serotonin, dopamine, gamma aminobutyric acid, sleep, temperature regulation and the stress response. Hormonal variability may therefore affect emotional regulation and the threshold at which the nervous system reacts to pressure.

Research from the Study of Women’s Health Across the Nation found that women with low anxiety before menopause were more likely to experience increased anxiety symptoms during the menopausal transition than before it (Bromberger et al., 2013). This does not mean that hormones are always the sole cause. It means that the menopausal transition can create a period of increased vulnerability, particularly when hormonal changes occur alongside sleep disruption, health concerns or sustained life pressure.

The Biochemical Anxiety Response

When the brain detects a possible threat, the sympathetic nervous system and hypothalamic pituitary adrenal axis can activate. Adrenaline and noradrenaline increase alertness, heart rate and muscle readiness, while cortisol helps mobilise energy.

Blood flow and digestive activity may also change. This can produce nausea, butterflies, abdominal discomfort, diarrhoea, reflux or an urgent need to use the toilet. The person may then notice these sensations and think, “Something is wrong with me,” which adds another layer of fear and intensifies the response.

During perimenopause, a hot flush, palpitation, dizzy sensation or sudden temperature change may be interpreted as danger, especially if it happens unexpectedly. The body reacts to the sensation, the mind reacts to the body, and a self reinforcing anxiety cycle develops.

Anxiety Is Usually Multifactorial

It is rarely helpful to decide that anxiety is caused entirely by hormones or entirely by psychology. Several factors may be interacting:

1. Hormonal variability during perimenopause.
2. Hot flushes, night sweats and disrupted sleep.
3. Previous experiences of anxiety, panic or trauma.
4. Family, relationship, financial or workplace pressure.
5. Caring responsibilities and years of being the dependable person for everybody else.
6. Health concerns, grief, loss or major life transitions.
7. Thyroid difficulties, anaemia or deficiencies involving iron, vitamin B12 or vitamin D.
8. Medication effects or changes in medication.
9. Caffeine, nicotine, vaping, alcohol or other substances.
10. Reduced movement, irregular meals or inadequate hydration.
11. Fear of anxiety itself and increasing avoidance of situations in which symptoms have previously occurred.
12. Existing neurodevelopmental differences, sensory sensitivity or difficulty regulating attention and emotion.

The most effective support often addresses several parts of this picture rather than searching for one single explanation.

Twelve Evidence Based Strategies for Menopause Related Anxiety

1. Obtain a Thorough Medical and Menopause Review

New or changing anxiety symptoms deserve a proper medical review. A GP can explore the timing of symptoms, menstrual changes, hot flushes, sleep, medication, physical health and previous mental health history.

Depending on the person’s symptoms and medical history, assessment may include thyroid function, a full blood count, iron or ferritin, vitamin B12, folate, vitamin D and other relevant investigations. Normal blood results do not invalidate anxiety, but testing can identify physical contributors that may be treatable.

Menopause is usually diagnosed clinically from age, symptoms and menstrual changes. A single hormone blood test may not provide a clear answer during perimenopause because hormone levels can fluctuate considerably.

Recurrent episodes involving altered awareness, memory gaps, repetitive movements, unusual smells or tastes, confusion afterwards or highly stereotyped rising stomach sensations should also be discussed with a doctor. Most sudden anxiety episodes are not seizures, but symptoms that appear neurological should not automatically be attributed to anxiety.

2. Discuss Menopausal Hormone Therapy Individually

Menopausal hormone therapy is the most effective treatment for vasomotor symptoms such as hot flushes and night sweats. When anxiety is being intensified by severe physical symptoms or sleep disruption, treating those underlying symptoms may also improve emotional wellbeing.

Hormone therapy is not an anxiety treatment in itself, and its psychological effects vary. Decisions should consider age, symptoms, time since menopause, type of menopause and individual medical history. It is not appropriate for everyone, and people with a history of certain cancers, clotting conditions or other relevant risks require specialist advice (The North American Menopause Society, 2022).

Someone who has been told that she is “too young” for menopause treatment may benefit from an assessment by a clinician with specific expertise in perimenopause and menopause. Premature ovarian insufficiency and early menopause require careful medical consideration because hormonal health can affect the bones, cardiovascular system and overall wellbeing.

3. Use Cognitive Behavioural Therapy Strategies

Cognitive behavioural therapy does not suggest that menopausal symptoms are imagined. It helps people change the interpretations and behaviours that may unintentionally intensify distress.

For example, the thought “If this happens while I am away, I will not cope” can increase anticipatory anxiety long before the event. A more balanced response might be:

“I may experience an anxiety wave, but I understand what it is, I can allow it to pass, and I have a plan for responding.”

Cognitive behavioural therapy has strong evidence for anxiety disorders generally and can also help people manage the distress, sleep disruption and negative interpretations associated with menopausal symptoms (Hofmann et al., 2012; National Institute for Health and Care Excellence, 2024).

4. Practise a Safety Orienting Reset

When anxiety appears suddenly, look slowly around the room and name five neutral things you can see. Identify three sounds and two sensations of physical support, such as your feet against the floor or your back against the chair.

Then say:

“My alarm system has activated. I do not need to solve everything right now. I am safe enough in this moment.”

This exercise redirects attention from internal threat monitoring towards present sensory information. Practising it when calm makes it easier to access during an anxiety wave.

5. Slow the Breathing Without Taking Huge Breaths

Breathe gently through the nose for approximately four seconds and breathe out slowly for approximately six seconds. Repeat this for four or five comfortable breaths.

The aim is not to inhale as deeply as possible. Large or rapid breaths can increase light headedness and tingling. Slow, comfortable breathing can reduce physiological arousal and may support autonomic regulation (Balban et al., 2023; Zaccaro et al., 2018).

If breath focused exercises increase anxiety, use external grounding instead. No strategy is universally calming.

6. Track Patterns Without Constantly Monitoring Yourself

For two to four weeks, record the approximate time of each episode and what was happening beforehand. Include sleep, meals, caffeine, alcohol, nicotine, hot flushes, menstrual changes, conflict, workload and physical symptoms.

The purpose is to identify patterns, not to watch the body continuously. Excessive checking can reinforce anxiety. Keep the record brief and review it at a set time rather than repeatedly throughout the day.

A pattern may reveal that symptoms are more likely after poor sleep, on an empty stomach, following several coffees or during particular phases of the menstrual cycle. This information can guide more specific intervention.

7. Reduce Avoidance Gradually

Avoidance brings immediate relief, but it can teach the brain that the avoided situation was genuinely dangerous. This may gradually shrink a person’s world and increase anxiety about travel, shops, social events, enclosed spaces or being away from home.

Instead of forcing yourself into the most frightening situation, build a gradual exposure ladder. Begin with a manageable step, remain there long enough to discover that the anxiety can rise and fall, and repeat the experience before progressing.

The goal is not to guarantee that anxiety will never appear. It is to build confidence that you can respond to it without escaping immediately. Exposure based methods are a central component of evidence based anxiety treatment (Craske et al., 2014).

8. Protect Sleep as a Core Treatment Target

Sleep disruption can increase emotional reactivity, physical tension, brain fog and sensitivity to bodily sensations. Hot flushes and night sweats may also create repeated awakenings, leaving the nervous system more vulnerable the following day.

Keep wake time reasonably consistent, obtain daylight early in the day, reduce caffeine later in the day and create a short wind down routine. If insomnia has become persistent, cognitive behavioural therapy for insomnia has stronger evidence than relying on sleep hygiene alone (Edinger et al., 2021).

Treating vasomotor symptoms may also be necessary. It is difficult to regulate anxiety effectively when the body is repeatedly pulled out of sleep.

9. Complete an Evening Brain Dump

Spend five to ten minutes before bed writing down worries, unfinished tasks, appointments, decisions and anything you are afraid of forgetting. Beside each item, note the next realistic action or the date when you will revisit it.

Finish with:

“This information is recorded. I do not need to hold it in my head tonight. I can return to it tomorrow.”

Bedtime writing may reduce the mental effort involved in rehearsing unfinished tasks and may help some people fall asleep more quickly (Scullin et al., 2018). The journal becomes an external memory system rather than another task that must be completed perfectly.

10. Use Regular Movement Rather Than Punishing Exercise

Physical activity can reduce anxiety symptoms, improve sleep and provide a safe outlet for physiological arousal. Exercise does not need to begin with weight loss, a gym membership or an exhausting programme.

A ten minute walk, gentle cycling, dancing to two songs, stretching or light resistance exercises all count. Start below your maximum capacity so that movement feels achievable rather than becoming another demand.

Exercise has demonstrated anxiety reducing effects, although it should form part of a broader plan when symptoms are severe or persistent (Stubbs et al., 2017).

11. Support the Gut Brain System Through Food

The gut and brain communicate through neural, hormonal, metabolic and immune pathways. Gut microorganisms break down certain dietary fibres and produce substances that participate in immune and metabolic regulation. This does not mean that the gut is the sole cause of anxiety, but nutrition can contribute to overall physical and psychological health (Cryan et al., 2019).

Helpful foods may include:

1. Live natural yoghurt, kefir, kimchi, miso, tempeh and refrigerated sauerkraut containing live cultures.
2. Oats, barley, beans, lentils and chickpeas.
3. Onions, garlic, leeks and asparagus where these are comfortably tolerated.
4. Apples, berries, slightly green bananas and other fruits.
5. Vegetables of different colours.
6. Nuts, seeds, whole grains, herbs and spices.
7. Cooked and cooled potatoes, rice or pasta as sources of resistant starch.

Research on probiotics and anxiety remains mixed. Effects may depend on the bacterial strain, dose, diet and individual person, so probiotics should not be presented as a stand alone treatment (Liu et al., 2019). Fibre and fermented foods should be introduced gradually, particularly for anyone with irritable bowel symptoms.

12. Review Caffeine, Nicotine, Vaping and Alcohol

Caffeine and nicotine can increase alertness, heart rate, tremor, stomach activity and palpitations. These sensations can closely resemble anxiety and may trigger fear in someone who has become sensitive to bodily changes.

Alcohol may initially feel calming, but it can disrupt sleep and contribute to rebound anxiety. Rather than stopping everything abruptly, track the relationship between substances and symptoms and discuss withdrawal or dependence concerns with a healthcare professional.

13. Practise Mindfulness and Acceptance

Trying desperately to suppress an anxious thought or sensation can make it more dominant. Acceptance based approaches encourage a different response:

“I do not like this feeling, but I can make room for it without treating it as an emergency.”

Mindfulness can help a person notice thoughts as mental events rather than facts. Evidence indicates that mindfulness based approaches can reduce anxiety for some people, although they are not equally helpful for everyone and may require adaptation for people with trauma histories (Goldberg et al., 2018).

14. Reduce the Invisible Load

Many people reach menopause after years of carrying responsibility for children, parents, work, relationships and the emotional wellbeing of others. Hormonal changes may reduce the capacity to keep absorbing this load without consequence.

Write down everything you currently manage, including tasks that nobody else notices. Identify what can be delegated, delayed, simplified or stopped. Reducing pressure is not laziness. It is an intervention for a nervous system that may have been operating beyond capacity for years.

15. Strengthen Social and Workplace Support

Anxiety often becomes more frightening when it is hidden. Choose one or two safe people who can respond calmly rather than dismissing the experience or repeatedly reassuring you that nothing will ever happen.

At work, helpful adjustments may include predictable breaks, access to water, ventilation, temporary flexibility, a quieter workspace or clearer communication around workload. Support should address the environment as well as asking the individual to become more resilient.

16. Seek Psychological Treatment When Self Help Is Not Enough

Professional support is important when anxiety is persistent, causes significant distress, interferes with sleep or concentration, or leads to avoidance of work, travel, relationships or ordinary activities.

Evidence based options may include cognitive behavioural therapy, exposure based treatment, acceptance and commitment therapy, mindfulness informed interventions and treatment for trauma when relevant. Medication may also be appropriate and can be discussed with a GP or psychiatrist.

Seeking support does not mean that the anxiety is “just psychological.” Psychological treatment works directly with the brain, body, behaviour and nervous system responses that maintain anxiety.

When to Seek Urgent Help

Urgent medical assistance should be sought for a first suspected seizure, loss of consciousness, severe chest pain, significant breathing difficulty, new weakness, sudden neurological symptoms or any episode that appears medically different from previous anxiety.

Immediate mental health support is required if anxiety is accompanied by thoughts of self harm, suicide or an inability to remain safe.

Moving Forward Without Trying to Fix Everything at Once

Menopause related anxiety is rarely solved through one supplement, one breathing exercise or one change in thinking. A more realistic approach is to understand the interacting factors and begin with one manageable intervention.

Choose the strategy that most closely matches what is maintaining the anxiety. This may involve treating sleep disruption, seeking a menopause review, reducing avoidance, changing the relationship with bodily sensations or creating boundaries around an overwhelming workload.

Small, repeated actions can help the nervous system relearn safety. The aim is not to eliminate every uncomfortable sensation. It is to reduce fear of those sensations, increase confidence and restore the ability to participate in everyday life.

Support Through Collins Psychology

If you found this article helpful and would like to explore practical strategies that are more closely suited to your particular experiences, you are welcome to contact Collins Psychology. Collins Psychology provides evidence informed educational resources designed to help people understand their patterns, develop effective regulation strategies and identify realistic starting points for change.

You can also access further free articles and practical resources through the Collins Psychology blog.

References

Balban, M. Y., Neri, E., Kogon, M. M., Weed, L., Nouriani, B., Jo, B., Holl, G., Zeitzer, J. M., Spiegel, D., & Huberman, A. D. (2023). Brief structured respiration practices enhance mood and reduce physiological arousal. Cell Reports Medicine, 4(1), Article 100895. https://doi.org/10.1016/j.xcrm.2022.100895

Bromberger, J. T., Kravitz, H. M., Chang, Y. F., Randolph, J. F., Avis, N. E., Gold, E. B., & Matthews, K. A. (2013). Does risk for anxiety increase during the menopausal transition? Study of Women’s Health Across the Nation. Menopause, 20(5), 488–495. https://doi.org/10.1097/GME.0b013e3182730599

Craske, M. G., Treanor, M., Conway, C. C., Zbozinek, T., & Vervliet, B. (2014). Maximizing exposure therapy: An inhibitory learning approach. Behaviour Research and Therapy, 58, 10–23. https://doi.org/10.1016/j.brat.2014.04.006

Cryan, J. F., O’Riordan, K. J., Cowan, C. S. M., Sandhu, K. V., Bastiaanssen, T. F. S., Boehme, M., Codagnone, M. G., Cussotto, S., Fulling, C., Golubeva, A. V., Guzzetta, K. E., Jaggar, M., Long Smith, C. M., Lyte, J. M., Martin, J. A., Molinero Perez, A., Moloney, G., Morelli, E., Morillas, E., O’Connor, R., Cruz Pereira, J. S., Peterson, V. L., Rea, K., Ritz, N. L., Sherwin, E., Spichak, S., Teichman, E. M., van de Wouw, M., Ventura Silva, A. P., Wallace Fitzsimons, S. E., Hyland, N., Clarke, G., & Dinan, T. G. (2019). The microbiota gut brain axis. Physiological Reviews, 99(4), 1877–2013. https://doi.org/10.1152/physrev.00018.2018

Edinger, J. D., Arnedt, J. T., Bertisch, S. M., Carney, C. E., Harrington, J. J., Lichstein, K. L., Sateia, M. J., Troxel, W. M., Zhou, E. S., Kazmi, U., Heald, J. L., & Martin, J. L. (2021). Behavioral and psychological treatments for chronic insomnia disorder in adults: An American Academy of Sleep Medicine clinical practice guideline. Journal of Clinical Sleep Medicine, 17(2), 255–262. https://doi.org/10.5664/jcsm.8986

Goldberg, S. B., Tucker, R. P., Greene, P. A., Davidson, R. J., Wampold, B. E., Kearney, D. J., & Simpson, T. L. (2018). Mindfulness based interventions for psychiatric disorders: A systematic review and meta analysis. Clinical Psychology Review, 59, 52–60. https://doi.org/10.1016/j.cpr.2017.10.011

Hofmann, S. G., Asnaani, A., Vonk, I. J. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta analyses. Cognitive Therapy and Research, 36, 427–440. https://doi.org/10.1007/s10608-012-9476-1

Liu, R. T., Walsh, R. F. L., & Sheehan, A. E. (2019). Prebiotics and probiotics for depression and anxiety: A systematic review and meta analysis of controlled clinical trials. Neuroscience & Biobehavioral Reviews, 102, 13–23. https://doi.org/10.1016/j.neubiorev.2019.03.023

National Institute for Health and Care Excellence. (2024). Menopause: Identification and management (NICE Guideline No. 23). https://www.nice.org.uk/guidance/ng23

Scullin, M. K., Krueger, M. L., Ballard, H. K., Pruett, N., & Bliwise, D. L. (2018). The effects of bedtime writing on difficulty falling asleep: A polysomnographic study comparing to do lists and completed activity lists. Journal of Experimental Psychology: General, 147(1), 139–146. https://doi.org/10.1037/xge0000374

Stubbs, B., Vancampfort, D., Rosenbaum, S., Firth, J., Cosco, T., Veronese, N., Salum, G. A., & Schuch, F. B. (2017). An examination of the anxiolytic effects of exercise for people with anxiety and stress related disorders: A meta analysis. Psychiatry Research, 249, 102–108. https://doi.org/10.1016/j.psychres.2016.12.020

The North American Menopause Society. (2022). The 2022 hormone therapy position statement of The North American Menopause Society. Menopause, 29(7), 767–794. https://doi.org/10.1097/GME.0000000000002028

The North American Menopause Society. (2023). The 2023 nonhormone therapy position statement of The North American Menopause Society. Menopause, 30(6), 573–590. https://doi.org/10.1097/GME.0000000000002200

Zaccaro, A., Piarulli, A., Laurino, M., Garbella, E., Menicucci, D., Neri, B., & Gemignani, A. (2018). How breath control can change your life: A systematic review on psychophysiological correlates of slow breathing. Frontiers in Human Neuroscience, 12, Article 353. https://doi.org/10.3389/fnhum.2018.00353

Medical and Mental Health Disclaimer

This article is for general educational purposes only and is not a substitute for individual medical, psychological or psychiatric assessment, diagnosis or treatment. If you are experiencing new, severe or worsening symptoms, significant impairment, thoughts of self harm or concerns about your safety, seek support promptly from an appropriately qualified healthcare professional or emergency service.

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