Mood and stress · 17 minute read
Perimenopause anxiety is common and often new. Why shifting hormones trigger it, and what helps: from sleep to MHT to herbs.
Adrian Stone, nutritionist and naturopath
By Adrian Stone, BHSc (Nutritional Medicine), BHSc (Naturopathy), Living Holistic Health — the final part of our Stuck in Fight or Flight series: perimenopause anxiety, why it so often appears out of nowhere in your forties, and what genuinely helps.
Perimenopause anxiety is common, and it is often new. Swinging oestrogen and progesterone unsettle the brain’s calming chemistry and the stress system, and night sweats break sleep. What helps is layered: sleep, daily movement, CBT, checking iron and thyroid, and a conversation with your GP about menopausal hormone therapy.
At this stage of life, one sentence comes up in my consulting room more than any other. ‘I’ve never been an anxious person. Now I wake at 3am with my heart racing.’ Perimenopause anxiety is real, common and physiological. It is not a personality change.
This is also where the whole series meets. The stress system from Part 1, the nutrients from Part 2, the herbs from Part 3 and the burnout from Part 4 all land on a body whose hormonal brakes are shifting. Women have managed ‘the change’ with plant medicines for centuries, and modern trials now tell us which of those traditions hold up.
So, as in every part, I show two kinds of evidence separately. Traditional use records what a healing system has documented over centuries. Trials are a separate, modern test. A long tradition is not proof, and it never means something is safe for you.
Yes. Perimenopause anxiety is common, and it often appears in women with no history of anxiety. A large 2026 analysis estimated that roughly three in ten perimenopausal women have significant anxiety symptoms. Because fluctuating oestrogen and progesterone affect the brain’s calming chemistry and the stress response, anxiety can arrive years before periods stop.
That analysis pooled 102 studies covering more than a million women.1 It put anxiety symptoms at about 29% in perimenopause and depressive symptoms at about 32%, and the figures stayed high after menopause. In other words, if this is you, you are far from alone.
Perimenopause anxiety symptoms often include a racing heart, a sense of dread, irritability and new panic attacks. Many women also wake at 3 or 4am with a racing mind, feel overwhelmed and simply don’t feel like themselves. For a 44-year-old, these often sit alongside changing periods, hot flushes and broken sleep, which is why the full list of perimenopause symptoms is worth a look.
Perimenopause anxiety happens largely because hormones fluctuate rather than simply fall. Swings in oestrogen and progesterone, and in the calming brain chemicals made from progesterone, unsettle the stress system. Then add broken sleep from night sweats, midlife pressures and existing stress, and the nervous system tips into fight or flight more easily.
Researchers have proposed a model that links three things. First, the ovarian hormones swing. Second, the calming ‘neurosteroids’ made from them swing with them. Finally, the stress axis becomes more reactive.2 Here is the plain-English version. Progesterone is converted into a natural calming compound, allopregnanolone, that works on the same brain receptors as some anti-anxiety medicines. So when progesterone becomes erratic, that brake becomes unreliable.
That is why the timing feels so random. It is not only the level of a hormone that matters, but how quickly it changes.
Night sweats fragment sleep, and lost sleep pushes cortisol up. For example, in a classic study, one night of partial sleep loss raised cortisol the next evening by 37%.3 Cortisol also starts its natural climb in the early hours. As a result, a lighter sleeper wakes into that rise, and an unsettled nervous system turns it into racing thoughts.
Night sweats can run for years. In a large American study, hot flushes and night sweats lasted a median of 7.4 years.4 That is why it is worth addressing rather than waiting out. My colleague Morgan Helmling’s article on perimenopause fatigue covers sleep and the 3am waking in depth.
Some women are more vulnerable. Risk is higher with previous anxiety or depression, or a history of PMS, PMDD or postnatal depression. A family history of depression, stressful life events and severe hot flushes add to it. In one long-running study, a family history of depression roughly doubled the odds of major depression in midlife.5 Guidelines also note that most women with depression in perimenopause have had an episode before.6
Perimenopause raises the risk of depression as well as anxiety. One analysis found perimenopausal women had about 40% higher odds of depressive symptoms than women before perimenopause. Thyroid problems, low iron and heart rhythm issues can mimic perimenopause anxiety too. So persistent symptoms deserve a proper check, not an assumption that it is ‘just hormones’.
In that 2024 analysis, the odds were raised in perimenopause but not significantly after menopause.7 So the window of risk is the transition itself. If your mood is low, please talk to your GP, and if you feel unsafe, call Lifeline on 13 11 14.
Palpitations are common in perimenopause and are often hormone-related. Even so, new palpitations in midlife always deserve a GP review and usually an ECG. A 2026 Australian review points out that palpitations, breathlessness, fatigue and poor sleep in perimenopause can sometimes be unrecognised heart disease.8 Get them checked first; then you can work on the rest with a clear mind.
Irritability and anger are as common as anxiety, and they come from the same place: an unreliable hormonal brake plus poor sleep. Many women feel ashamed of it, but it is a physiological change, not a character flaw, and naming it is often the first relief.
Brain fog is usually a mix of broken sleep, shifting hormones and stress, and it tends to improve as those settle. Morgan’s article covers it alongside fatigue.
What helps perimenopause anxiety is a layered approach. First, protect sleep and manage night sweats, move daily and practise slow breathing. Then check for iron, thyroid and other contributors, and talk to your GP about menopausal hormone therapy, which has good evidence for mood in perimenopause. CBT also helps both anxiety and hot flushes.
Menopausal hormone therapy (MHT) is a medical decision, and it is a legitimate one. MHT and naturopathic support have different strengths, and there is room for both. In a 12-month trial of 172 women, oestrogen through the skin with intermittent progesterone roughly halved new depressive symptoms compared with placebo (17% versus 32%). However, the benefit showed up only in women in the early transition.9 A meta-analysis of 14 trials found oestrogen improved depressive mood, and perimenopausal women responded most.10 The Australasian Menopause Society also notes evidence that oestrogen has antidepressant effects, particularly in perimenopause.11
A UK clinic study of 920 women found mood scores fell by about 45% after they started or adjusted MHT.12 However, it looked back at records from a single private clinic, with no comparison group, so it is weaker evidence. Guidelines note that MHT is not approved for depression itself, and antidepressants remain first-line for major depression.6 Some GPs also use low-dose hormonal contraception in perimenopause; that, too, is an individual decision for your doctor.
Our work sits alongside that decision, never in place of it. Please don’t start, stop or change a hormone or other medicine because of anything you read here.
Cognitive behavioural therapy (CBT) has good evidence in menopause. One trial looked at 130 women after breast cancer. Group CBT reduced how much hot flushes were a problem by 46%, compared with 15% with usual care.13 It also improved anxiety, depression and sleep. That was a specific group of women, but CBT for menopause symptoms is supported more widely. Your GP can tell you how to access a psychologist.
A 2026 meta-analysis of 12 trials with 1,050 women found that exercise improved menopause symptoms, quality of life, anxiety and depression.14 The review also included mind-body practices such as yoga. So a daily walk with a friend counts. For the breathing how-to, see Part 4.
If sleep is broken, almost everything else is harder. CBT for insomnia is the first-line treatment, and perimenopause fatigue sets out the order we work in.
We arrange and interpret iron studies, thyroid tests, B12 and vitamin D, as well as hormone and cortisol testing. One honest note: a single blood test for FSH or oestrogen is unreliable in perimenopause, because levels swing from week to week. Instead, diagnosis is usually based on your age and symptoms. Our perimenopause testing post explains what blood tests can and can’t tell you. Heavy periods are also common in perimenopause and can drain iron, which Part 2 covers in more detail.
Several approaches outside medication have evidence in perimenopause, including regular exercise, CBT and correcting deficiencies such as low iron. However, some herbs used for hot flushes, such as black cohosh, carry safety warnings. Because perimenopause often overlaps with medicines and MHT decisions, get individual advice rather than stacking supplements.
A 2025 meta-analysis of 32 trials found non-drug approaches reduced depression, anxiety and sleep problems in midlife women. Nutritional and herbal approaches were also among the most consistent.15 The effects looked large, but the trials were small and varied, so treat the size with caution.
One honest caveat: the Australasian Menopause Society says there is no evidence to recommend complementary therapies for treating perimenopausal depression.11 So the herbs below are reported as research, mostly on symptoms such as hot flushes, sweating and sleep, alongside your GP’s care. They are not a treatment for depression or anxiety.
Here is how the main options stack up, rated on each layer separately.
Each layer is rated on its own: ●●● strong, ●●○ some, ●○○ limited. A long tradition is not evidence that something works or that it suits you.
Black cohosh
Sage
Saffron
Exercise and mind-body practice
Traditional use
Native Americans used black cohosh root traditionally, including for conditions related to women’s health.16 Later, 19th-century American physicians took it up, most notably for period pain and premenstrual complaints.17
What the trials show
The European Medicines Agency lists specific black cohosh extracts as a well-established medicine ‘for the relief of menopausal complaints such as hot flushes and profuse sweating’. In other words, that listing rests on clinical data rather than tradition.18 In a 2022 position statement, the Spanish Menopause Society concluded that one type of extract reduced hot flushes, especially intense ones, and also improved mood.19 As with kava and ashwagandha, the type of extract matters.
Safety
In Australia, black cohosh medicines must carry a warning that in very rare cases it has been associated with liver failure.20 Stop it and see your doctor if you notice yellowing of the skin or eyes, dark urine, nausea, unusual tiredness or stomach pain. The EMA also advises against combining it with oestrogens unless your doctor advises it, and against using it after breast cancer without medical advice.18
Traditional use
Sage leaf has a long history in European herbal medicine. The European Medicines Agency recognises its traditional use ‘for relief of excessive sweating’, including night sweats.21 It does not list hot flushes or menopause.
What the trials show
In a Swiss study of 71 postmenopausal women, hot flush scores fell by 50% at four weeks and 64% at eight weeks. The psychological part of the symptom score also fell, by 43%.22 However, there was no placebo group, and the women were past menopause rather than in it, so treat this as early evidence.
Safety
The EMA does not recommend sage in pregnancy or breastfeeding, and concentrated sage oil isn’t for home use.21 Cooking with sage is fine.
Perimenopause supplements are a crowded shelf, so here is the short, brand-free version. Among the herbs, saffron has the most trial evidence for mood, although the trials were in adults generally rather than in perimenopause. A 2026 analysis of 34 trials found modest improvements in self-rated anxiety and depression.23 Part 3 covers it in full, including its long history in Persian medicine and its safety notes.24
Magnesium and omega-3 have some evidence for sleep and mood, and Part 2 covers both. Iron, though, is worth taking only if a blood test shows you are low. Vitamin B6 needs care, because the TGA warns it can cause nerve damage.25
Ashwagandha needs care at this age too. The TGA has warned of a very rare but real risk of liver injury.26 A 2026 review of trials also found effects on thyroid hormone, which matters if your thyroid is already being checked or treated.27 St John’s wort is sometimes combined with black cohosh, but it interacts with the pill, antidepressants and blood thinners, among other medicines.
General information only, not individual medical advice. Always discuss supplements and herbal medicines with your treating practitioner.
See your GP if anxiety or low mood is affecting daily life, or if you have palpitations, chest pain or breathlessness. Very heavy or irregular bleeding needs a visit too, and so does any wish to discuss menopausal hormone therapy. If you are struggling to cope or feel unsafe, call Lifeline on 13 11 14.
Our perimenopause page and menopause page explain how we work alongside your GP.
We don’t diagnose or treat anxiety, depression or menopause-related conditions; that stays with your doctor. Our part is the nutritional, herbal and lifestyle work that sits alongside their care.
Perimenopause anxiety is common, physiological and manageable from several directions at once. Protect sleep, move daily, use your nervous system’s brake, check for contributors, and have the MHT conversation with your GP. Then add the nutritional and herbal support that suits you, with advice.
That is the thread through all five parts of this series. We want the body to do most of the work; we just want to create the right conditions for health and healing. Our mood and stress page brings the series together.
If perimenopause has brought anxiety you have never felt before, we can look at the whole picture with you, alongside your GP.
Geelong, Drysdale or telehealth
Stuck in Fight or Flight, the full series: Part 1: How to reduce cortisol · Part 2: Magnesium for anxiety · Part 3: Natural remedies for anxiety · Part 4: How to recover from burnout · Part 5: Perimenopause anxiety (this post)
It varies. For some women it settles after periods stop, but for others it continues, and one large analysis found anxiety symptoms just as common after menopause. Hot flushes last a median of about seven years. Even so, working on sleep, stress and hormones usually reduces how much it affects you.
Yes, it is very common. Night sweats and lighter sleep wake you just as your stress hormones naturally start rising in the early hours. An unsettled nervous system then turns that into racing thoughts, so sleep support usually helps more than anything else.
Yes. Some women have their first panic attacks in perimenopause, and palpitations or hot flushes can also feel like panic. Because heart rhythm problems can look similar, get palpitations checked by your GP.
Menopausal hormone therapy can improve mood for many women, especially when hot flushes and poor sleep are driving symptoms. One trial found fewer new depressive symptoms in women early in the transition. Still, it is an individual decision to make with your GP.
There is no single best supplement. Saffron, magnesium and omega-3 have some evidence for mood, and correcting low iron or B12 can make a real difference. Some hot flush herbs carry liver warnings, so get advice that accounts for your medicines and any MHT.
Yes, alongside your GP. A naturopath can look at sleep, stress, nutrition and contributors like iron and thyroid, and use evidence-informed herbal and lifestyle support. A good one will also tell you when MHT or other medical care is worth discussing.
Free 14-day tracker
Wired at night, awake at 3am, flat by the afternoon? It may not be just stress. A free two-page guide from Adrian Stone shows what’s worth asking your GP about, with a 14-day tracker for your pattern.
General information only, not individual medical advice. Always discuss supplements and herbal medicines with your treating practitioner.
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