It Wasn’t Just Anxiety: The Perimenopause Conversation We Should’ve Been Having All Along

Around 40, things changed. Fast.

Night sweats that made no sense. Itchy ears that no one talks about. Brain fog so thick I’d lose words mid-sentence. A strange, disorienting sense that parts of my identity were harder to access, and a body that suddenly felt unfamiliar. Not gone, but not really there anymore.

And like a lot of women, the first narrative handed to me was anxiety, maybe depression, stress.

Which—sure. Those things exist. But this felt different, and more importantly, it wasn’t being understood correctly.

For years, women have been walking into doctor’s offices and therapy sessions trying to explain something that didn’t quite fit. Instead of expanding the framework, we kept forcing the experience into mental health diagnoses that only told part of the story.

On the surface, perimenopause can look like anxiety or depression—mood swings, irritability, low energy, disconnection, trouble concentrating, sleep disruption. That vague sense that something is off. But underneath it, there’s something else happening: hormonal shifts that impact the brain, the nervous system, and emotional regulation in ways we’re only recently starting to take seriously.

As Dr. Mary Claire Haver puts it, “Perimenopause is not a disease—it’s a natural transition. But the symptoms are real, and they deserve to be treated.”

And those symptoms don’t just stay physical—they hit mental health in a very real way.

Estrogen isn’t just about reproduction; it plays a role in serotonin, dopamine, and overall brain function. So when those levels start fluctuating, mood, focus, and emotional regulation shift with it. What I see clinically—and what many women experience—is a kind of mental and emotional whiplash.

You might feel more reactive than you used to be, or more flat, or both depending on the day. Small things feel bigger, big things feel overwhelming, and your capacity to tolerate stress narrows. The margin you once had just isn’t there in the same way, and that can be incredibly disorienting.

Because you know yourself. You know how you typically show up. And suddenly, your reactions don’t match the version of you that you’ve been for years.

That’s where a lot of the secondary distress comes in. It’s not just the symptoms—it’s the meaning we make of them. The quiet questions that start to creep in: Why can’t I handle this? What’s wrong with me? I shouldn’t feel this way.

Now we’ve layered shame on top of a physiological shift.

Dr. Mindy Pelz speaks to this gap, pointing out that women are often “treated for the symptom, not the root hormonal shift driving it.” So we pathologize it. We diagnose anxiety, depression, maybe even mood disorders. And again, those can absolutely be present. But when we don’t look at the hormonal piece, we risk missing a huge part of what’s actually going on—and that matters, because the treatment approach changes when we understand the full picture.

This isn’t just in your head. It’s in your body.

And for a long time, the treatment didn’t match the problem. Women were handed SSRIs, told to manage stress better, maybe encouraged to talk it out in therapy. While those things can help, they don’t address what’s actually driving a lot of this. We missed the physiological piece.

That’s starting to change.

Hormone replacement therapy—once dismissed or misunderstood—is coming back into the conversation as a legitimate option. There’s more research, more openness, and more willingness to actually listen to what women have been saying for decades.

At the same time, there’s another shift happening that doesn’t get talked about enough: tolerance drops.

Things you used to carry, smooth over, or make space for start to feel unnecessary, exhausting, or just not worth it anymore. For a lot of women, this shows up as less people-pleasing, fewer contortions to keep the peace, and a clearer sense of what’s okay and what isn’t.

It’s not dramatic or explosive. It’s quieter than that—more of a grounded I’m not doing that anymore.

There’s something powerful in that.

That doesn’t mean this phase is easy. There’s grief here too—grief for how things used to feel, frustration with a body that isn’t as predictable, moments of apathy or disconnection that don’t quite make sense. But there’s also a recalibration happening, a stripping away of what was never sustainable to begin with.

From a clinical standpoint, this matters. If we only look at this through a mental health lens, we miss the full picture. We risk pathologizing something that is, in many ways, a natural transition—one that deserves both medical and psychological support.

It’s not either/or. It’s both.

We need better screening, better education, and a more integrated approach that considers hormones, the nervous system, identity, and life stage simultaneously.

And maybe most importantly, we need to start trusting women when they say something feels off.

Because for a long time, we’ve been right.