Menopause, Mood and the Mind: Reflections from Clinical Practice on Mental Health in Midlife

Oona McEwan
Oct 18
5 min read

Many women expect hot flushes. Some expect the sudden anxiety at 3am, the dip in confidence at work, or the inexplicable sense that their mood is no longer anchored in the way it once was. In clinic, I often hear women say, “I thought I was coping fine—then my mood just changed, and I couldn’t explain why.”

As a clinical psychologist, I see how often mental health changes during perimenopause are misinterpreted as a personal failing or “just hormones.” The reality is more complex. Research over the past decade has clearly shown that perimenopause is associated with an increased risk of low mood and anxiety, particularly when symptoms like sleep disturbance and vasomotor changes are present (Freeman, 2015; Brown et al., 2024).

What Actually Changes During Perimenopause?

Perimenopause is not a steady decline in hormones—it is a period of neuroendocrine fluctuation, where oestrogen levels rise and fall unpredictably. These hormonal shifts interact with neurotransmitters involved in sleep, affect regulation and stress response (Freeman, 2015). Large cohort studies show that new-onset depressive symptoms are more common during perimenopause than before the transition, with mood often improving again postmenopause (Badawy et al., 2024). This suggests that mood changes at this stage are not simply “psychological” but are biologically primed—though always interacting with life context.

The Role of Sleep and Vasomotor Symptoms

During psychological interventions, we rarely speak about mood without exploring sleep. Night sweats and disrupted temperature regulation can fragment sleep, and research consistently links poor sleep with increased risk of depression and anxiety in menopause (Tomida et al., 2021; Natari et al., 2018).

This relationship appears bidirectional - hot flushes disrupt sleep, and sleep loss heightens emotional reactivity, making hot flushes feel more overwhelming (Natari et al., 2018). When sleep is targeted - whether through psychological strategies or medical treatment—mood sometimes stabilises quickly.

Life Load Matters Too

While hormones play a role, context is equally powerful. This stage of life often coincides with complex responsibilities: caring for ageing parents, supporting adolescents, managing work demands, navigating relationship changes or identity shifts. UK studies have noted that perceived lack of personalised menopause care can contribute to feelings of being dismissed or unsupported (Albano et al., 2023).

In this landscape, even a small change in sleep or mood regulation can tip someone into distress. It’s not a sign of weakness, it’s an entirely understandable response to cumulative load.

Mental Health During Menopause

What Helps: Evidence-Based Approaches

1. Hormone Replacement Therapy (HRT)

For women experiencing vasomotor symptoms or insomnia, HRT can reduce symptoms and indirectly improve mood, with some studies noting antidepressant effects in perimenopausal women (Borozan et al., 2024; Wium-Andersen et al., 2022). In the UK, NICE guidance recommends a collaborative discussion of risks and benefits rather than a blanket approach (NICE, 2024).

2. Therapy

While Cognitive Behavioural Therapy (CBT) has strong evidence base for managing menopausal symptoms such as anxiety, low mood, hot flush distress and sleep disturbance (Spector et al., 2024), a range of psychological approach are useful for managing symptoms. In clinical practice, we also draw on Acceptance and Commitment Therapy (ACT) to help women develop psychological flexibility when facing fluctuating symptoms and uncertainty, and Compassion-Focused Therapy (CFT) to address the self-criticism and shame that can surface around perceived changes in identity, appearance or productivity. Some women also benefit from nervous system–based interventions, such as grounding techniques and paced breathing, which can reduce sympathetic arousal during hot flushes or moments of panic. These approaches are not about “thinking positively” but about regulating the stress response, supporting identity through transition, and helping women respond to symptoms with agency rather than fear.

3. Supporting Sleep and the Nervous System

Sleep plays a central role in emotional resilience during menopause, and disrupted sleep, particularly due to night sweats or early waking, can significantly amplify feelings of anxiety, irritability and low mood (Tomida et al., 2021). Rather than focusing purely on cognitive techniques, we often work with women to regulate the nervous system and create conditions that support restorative sleep, which may include temperature regulation strategies, gentle evening routines that downshift the stress response, breathwork to reduce nocturnal adrenaline surges, and pacing stimulants such as caffeine and alcohol. Understanding that night-time awakenings are a physiological response, not a personal failing, can reduce distress around sleep and lower reactivity during the night. For some, small environmental adjustments and body-based calming practices make a noticeable difference long before formal sleep therapy is needed.

4. Recognising Systemic and Social Change in Midlife

Psychological well-being during menopause cannot be separated from the systemic and relational contexts women are living in. Research consistently shows that workplace pressures, lack of flexible policies, caring responsibilities for ageing parents or teenagers, and unequal distribution of emotional labour all contribute to heightened stress during this period (Albano et al., 2023; Brown et al., 2024). Women in midlife often describe feeling "stretched thin," carrying multiple roles with limited cultural recognition of their load. Studies in UK healthcare settings highlight that when menopause is viewed purely as an individual medical or psychological issue, the wider structural factors, such as under-resourced menopause care, limited workplace accommodations and cultural narratives that expect women to absorb change silently, are overlooked. From a psychological perspective, naming these pressures can be regulating in itself, helping women understand that their distress is not solely internal but a valid response to intersecting physiological change and systemic strain. Support with advocacy for systemic change can be incredibly impactful.

A Note from Clinic

One of the most powerful shifts we see is when women understand that their experience during menopause is not a matter of “coping better,” but a valid physiological and psychological response to change. Tracking symptoms, protecting sleep, asking informed questions about treatment options, all of this is not overreacting. It is self-advocacy. But self-advocacy does not mean women should carry the burden alone. Increasingly, research and clinical practice point to the importance of systems adapting to women, not just women adapting to systems. Whether that means asking for workplace adjustments, longer appointment times, or more menopause-aware clinical pathways, these requests are not inconveniences, they are part of a necessary cultural shift. Naming the need for support is not a personal failing; it is a step toward creating environments that recognise and respond to women’s health with accuracy, respect and equity.