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Anxiety in menopause

Anxiety in menopause often arrives as something new: worry, a racing heart or panic in your 40s can be part of perimenopause. In SWAN, women who hadn't been anxious before were more likely to develop high anxiety during and after the transition. Hot flashes, palpitations and broken sleep feed it. CBT helps, HRT can help when anxiety starts with other menopause symptoms, and persistent anxiety still deserves full treatment.

New anxiety or panic attacks in your 40s can be hormonal. How perimenopause affects anxiety, how to tell it apart, and treatments including HRT and CBT.

Find your stage · 2 min 14 sources

Anxiety in menopause: expectation vs reality

What people often expect

“If you've never been anxious, midlife anxiety must be about life events”

What the evidence shows

SWAN followed 2,956 women aged 42 to 52 for 10 years. Women with low anxiety before the transition had higher odds of high anxiety in early or late perimenopause or postmenopause than before it, odds ratios of 1.56 to 1.61, even after accounting for upsetting life events, financial strain, poor health and hot flashes. So the transition itself seems to raise anxiety for women who weren't anxious before.

Why perimenopause causes anxiety

Perimenopause raises anxiety in women who weren't anxious before

SWAN scored anxiety from four symptoms rated over the previous 2 weeks, with high anxiety in the top fifth. For women who were calm at the start, the odds of high anxiety were higher in early perimenopause, late perimenopause and after menopause than before the transition. Women who were already highly anxious stayed that way throughout, but their risk didn't climb further with each stage.

Hot flashes, palpitations and anxiety feed each other

Physical symptoms overlap. The NHS lists difficulty sleeping, palpitations, dizziness, tension and stomach problems among anxiety symptoms, and describes hot flashes that bring palpitations or anxiety. When a flash sets your heart racing, it can feel like the start of a panic attack, and worry about the next one keeps you on edge. Each cluster can amplify the other until flashes and sleep are treated.

Poor sleep makes menopause anxiety worse

Sleep problems can make you feel irritable, stressed and anxious, and they're worse if you also have night sweats. The NHS notes that getting enough sleep gives you the energy to cope with difficult feelings. In perimenopause, when sleep is often broken, anxiety and insomnia easily lock into a cycle, which is why treating sleep is part of treating anxiety.

Anxiety attacks and panic in perimenopause

Panic attacks are sudden bursts of intense fear with a pounding heart, breathlessness, sweating and dizziness. In perimenopause, the palpitations, heat and dizziness of a hot flash can trigger panic in someone who has never had it, or be mistaken for it. Panic disorder is a recognized type of anxiety disorder, and it's common to have more than one anxiety disorder at the same time.

Anxiety and depression often come together

Many people with depression also have symptoms of anxiety, and low mood is listed among the symptoms of generalized anxiety disorder. The NHS notes that hot flashes may improve over time and be replaced by other symptoms such as low mood and anxiety. So anxiety that starts in perimenopause can come with, or turn into, low mood, and both respond to CBT and, if needed, medicine.

How common is anxiety in menopause?

From the studies on this page

higher odds of high anxiety in perimenopause or after, for women not anxious before
1.56–1.61×
Relative odds vs comparison group (1× = same odds)

2,956

women were followed for 10 years in the SWAN anxiety analysis

Studies measure anxiety in different ways, so there's no single figure for how many women get it around menopause. The NHS describes anxiety as common at this time.

Anxiety symptoms that need a closer look

The racing heart, sweating and dizziness of anxiety overlap with several physical conditions. These are worth ruling out, especially if anxiety is new.

Overactive thyroid
Check →
Anxious, restless, irritable, with weight loss, a racing heart and feeling hot.
Test: TSH blood test
Heart rhythm problems
Check →
Palpitations that come on out of the blue, last minutes, or come with fainting.
Test: ECG
Caffeine, alcohol or medicines
Worse after coffee, drinking, or a new medicine.
Test: Cut back for two weeks
Generalized anxiety disorder
Hard-to-control worry about many things, most days, for at least 6 months.
Test: Doctor's assessment
Iron deficiency anemia
Check →
A racing heart and breathlessness with tiredness and heavy periods.
Test: Full blood count and ferritin

Anxiety treatment in perimenopause and menopause

CBT for menopause anxiety
Strong evidence
The NHS recommends cognitive behavioral therapy for low mood and anxiety around menopause and notes it can help sleep. For generalized anxiety, doctors usually suggest talking therapy before medicine. NICE suggests menopause-specific CBT for hot flashes and the sleep problems they cause, which often come with midlife anxiety. In the UK you can often refer yourself to talking therapy services.
HRT for menopause anxiety
Some evidence
The NHS lists relief of anxiety and low mood caused by menopause among HRT's benefits, alongside hot flashes and sleep problems, and says symptoms often improve within days or weeks. NICE says to consider HRT for low mood that starts alongside other menopause symptoms. Longstanding anxiety may still need CBT or other treatment.
Related guide →
SSRIs for anxiety
Strong evidence
If anxiety is severe or doesn't respond to therapy, the usual medicine is an SSRI antidepressant. Some SSRIs also reduce hot flashes, which can help women with both. NICE doesn't recommend SSRIs as the first treatment for hot flashes alone, so the reason for taking one should be anxiety or depression.
Exercise, breathing and rest
First step
The NHS suggests regular exercise such as running, walking, swimming or yoga, calming breathing exercises, relaxing activities and as much rest as you can get. Eat regular meals to keep energy stable. Avoiding smoking and limiting alcohol and caffeine can also ease the hot flashes and palpitations that drive anxious nights.
Treat hot flashes and insomnia behind anxiety
If this is the cause
Treating hot flashes and insomnia often lowers anxiety. SWAN adjusted for hot flashes and still found higher anxiety in the transition, so they're not the whole story, but the NHS notes that sleep problems and flushes make mood worse when they stack together. Cooling the bedroom, CBT for insomnia and, where suitable, HRT or non-hormonal medicines for hot flashes all reduce the physical triggers that set anxiety off at night.
Related guide →

When menopause anxiety needs a doctor

Urgent: You're in crisis or feel unsafe
Call or text 988. In the UK, call 111 (mental health option) or Samaritans on 116 123. In an emergency, call 911 (999 in the UK).
Urgent: Palpitations with chest pain, breathlessness or fainting
Call 911 (999 in the UK). Don't drive yourself.
Anxiety most days that affects your life
See a doctor. Talking therapy and medicines work.
Treatments for anxiety aren't helping
Go back to your doctor. You may need a different therapy, a medicine, or a referral to a specialist team.

Menopause anxiety: questions women ask

Can perimenopause cause anxiety?

Yes. In SWAN, women without prior anxiety were more likely to develop high anxiety during and after the transition, even after accounting for life stress and hot flashes. The NHS lists anxiety among common menopause symptoms.

Can perimenopause cause panic attacks?

The palpitations, heat and dizziness of perimenopause can trigger panic, and anxiety risk rises in the transition. A hot flash can also be mistaken for a panic attack. A doctor can help tell them apart and treat both.

Does HRT help menopause anxiety?

The NHS lists relief of menopause-related anxiety and low mood among HRT's benefits. For longstanding anxiety, CBT or other treatment may be needed too. NICE also says to consider HRT when low mood starts at the same time as other menopause symptoms. Many women use HRT and CBT together.

What are the symptoms of menopause anxiety?

Worry that's hard to control, restlessness, irritability, trouble concentrating, tiredness, tension, trouble sleeping, stomach problems, palpitations and feeling lightheaded. In menopause these often come with hot flashes and night sweats, which can make them worse.

Can menopause cause anxiety and depression?

Yes. Both become more likely during the transition, and they often occur together. The NHS notes that hot flashes can fade and be replaced by low mood and anxiety. CBT helps both, and HRT can help when they start alongside other menopause symptoms.

How do you treat perimenopause anxiety?

Talking therapy, usually CBT, comes first, with regular exercise, breathing exercises and good sleep. If anxiety started with hot flashes and other menopause symptoms, HRT may help. An SSRI is the usual medicine if anxiety is severe. Treating night sweats and insomnia removes fuel for anxiety.

Why do I feel nervous for no reason in perimenopause?

Hormone changes in the transition raise anxiety risk even without an obvious trigger, SWAN found. Palpitations and hot flashes can create physical feelings of nervousness that the mind then tries to explain. If nervousness is constant or affecting your life, see a doctor.

How long does menopause anxiety last?

There is no fixed timeline. In SWAN, higher anxiety risk continued from early perimenopause into postmenopause for women who had not been anxious before, so it can last years without treatment. The good news is that CBT, better sleep and, where appropriate, HRT or an SSRI work well, so there is no need to wait for it to pass.

Sources

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Anxiety in menopause

Anxiety in menopause: expectation vs reality

Why perimenopause causes anxiety

Perimenopause raises anxiety in women who weren't anxious before

Hot flashes, palpitations and anxiety feed each other

Poor sleep makes menopause anxiety worse

Anxiety attacks and panic in perimenopause

Anxiety and depression often come together

How common is anxiety in menopause?

Anxiety symptoms that need a closer look

Overactive thyroid

Heart rhythm problems

Caffeine, alcohol or medicines

Generalized anxiety disorder

Iron deficiency anemia

Anxiety treatment in perimenopause and menopause

CBT for menopause anxiety

HRT for menopause anxiety

SSRIs for anxiety

Exercise, breathing and rest

Treat hot flashes and insomnia behind anxiety