In the United States, more than 1.3 million women reach menopause each year. The transition to menopause, or perimenopause, marks the shift from reproductive to non-reproductive life. During this time, women often experience irregular menstrual cycles, including shorter or longer cycles, reflecting significant fluctuations in ovarian hormone secretion. Additionally, perimenopause is commonly associated with vasomotor symptoms, sleep disruption, and changes in cognitive functioning.

During the menopausal transition, many women experience the worsening or new onset of psychiatric symptoms, including depression and/or anxiety.  This may be attributed to the dramatic hormonal fluctuations that occur during the perimenopause; however, midlife women also experience increased life stressors that may contribute to increased vulnerability to depression and anxiety, including balancing increased professional demands, family caregiving responsibilities and major life transitions, like children leaving home.

The following article was written and updated by Ruta Nonacs, MD, PhD on February 1, 2025.

Table of Contents

Symptoms Associated with the Menopausal Transition

Most women begin the menopausal transition between the ages of 45 and 55; the average age of menopause — defined as 12 months since the final menstrual period — is 51 years in the United States. However, the menopausal transition can begin up to a decade before menopause, with menopausal symptoms lasting an average of 4 to 8 years. This means that many women face a combination of physical and emotional changes for a significant period of time before finally reaching menopause.

In addition to irregular menstrual cycles leading to the ultimate cessation of menstruation, the menopausal transition is often marked by:

• Vasomotor Symptoms: Hot flashes and night sweats affect 45-85% of women, sometimes even before menstrual irregularities begin.  A hot flash is described as a transient episode of flushing, sweating, and an intense sensation of heat, sometimes accompanied by palpitations and anxiety, followed by chills. 
• Sleep Disruption: Night sweats can interfere with sleep, leading to insomnia and fatigue. However, even in the absence of night sweats, sleep may become more fragmented and less restful.
• Cognitive Problems: About two-thirds of women report memory complaints, such as forgetfulness, during the menopause transition.  Poor sleep may worsen memory and impair concentration.
• Other Physical Changes: These may include skin changes, weight gain, sexual dysfunction, and increased risk of osteoporosis and cardiovascular disease.

The timing and severity of menopausal symptoms are highly variable and are likely influenced by multiple factors, including genetic vulnerability, race and ethnicity, culture, lifestyle, and environment. Compared to White women, Black women are more likely to experience an early onset of menopause and are more likely to suffer from more severe menopausal symptoms for a longer period of time. In contrast, Asian women are less likely to experience menopausal symptoms.

Women who undergo surgical menopause (removal of both ovaries) often experience more severe vasomotor symptoms immediately after surgery compared to those undergoing natural menopause.

Depression and the Menopausal Transition

It is now acknowledged that the perimenopause represents a time of increased risk for the onset, as well as the recurrence or worsening, of mood and anxiety disorders.  Potential risk factors for depression during the menopausal transition include:

• Lifetime history of major depressive disorder
• History of postpartum depression or premenstrual mood symptoms
• More severe vasomotor symptoms during perimenopause
• Recent stressful life events
• Poor physical health

During the perimenopause, fluctuating levels of estrogen and progesterone can directly influence neurotransmitters, including serotonin and dopamine, that play an important role in mood regulation. These hormonal shifts may exacerbate existing vulnerabilities, leading to the onset or recurrence of depression or anxiety symptoms.  Additionally, somatic symptoms (night sweats) can indirectly influence mood through sleep disruption.

Social and psychological factors may also play an important role in the onset or worsening of depressive symptoms and anxiety during the perimenopause. The menopausal transition can prompt increased focus on aging, identity, and life goals, leading to existential worries or a sense of loss. For many women, the menopausal transition coincides with other major life and role transitions, including changes in professional responsibilities and family structure, which may add additional layers of stress. 

Clinical Evaluation

A comprehensive evaluation ensures that menopausal symptoms are accurately attributed and underlying or comorbid conditions are not missed. Clinical assessment of women with menopausal symptoms must be holistic, integrating mental health, symptom burden, functional status, and exclusion of medical and psychiatric mimics to ensure appropriate diagnosis and individualized care

Assess Menopausal Status: Carefully obtain menstrual history to determine menopausal status.  For patients with irregular cycles, daily charting of symptoms may be helpful.

• Perimenopause: irregular cycles, changes in flow, new onset of symptoms
• Menopause: 12 months of amenorrhea not due to another cause

Document severity of the following symptoms and impact on daily functioning:

• Vasomotor symptoms: hot flashes, night sweats
• Genitourinary symptoms: vaginal dryness and discomfort
• Sleep: insomnia, disrupted sleep patterns, non-restorative sleep
• Psychological symptoms: depression, anxiety, mood swings, irritability, cognitive complaints (“brain fog”)
• Somatic symptoms: joint/muscle pain, headaches, fatigue

Evaluate for Major Depressive Disorder and Other Psychiatric Comorbidities: 

• Vasomotor Symptoms: Especially when severe, VMS are closely linked with depressive symptoms, and their presence often signals increased risk and severity of depression.
• Bipolar Disorder: While most depressive symptoms in this setting are indicative of unipolar depression, there is a small but measurable risk for the new onset of bipolar disorder during perimenopause. However, most cases are exacerbations in existing diagnoses
• Comorbid Anxiety: Estimates vary, although several studies have documented significant anxiety symptoms in about 50% of women during the menopausal transition. Anxiety symptoms may be more prominent in women with more severe vasomotor symptoms.

Standardized Questionnaires: May be helpful to assess severity of symptoms and document response to treatment.

• Menopause Rating Scale (MRS): Assesses severity of 11 common menopausal symptoms, including mood and physical changes.
• Greene Climacteric Scale: Evaluates 21 menopausal symptoms across psychological, physical, and vasomotor domains.
• Menopause-Specific Quality of Life Questionnaire (MenQoL): Measures how menopausal symptoms affect quality of life, including emotional well-being.
• Meno-D Rating Scale: Screens specifically for depression associated with perimenopause and menopause.
• Kupperman Menopausal Index (KMI): Classic scale that quantifies the severity of physical and psychological menopausal symptoms.
• Patient Health Questionnaire-9 (PHQ-9): General depression screening tool frequently used in medical populations to assess mood symptoms.

Lifestyle Modifications and Non-Pharmacologic Interventions 

A holistic approach to managing symptoms during the perimenopause and menopause is essential. Evidence-based lifestyle modifications and non-medication interventions can be effective for many women—especially for those with milder symptoms.  

Managing Vasomotor Symptoms: The following have been associated with decreases in the frequency and severity of vasomotor symptoms:

• Avoidance of caffeinated beverages
• Abstaining from alcohol
• Regular aerobic exercise
• Weight loss – Especially when combined with a healthy low-fat diet

Sleep Interventions: Because sleep disruption is so common during the menopausal transition, providing effective sleep strategies is essential.  Furthermore, addressing sleep problems may lead to significant improvements in mood, cognitive functioning and quality of life. 

• Sleep Hygiene: Establishing a regular bedtime routine, limiting screen time and caffeine in the evening, and keeping the bedroom at a cooler temperature can improve sleep quality.
• Cognitive-Behavioral Therapy for Insomnia (CBT-I): This structured, evidence-based therapy targets dysfunctional beliefs and behaviors around sleep. CBT-I improves sleep quality, lowers sleep-related anxiety, and is recommended as first-line treatment for insomnia during menopause.

Psychotherapy: During the menopausal transition, women may benefit from structured psychotherapeutic interventions that address both mood and physical symptoms. Several types of psychotherapy have demonstrated effectiveness in research and clinical practice for this population, especially for managing depressive symptoms, anxiety, insomnia, and vasomotor symptoms.

• Cognitive-Behavioral Therapy: CBT-Meno is effective for the management of vasomotor symptoms, depression, and sleep problems in perimenopausal women.
• Mindfulness-Based Cognitive Therapy (MBCT) for Menopause:  Several studies and systematic reviews support the use of mindfulness-based cognitive therapy (MBCT) for menopausal symptoms:
• Relaxation Training: Mind-body therapies such as progressive muscle relaxation, guided imagery, and breathing exercises help alleviate hot flashes, improve sleep, and decrease overall stress.

Acupuncture: Some randomized trials suggest acupuncture may modestly reduce vasomotor symptoms.

Hormonal Therapies for Menopause-Related Symptoms

Historically hormone replacement therapy (HRT) was the primary treatment for menopause-related symptoms, and many women remained on HRT for prolonged periods of time; however, results of large, prospective studies (e.g., HERS, WHI) have raised concerns regarding the safety of long-term use of HRT.  Newer research indicates that short-term HRT (up to 3-5 years) remains a viable treatment option, especially for women with more severe vasomotor symptoms.  

HRT is typically used within 10 years of menopause onset and in women with no contraindications, such as: 

• History of breast cancer or other estrogen-sensitive cancer
• Undiagnosed vaginal bleeding
• History of venous thromboembolism (DVT, pulmonary embolism)
• History of stroke, myocardial infarction, or angina

Women who have undergone hysterectomy may safely use estrogen-only HRT.  

In contrast, women with an intact uterus require a combination of estrogen and a progestin to protect against endometrial hyperplasia and cancer.  Common regimens include continuous combined therapy, in which both hormones are taken daily, or a cyclic regimen, where progestin is added to estrogen for only part of each month. Estrogen can be administered orally or via a patch or gel, while progestins may be provided in oral, transdermal, or intrauterine forms.

Combining HRT with an antidepressant may be useful for women with moderate to severe depression or when monotherapy is insufficient.

Non-Hormonal Treatments for Menopause-Related Symptoms

While there is data to support the short-term use of HRT; many perimenopausal are not good candidates for hormonal therapies.  Women and their providers must weigh the risks and benefits of HRT and should consider alternative treatments for menopause-related symptoms:

Antidepressants: SSRIs and SNRIs have been shown to alleviate vasomotor symptoms and are also effective for managing anxiety and depressive symptoms.

Gabapentin (Neurontin): Low-dose gabapentin is effective for vasomotor symptoms and may have significant benefits for sleep quality.

Clonidine: Typically used as an antihypertensive, clonidine may be also used to treat vasomotor symptoms.  The overall evidence from clinical trials suggests that clonidine does not improve mood.

Neurokinin 3 (NK3) Receptor Antagonists:  The first in this class – fezolinetant (marketed as Veozah) – was approved by the FDA in 2023 for moderate to severe hot flashes. This medication works by blocking NK3 receptors in the brain, which play a role in regulating body temperature. Clinical trials of NK3 receptor antagonists have focused on hot flashes, sleep disturbance, and overall quality of life, and have not examined the impact of this class of medication on mood.

While fatigue and memory complaints are common during the menopausal transition, treatment options targeting these symptoms are limited.  Treatment of underlying sleep problems and depressive symptoms or anxiety may yield some benefit.  Several small studies have demonstrated the beneficial effects of transitional stimulants and wake-promoting agents, including modafinil and armodafinil.  

Alternative therapies, including black cohosh, soy isoflavones, and bioidentical hormones, are commonly used to treat menopausal symptoms; however, data supporting their benefits is sparse.  

Seeking Care

Women experiencing mood or anxiety symptoms during the menopausal transition may benefit from a comprehensive evaluation by a mental health professional in collaboration with a gynecologist.  If you are in or near the Boston area or Massachusetts, you may schedule a consultation at the MGH Center for Women’s Mental Health by contacting our intake coordinator at 617-724-7792.

For those living outside of the Boston area, the Menopause Society maintains a Directory of Healthcare Providers caring for individuals with menopausal symptoms.

Other resources may be found on our RESOURCES PAGE.

Research Opportunities

There are currently no active studies for MENOPAUSAL SYMPTOMS at the Center.  Learn more about our RESEARCH PROGRAM.