Perimenopause and Mental Health: Changes in the Body, Mood, and Sexuality

Perimenopause is often talked about in terms of hot flashes, irregular periods, and sleep changes. But many women notice other changes too.

Their bodies may look or feel different. Anxiety or irritability may become more noticeable. Sexual desire may change. Sometimes the experience is less specific than that — they just know they do not quite feel like themselves.

Not every change in midlife is caused by perimenopause, and women do not experience this transition in the same way. But physical and emotional changes can happen alongside each other, and that overlap is easy to miss.

When the Body Starts to Feel Different

One change women may notice is that their body begins to carry weight differently.

Research from the Study of Women’s Health Across the Nation (SWAN) found changes in body composition around the menopause transition. Fat mass increased more quickly and lean mass began to decline. Body weight itself did not suddenly accelerate in the same way.

It is tempting to explain this simply as lower estrogen causing a slower metabolism, but the research is more complicated than that. Hormonal changes are part of the picture, along with aging, activity, sleep, muscle mass, and other metabolic factors.

What can be harder to talk about is how these changes actually feel.

Clothes fit differently. The shape of the body changes. A body that has felt familiar for years can begin to feel unfamiliar.

That can affect confidence and body image in ways that may seem superficial from the outside but often do not feel superficial at all. Changes in the body can bring up questions about aging, attractiveness, identity, and how someone feels in her own skin.

Anxiety, Mood, and Sleep

Mood changes can also become more noticeable during perimenopause.

Research has found increased vulnerability to depression during the menopause transition. Anxiety may also become more noticeable for some women. Hormonal changes may play a role, but so can disrupted sleep, hot flashes, life stress, and a previous history of anxiety or depression.

Sleep is often part of the picture too. Night sweats and hot flashes can interrupt sleep, which can then affect mood, concentration, energy, and the ability to manage stress.

A woman may come to therapy because she feels anxious, irritable, exhausted, or unable to concentrate. Those concerns may be what brings her to therapy.

At the same time, asking about sleep, menstrual changes, hot flashes, or other changes in health may give us a fuller picture of what she is experiencing.

Changes in Sexuality

Sexual changes are another part of perimenopause that may not be easy to talk about.

Some women experience less desire, while others notice little change or even more interest. Sexuality during midlife is influenced by many things, including sleep, mood, body image, medications, health conditions, relationships, and hormonal changes.

Changes in estrogen level can also contribute to vaginal dryness, irritation, reduced lubrication, and discomfort or pain during sex.

When desire changes, women may start asking themselves questions that are not purely medical.

• Why don’t I want sex the way I used to?

• Am I less attracted to my partner?

• Is something changing in my relationship?

• Is something wrong with me?

Sometimes the issue is physical. Sometimes it is relational. Often, several things are happening at the same time.

Fertility and the End of a Life Stage

Perimenopause also marks the transition toward the end of fertility. For some women, that feels like a relief. For others, there may be sadness or a sense that a stage of life is ending.

That does not necessarily mean wanting another child.

The feelings may have more to do with aging, sexuality, identity, or recognizing that life is changing.

There is no particular way a woman is supposed to feel about this transition.

Why It Can Be Difficult to Bring Up

These concerns do not always fit neatly into one appointment.

A woman may talk to her therapist about anxiety but not mention that her periods have changed. She may talk to her medical provider about hot flashes but not mention that she no longer feels comfortable in her body. She may experience pain with sex but feel embarrassed to ask about it. Or she may simply not know whether something belongs in a medical conversation or a mental health conversation.

That separation can make the experience harder to understand.

How to Start the Conversation

You do not need to know what is causing a change before talking about it.

With a medical provider, it can help to describe what has changed, when it started, and whether it is getting better, worse, or staying about the same.

This might include changes in periods, hot flashes, sleep, mood, anxiety, concentration, sexual desire, vaginal dryness or discomfort, energy, or changes in the body.

A simple question can be:

“Could perimenopause be part of what I am experiencing?”

You can also ask whether there are other health factors that should be considered and what treatment options may be available.

With a mental health provider, the conversation may be different. You might talk about what these changes mean to you.

• Do you feel less comfortable in your body?

• Has a change in sexual desire affected your relationship?

• Are you worried about aging?

• Do you feel unlike yourself and not know why?

You do not have to decide whether an experience is physical or psychological before bringing it up. Sometimes both may matter.

Perimenopause and Mental Health

The connection between perimenopause and mental health is something I have been thinking about more in my clinical work, and as I study women’s health through Harvard Medical School Executive Education.

When a woman comes to therapy feeling anxious, exhausted, uncomfortable in her body, less interested in sex, or simply unlike herself, it can be easy to focus only on the mental health symptoms.

Sometimes physical changes are happening at the same time. Mental health providers do not need to diagnose or treat menopause. But it is reasonable for us to ask about changes in health, notice when it may be helpful to talk with a medical provider, and make room for how these changes are affecting someone emotionally and relationally.

Medical care can also be more complete when women feel able to talk about the parts that may be harder to measure, including sexuality, body image, relationships, identity, and how they feel about themselves.

I am less interested in deciding whether an experience belongs to physical health or mental health than in making sure we do not miss part of the person by separating the two too quickly.

Sources and Further Reading

American College of Obstetricians and Gynecologists (ACOG). Mood Changes During Perimenopause Are Real. Here’s What to Know.

American College of Obstetricians and Gynecologists (ACOG). Menopause Symptom Tracker.

The Menopause Society. Sexual Health and Menopause.

Greendale GA, et al. Changes in Body Composition and Weight During the Menopause Transition. Study of Women’s Health Across the Nation (SWAN).