Are you starting to experience hot flashes and changes in your energy? Maybe the space between your periods is growing wider? These are some of the signs and symptoms of menopause. But what some women don't realize is that menopause and anxiety can also go hand in hand.

Hormonal changes can lead to mood disturbances, including anxiety, depression, and mood swings. You likely know this to be true just by experiencing hormonal changes during your monthly cycle. But menopause lasts a lot longer than three to five days a month, so it's important to address these symptoms if they're affecting your life.

A systematic review of studies linking menopause and anxiety observed a potential correlation, although more work needs to be done in this area (1). While the studies ranged in their measurement tools and objectives, at least eight of those studies showed that anxiety and hot flashes could be connected (2).

It's still unclear whether it's the mechanism that causes hot flashes or the emotional result of experiencing hot flashes that causes an emotional disturbance, but it's worth thinking about.

If you've been experiencing menopause symptoms alongside increased anxiety, depression, or panic attacks, you're not alone. Understanding how your mental and emotional health is related to your physical symptoms is a great place to start so you can get the help you need.

Symptoms of Menopause

Women who are experiencing menopause usually range in age from 40 to their late 50s, but the average age is 51 (3). Wherever you are in that range, you are likely experiencing the same physical symptoms as most women going through menopause or perimenopause. There are three main stages of menopause (4):

• Perimenopause: 3-5 years, when your hormones begin shifting.
• Menopause: 1-3 years, you've missed your menstrual cycle for 12 months straight.
• Postmenopause: begins after 12 months without a cycle. This phase marks the end of the menopausal transition and is associated with an increased risk of heart disease, osteopenia, and osteoporosis, due to the decrease in estrogen levels.

The Mayo Clinic reports that the most common symptoms of menopause include (3):

• Irregular periods
• Vaginal dryness
• Hot flashes
• Chills
• Night sweats
• Sleep problems
• Mood changes
• Slowed metabolism
• Weight gain
• Thinning hair
• Dry skin
• Loss of breast fullness

Menopause and Anxiety

Mood changes could include symptoms of anxiety, depression, mood swings, and even anxiety attacks. As much as 20% of women going through menopause experience some form of depression, especially at the beginning stages of perimenopause (5).

In fact, one Harvard study took a survey of premenopausal women (ages 36-44) without any history of depression, asking them about their mood and mental health. They then followed up with them nine years later and found that the perimenopausal women were twice as likely as the women who had not begun experiencing changes to have clinically significant depressive symptoms (6).

Another study observed that women who already had a history of depression or other mood disorders were more likely to experience depression and anxiety symptoms than women who had no history of mental illness (7).

The mechanisms behind these shifts likely have to do with a drop in estrogen. Estrogen levels affect both serotonin and norepinephrine, two of the main neurotransmitters that can impact mood (5).

Beyond the chemical changes, it makes sense that the physical changes that result from menopause could create mood changes on their own, whether you have a history of mental illness or not.

Women at the beginning of the transition are experiencing these changes in their bodies for the first time, and these changes mark the end of fertility and youthfulness. All people, including women, experience resiliency to different degrees, and those who are less resilient to change in general might feel more resistant to these natural changes.

Furthermore, in a culture where youth is valued beyond most other things, it can take a toll on women emotionally to recognize the signs of midlife changes (8). Hair, in particular, plays an interesting role in how women see themselves and their beauty.

Historically, women have used their hair in a number of ways to gain status, attract a partner, or get attention in some way. The social norms around women's hair have changed over time, but a simple Google search will reveal how important hair is to most women, across cultures and throughout history as well (9).

Although there are options to color and process hair to help women maintain their youthful appearance, the textural change and loss of thickness can take a toll psychologically, especially for women who strongly tie their identity to their hair.

The Role of Hot Flashes in Anxiety

There are a number of studies that observe a link between hot flashes (also called hot flushes) and anxiety. Hot flashes are not completely understood, but medical professionals suggest that they're likely related to changes in reproductive hormones and your hypothalamus (10).

The hypothalamus is your body's thermostat, and it can become more sensitive to slight body temperature shifts as you move through the stages of menopause.

The Mayo Clinic defines the symptoms of hot flashes as (10):

• A sudden feeling of warmth spreading through your upper body and face
• A flushed appearance with red, blotchy skin
• Rapid heartbeat
• Perspiration, mostly on your upper body
• A chilled feeling as the hot flash lets up

These symptoms not only affect your waking life but can dramatically affect your quality of sleep. Sleep is critically important for mood regulation, so there's a good chance that the sleep disruptions associated with hot flashes are at least partially to blame for mood disturbances during these years.

Sleep deprivation can create feelings of anxiety and lack of focus. It can also impede cognitive function and immune activity at any age. But it is especially harmful as we get older and become more susceptible to age-related illnesses (11)(12)(13).

Getting enough sleep is super important to help stave off some of the emotional side effects of hot flashes. Take steps to ensure your best night's sleep by keeping your bedroom cool, running a fan to keep air circulating, and sleeping in breathable, light-weight clothing and sheets.

Avoid synthetic materials that trap heat, and consider a cooling pad for your bed if you find that you're sweating a lot throughout the night. You might also consider having a cold pack on your night stand to place on the back of your neck if you wake up hot in the night.

More work needs to be done to better understand the connection between hot flashes and mood changes, but there does seem to be a consistent link, and getting enough sleep can surely help.

How to Manage Menopausal Anxiety

While an occasional mood swing is normal for just about anyone, on-going psychological symptoms can affect your overall quality of life. It's important to listen to your body and take care of yourself during the menopause transition. Ignoring these changes can affect your personal and professional relationships, which could make matters worse for your mood in the end.

Support Groups

One step that requires minimal physical intervention is finding a support group of women going through the same changes you are. By connecting with other women, you will not only realize that you're not alone in this process, you might also pick up some tips and tricks that have worked for the women in your group.

Lifestyle Changes

A healthy lifestyle can help improve your overall menopause experience. By staying active and eating lots of nutrient-dense foods, you can help your body naturally combat the symptoms of menopause, especially the mood swings, sleep disturbances, and hot flashes.

It might seem counterintuitive to voluntarily break a sweat if you're prone to hot flashes, but active people actually have better thermoregulation than sedentary people. One study showed that women who embarked on a 16-week exercise program reported experiencing fewer hot flashes (14). Another study asked women to rate their mood, sleep quality, and insomnia symptoms before and after a 12-week exercise program, and they saw improvements in all categories (15).

On the food front, eating foods rich in micronutrients and cutting sugar and processed foods helps reduce insulin spikes (which affect mood) and promote hormonal regulation. Two studies showed a connection between increasing fruits and vegetables and a decrease in the signs and symptoms of menopause (16)(17).

Staying on a good sleep schedule and maintaining good sleep hygiene is another way to help reduce symptoms. Stay away from bright lights after dark, take the blue light out of your phone or computer using an app or the built-in iPhone setting, avoid spicy or heavy foods before bed, and set up your room to be a cool-temperatured sanctuary for sleeping.

Herbal remedies like ashwagandha and berberine may also help keep symptoms away. (Keep in mind, however, that natural herbs and supplements aren't regulated by the FDA.) These herbs help promote a healthy hypothalamus, pituitary gland, and adrenal glands, which regulate the areas of concern for women going through menopause (18)(19). These areas include temperature regulation, sleep, metabolism, and energy.

Hormonal Replacement Therapy

Hormone replacement therapy (HRT), which adds estrogen or progestin back into the system, is a more aggressive medical option. Every woman is different, so it's important that your health care provider play a big role as you wade through the medical advice on this topic. HRT has been shown to improve cardiovascular health and reduce the risk of osteoporosis in menopausal women.

But some women experience side effects of hormonal therapy, including a slightly elevated risk of breast cancer (which goes away when use is stopped). Unopposed estrogen has a strong association with endometrial cancer in women who haven't had a hysterectomy, but adding progestin seems to strongly mitigate that risk.

There's also an increased risk in blood clotting on HRT, both venous (veins) and pulmonary (lungs) clots have occurred. Overall, the risks seem to only be relevant during the treatment, and once the treatment stops, the risks do as well (20).

Antidepressants

Many women have good luck with antidepressants as they move through the change. Selective serotonin reuptake inhibitors (SSRIs) can be a good place to start.

SSRIs are most commonly used for bipolar disorder, anxiety disorders, panic disorders, and sometimes for sleep disturbances. As we mentioned, estrogen is linked to serotonin, so considering this type of drug, even for temporary use, could help you get your mood and sleep back on track until things level out again.

Unfortunately, some women experience sexual side effects when using antidepressants (21). These can include loss of libido, difficulty in arousal, or lack of ability to orgasm. Other antidepressants that are not known to cause this side effect are available as well. These options are a different class of drug and include bupropion and duloxetine.

Take Care of Yourself

Only you can decide what's right for you. Starting with the least invasive options is the best way to reduce the risk of side effects and other potential health concerns, so we recommend looking at these options first. Lifestyle changes aren't always easy, but combining your efforts with a support group or a partner who wants to make similar changes will help you stay on track and keep your body in good shape.

Anxiety can be debilitating, so make sure you have the support you need as you move through this process, and listen to your body along the way.