Perimenopause Depression vs Anxiety: How to Tell the Difference and What to Do About Each

When you can't tell if you're sad, anxious, or both

You're lying in bed at 3am with your heart racing, dreading tomorrow. Is that anxiety? You've lost interest in things you used to enjoy. You feel heavy and slow. Is that depression? Some mornings it's both at once, and some days you genuinely cannot tell what you're feeling, only that it doesn't feel like you.

Depression and anxiety are the two most common psychological symptoms of perimenopause, and they frequently overlap. But they have different hormonal drivers, different patterns, and different treatment approaches. Learning to distinguish them helps you describe what you're experiencing to your doctor, seek the right support, and stop blaming yourself for something your body is generating at a chemical level.

This guide breaks down both conditions: what causes each one during perimenopause, how to tell them apart, and what helps.

The hormonal chemistry behind mood and anxiety changes

Both depression and anxiety during perimenopause have identifiable biological roots. You are not imagining them, and they are not the same thing.

Estrogen and serotonin: the depression connection. Estrogen has a direct relationship with your serotonin system. It increases serotonin production, enhances the sensitivity of serotonin receptors, and slows the breakdown of serotonin in the brain. When estrogen levels decline or fluctuate wildly (as they do during perimenopause rather than declining in a straight line), serotonin availability becomes unpredictable. Low or unstable serotonin is one of the primary biological contributors to depression. This is why the first emergence of depressive symptoms in perimenopause often correlates with the most erratic phases of estrogen fluctuation, rather than with the lowest estrogen levels.

Progesterone and GABA: the anxiety connection. Progesterone is your nervous system's natural calming agent. It enhances the activity of GABA, the brain's primary inhibitory neurotransmitter. GABA tells your nervous system to slow down, stop scanning for threats, and rest. During perimenopause, progesterone is typically the first hormone to decline significantly, often before estrogen drops noticeably. When progesterone falls, GABA activity weakens. The result is a nervous system that is more reactive, harder to settle, and more likely to experience anxiety. This is why many women notice anxiety as their first perimenopause psychological symptom, even before their cycles have become notably irregular.

Where they overlap. Chronic anxiety depletes serotonin over time, which can lead to depression. Chronic sleep deprivation, which is common in perimenopause and driven partly by night sweats and partly by cortisol dysregulation, worsens both. Cortisol, the stress hormone, runs higher during perimenopause in many women and contributes to both anxious and depressive symptoms simultaneously. This is why it is genuinely common to experience both conditions at once during this transition.

How to tell depression and anxiety apart

Anxiety and depression feel different in quality, even when they overlap in timing.

Anxiety in perimenopause tends to feel like: a physical tension or tightness that doesn't fully release, racing thoughts or an inability to slow your mind, excessive worry about future events, a sense of dread or apprehension without a clear cause, difficulty falling asleep because your mind won't stop, heart palpitations, a feeling of being on edge or easily startled, and occasionally full panic attacks.

Depression in perimenopause tends to feel like: a flattening of emotion rather than an intensification, loss of interest or pleasure in things you normally enjoy, a heaviness in the body, fatigue that doesn't lift even after adequate rest, a sense of hopelessness or the feeling that things won't improve, difficulty concentrating or making decisions, withdrawal from people and activities, and sometimes a low-level irritability that isn't quite anger.

The key question to ask yourself: Is my primary experience one of emotional intensity, even painful intensity (anxiety)? Or is it one of emotional flatness, loss, and slowing down (depression)? Both are painful. Anxiety tends to be electrically painful. Depression tends to be heavily, quietly painful.

Overlapping presentations. Anxious depression is very common during perimenopause. Symptoms include feeling both wired and exhausted at the same time, being unable to relax but also unable to take action, worrying constantly about things while simultaneously feeling too flat and hopeless to address them. If this description feels familiar, you are likely dealing with both, and treatment needs to address both.

Hormonal depression versus clinical depression. Hormonal depression is specifically triggered by hormonal fluctuation. It often improves during periods of hormonal relative stability (certain parts of your cycle, or after you're through the transition into postmenopause) and worsens during hormonal volatility. Clinical depression can occur independently of hormonal changes and may have been present before perimenopause. The distinction matters because hormonal depression often responds well to hormonal treatment, while clinical depression typically requires antidepressant therapy, psychological treatment, or both.

What does the research say?

The research on perimenopause mood changes has become significantly clearer over the past decade.

A landmark longitudinal study, the Study of Women's Health Across the Nation (SWAN), followed thousands of women through the menopausal transition. It found that women were significantly more likely to report depressive symptoms during perimenopause than before or after it. The risk was highest during the early stages of the transition when estrogen fluctuates most erratically. This pattern supports the hormonal fluctuation hypothesis rather than a simple "low estrogen causes depression" model.

For anxiety, research consistently shows that perimenopause is a vulnerable period for new-onset anxiety disorders, including generalized anxiety, panic disorder, and health anxiety. Women with no prior history of anxiety can develop it during perimenopause due to progesterone loss and cortisol dysregulation. Research published in Menopause found that anxiety symptoms were more prevalent during the menopausal transition than before or after it.

The relationship between sleep disruption and both depression and anxiety during perimenopause is well-established. Studies find that treating sleep disruption (whether through behavioral, hormonal, or pharmacological means) improves mood and anxiety outcomes. This matters practically: sometimes targeting sleep is the most direct first step.

For treatment, research supports estrogen therapy for both perimenopausal depression and anxiety, particularly for women whose symptoms are clearly hormonally driven. Antidepressants (particularly SNRIs and SSRIs) have good evidence for both conditions. CBT has strong evidence for anxiety and moderate evidence for depression. Physical exercise has meaningful evidence for both.

When lifestyle approaches aren't enough

Exercise, meditation, sleep improvement, reduced alcohol, and dietary changes all have real evidence behind them for both anxiety and depression. They are worth doing. But there are clear signs that they are not enough on their own.

Seek medical evaluation if: you have experienced two or more consecutive weeks of low mood or lost interest in most activities, anxiety is preventing you from doing things you need or want to do, you are having thoughts of self-harm or that you would be better off not being here, your symptoms are severely affecting your relationships or your ability to work, you are using alcohol or other substances to manage how you feel, or your symptoms feel beyond what any amount of lifestyle adjustment is reaching.

What medical treatment looks like. A complete evaluation should include a discussion of your hormonal status and symptoms, a review of your menstrual cycle history, and screening for thyroid dysfunction (which is common in this age group and produces nearly identical symptoms). From there, options include hormone therapy (particularly effective for hormonally-driven anxiety and depression), SSRIs and SNRIs (which address both anxiety and depression and also reduce hot flash frequency), and referral to a therapist or psychiatrist.

You don't have to be in crisis to ask for help. Mental health symptoms that are at a moderate level and not getting better are a valid reason to seek medical support. You don't have to wait until you are at rock bottom to have a productive conversation with your doctor.

Treatment options and what works for each

Anxiety and depression during perimenopause have overlapping but distinct treatment priorities.

For hormonal anxiety (progesterone-GABA mechanism): The most direct treatment is micronized progesterone (body-identical progesterone), which restores GABA-enhancing activity. Many women notice significant anxiety relief within weeks of starting this. Non-hormonal options include SSRIs and SNRIs, which modulate serotonin and norepinephrine pathways that interact with the anxiety circuit. CBT is the most evidence-backed psychological treatment. Magnesium glycinate has emerging research for anxiety support and a strong safety profile.

For hormonal depression (estrogen-serotonin mechanism): Estrogen therapy addresses the root cause and has good evidence for perimenopausal depression, particularly in women who have never had depression before and whose onset correlates with perimenopause. SSRIs and SNRIs are effective and are often used alongside or instead of hormones. Psychotherapy, particularly CBT, is effective and particularly useful for preventing relapse. Exercise has robust evidence for depression comparable to antidepressants for mild to moderate severity.

For mixed presentations: When both are present, treatment typically begins with whatever is causing the most functional impairment. A complete medical evaluation is worth pursuing before committing to a treatment path, since thyroid dysfunction, vitamin D deficiency, iron deficiency, and other treatable conditions can drive or amplify both anxiety and depression during perimenopause.

For suicidal thoughts or severe impairment: Please contact your doctor, a crisis line, or emergency services. Severe depression is a medical emergency. The hormonal context explains it but does not make it less urgent.

What this means for you

Here are practical steps based on what you're experiencing.

1. Try to characterize what you're feeling. Is it predominantly intensity and activation (anxiety) or predominantly flatness and withdrawal (depression)? Or both? Write it down. This description will help your doctor significantly.

2. Track your symptoms alongside your cycle. Even if your cycles are irregular, noting when symptoms worsen and improve over four to six weeks can reveal hormonal patterns that inform treatment. PeriPlan lets you log mood, sleep, and symptoms together so these connections become visible.

3. Talk to your doctor with specifics. "I've been feeling low" gives your doctor limited information. "I've had low mood for three weeks, I've lost interest in exercise and socializing, and it seems worse in the week before my period" gives them a clinical picture.

4. Ask specifically about hormonal evaluation. If your symptoms started during perimenopause or correlate with your cycle, ask your doctor whether a hormonal assessment and trial of hormone therapy or progesterone is appropriate.

5. Don't rule out therapy even if you think your problem is hormonal. The biological and psychological layers interact. CBT or other therapy addresses the thought patterns and behavioral responses that develop around hormonal symptoms, and those patterns can persist even after the hormonal triggers improve.

6. Check for thyroid and other contributors. Ask your doctor to check your thyroid function (TSH at minimum), vitamin D, iron, and B12. Deficiencies in any of these produce anxiety and depression symptoms that are often attributed to perimenopause when they have a more directly treatable cause.

7. Be honest about alcohol. Alcohol reliably worsens both anxiety and depression over time, even though it appears to help acutely. If alcohol use has increased during perimenopause as a coping mechanism, that is worth examining honestly and discussing with your doctor.

What you're feeling is real. Whether it's anxiety, depression, or the painful overlap of both, your experience has biological roots that are understood and treatable. This is not just hormones in a dismissive sense. It is hormones in the sense that your brain chemistry is changing and it is producing genuine suffering that you deserve real help for.

You don't have to figure out exactly what it is before you seek support. Describing your experience to your doctor is enough to start. They can help you distinguish and treat what's actually happening.

You are not losing your mind. You are navigating a transition that is genuinely difficult, and you deserve the right kind of support to do it.

This content is for informational purposes only and does not replace medical advice. Always consult your healthcare provider about your specific situation.