Managing Anxiety in Perimenopause: A Practical Guide to Calming a Sensitised Nervous System
Anxiety often intensifies during perimenopause. This guide explains why and covers evidence-based strategies to calm your nervous system and feel better.
Why Anxiety Increases During Perimenopause
Anxiety is one of the most frequently reported psychological symptoms of perimenopause, and one that often takes women by surprise. The hormonal explanation centres on oestrogen's role in the brain. Oestrogen modulates GABA, the primary inhibitory neurotransmitter that puts the brakes on the nervous system. It also influences serotonin pathways that regulate emotional stability. When oestrogen levels fluctuate unpredictably, the nervous system loses some of its usual buffering capacity. The brain becomes more reactive, the threat-detection system fires more easily, and the physiological stress response is triggered more readily. This is not a psychological weakness. It is a neurochemical reality of the perimenopause transition.
Recognising Anxiety in This Life Stage
Perimenopause anxiety can manifest in ways that are not always immediately recognisable. Constant background worry, a sense of impending doom without a clear source, racing thoughts at night, difficulty making decisions, and a heightened startle response are common. Physical symptoms such as a racing heart, shortness of breath, and tight chest can accompany anxiety and are sometimes mistaken for cardiac events or attributed to hot flashes. Irritability and a short fuse are frequently expressions of underlying anxiety rather than mood instability per se. Some women describe feeling wired but exhausted, unable to relax despite fatigue. Others experience panic attacks that peak within minutes and then subside.
The Role of Sleep and Cortisol
Anxiety and poor sleep create a feedback loop that is particularly troublesome in perimenopause. Night sweats fragment sleep, and broken sleep markedly increases anxiety sensitivity the following day. A sleep-deprived amygdala, the brain's threat detection centre, fires more readily and is harder to regulate. Meanwhile, oestrogen decline affects cortisol regulation, meaning the stress response does not wind down as efficiently as it once did. Elevated evening cortisol then interferes with falling asleep, perpetuating the cycle. Addressing sleep disruption is therefore central to anxiety management. Better sleep alone will not resolve anxiety driven by oestrogen fluctuation, but it makes every other strategy more effective.
Breathwork and Nervous System Regulation
Slow, controlled breathing is one of the most evidence-based tools for managing acute anxiety and progressively calming a chronically activated nervous system. Slow exhalation activates the parasympathetic nervous system via the vagus nerve, reducing heart rate and signalling safety to the brain. Box breathing, four counts in, hold four, four counts out, hold four, works well during anxiety spikes. Extended exhale breathing, inhaling for four counts and exhaling for six to eight, has a particularly strong calming effect. Physiological sighing, a sharp double inhale followed by a long exhale, quickly reduces CO2 and eases acute anxiety. Practising breathwork when calm makes it far more accessible when anxiety peaks.
Movement, Lifestyle, and Anxiety Reduction
Regular physical exercise is one of the most effective long-term strategies for anxiety management. It reduces cortisol, increases GABA and endorphins, improves sleep, and builds stress resilience over time. Moderate-intensity aerobic exercise, such as brisk walking, cycling, or swimming, tends to be particularly calming. Yoga and tai chi combine movement with breath and attention and have specific evidence for anxiety reduction in perimenopausal women. Caffeine amplifies the sympathetic nervous system response, and alcohol increases anxiety significantly in the hours and days following consumption. Reducing both makes a meaningful difference to baseline anxiety levels within a few weeks.
Therapeutic and Medical Options
Cognitive behavioural therapy is one of the most robustly evidenced treatments for anxiety and is particularly relevant in perimenopause because it addresses thinking patterns that amplify anxiety, as well as providing practical tools for managing it. For anxiety driven by hormonal fluctuation, HRT is a genuinely useful treatment option that is underused in this context. Stabilising oestrogen through HRT can significantly reduce the neurochemical turbulence driving anxiety. For women who cannot or choose not to use HRT, SSRIs and SNRIs have evidence for anxiety in perimenopause. Discussing options with a GP who understands the menopause context is important.
Tracking Anxiety Patterns and Getting Support
Anxiety during perimenopause often has patterns that become clearer when tracked over time. Some women find their worst anxiety clusters before a period, or after a run of night sweats. Others notice it worsens during high-stress periods or after alcohol. Logging how you feel each day in an app like PeriPlan makes these patterns visible, which reduces the sense that anxiety is random and uncontrollable. It also builds the evidence base you need for an informed conversation with a healthcare provider. Anxiety in perimenopause is real, biologically grounded, and highly treatable. The combination of nervous system regulation skills, lifestyle support, and appropriate medical care gives most women significant relief.
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