Is it perimenopause or anxiety? How to tell the difference

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One of the most common stories I hear from women in perimenopause is a variation of this: “My doctor said it’s anxiety and put me on an antidepressant. But this doesn’t feel like anxiety. It doesn’t feel like me.”

That instinct, that something is different this time, is often correct. And it deserves to be taken seriously.

Why perimenopause and anxiety look so similar

The symptoms of perimenopause and generalised anxiety disorder overlap significantly. Both can include racing heart, disrupted sleep, irritability, difficulty concentrating, a sense of dread, and feeling overwhelmed by things that never used to bother you.

The reason for this overlap isn’t a coincidence. Oestrogen and progesterone have direct effects on the brain and nervous system. When these hormones fluctuate and decline during perimenopause, the neurological consequences can look indistinguishable from clinical anxiety, at least on the surface.

The hormonal mechanisms behind perimenopausal anxiety

Progesterone and GABA

Progesterone is metabolised into a substance called allopregnanolone, which acts on GABA receptors in the brain, the same receptors that anti-anxiety medications target. When progesterone falls, as it does in early perimenopause, GABA activity drops, and the nervous system can become significantly more reactive. This is a physiological shift, not a psychological weakness.

Oestrogen and serotonin

Oestrogen supports serotonin production and the density of serotonin receptors in the brain. As oestrogen becomes erratic and declines, serotonin fluctuations can produce mood instability, anxiety, and low mood, symptoms that are often attributed to depression or anxiety rather than their hormonal root cause.

The cortisol connection

Disrupted sleep, which is extremely common in perimenopause, elevates cortisol levels. Cortisol is your primary stress hormone, and chronically elevated cortisol produces exactly the symptoms of anxiety: a racing mind, difficulty relaxing, heightened emotional responses, and physical tension.

Clues that it might be hormonal rather than psychological

There is no single test that distinguishes hormonal anxiety from “true” anxiety disorder, but there are patterns that suggest a hormonal driver:

• The anxiety appeared relatively suddenly in your late 30s or 40s, without a clear psychological trigger
• It feels cyclical, worse at certain points in your cycle, particularly in the week before your period
• It’s accompanied by other perimenopausal symptoms such as sleep disruption, irregular periods, weight changes, brain fog, or joint pain
• It doesn’t respond well to standard anxiety treatments, or it helps initially but then stops working
• It doesn’t feel like “you”. You have no history of anxiety, or this is qualitatively different from anxiety you’ve experienced before

The misdiagnosis problem

Research consistently shows that women in perimenopause are significantly more likely to be diagnosed with anxiety or depression than to have a hormonal investigation. A 2022 survey by Menopause Matters found that over 60% of women saw three or more healthcare professionals before getting a perimenopause diagnosis. Many had been prescribed antidepressants or anxiolytics first.

This is not to say that anxiety disorders don’t exist, or that antidepressants are never appropriate. But when anxiety appears suddenly in midlife, alongside other physical symptoms, the hormonal picture needs to be part of the assessment.

What a thorough assessment looks like

A proper perimenopausal assessment for mood and anxiety symptoms should include a detailed symptom history (including cycle patterns), consideration of thyroid function (thyroid disorders can mimic anxiety and are common in women over 40), sleep quality assessment, and evaluation of whether hormonal support might be beneficial.

Blood tests alone are often not sufficient to diagnose perimenopause, particularly in the early stages when hormones are fluctuating rather than consistently low. A clinician who understands this is essential.

You know your own body

If your anxiety feels new, cyclical, or simply “not like you”, that perception is clinically meaningful. It is not something to dismiss. The women I work with who have been most poorly served by the healthcare system are those who were told their feelings were psychological when the driver was physiological.

You deserve an investigation that takes both possibilities seriously.