Neha Pathak, MD, FACP, DipABLM: Welcome to the WebMD Health Discovered Podcast. I'm Dr Neha Pathak, WebMD’s Chief Physician Editor for Health and Lifestyle Medicine. Today, we're taking a step-by-step approach to perimenopause and its impact on mental health. Perimenopause is the natural transition to menopause, and it's characterized by erratic fluctuations in estrogen and progesterone, which can cause symptoms like irregular periods, hot flashes, mood swings, sleep issues, and brain fog.

As the ovaries gradually produce less of these hormones over months to years, these unpredictable shifts disrupt the body's rhythms, leading to diverse and often intense emotional and physical changes. These are changes that women can experience well before menopause officially begins.

In today’s conversation, we're gonna break down how perimenopause impacts our psychological, emotional, and cognitive health, and why some of these symptoms are still misunderstood or mislabeled. We'll talk about everything from subtle changes like decision fatigue and difficulty planning, and we'll also spend a little time acknowledging the lived experience of going through perimenopause—from bone-deep fatigue, sudden changes in skin and hair, things that can impact our confidence, sleep disruptions that make everyday life feel harder, and the emotional changes that can leave you feeling disconnected from yourself and the people you love.

We'll talk about how to prepare for a conversation with your doctor, how to advocate for yourself if you feel dismissed, and the evolving research that's giving women more options and more hope than ever before.

First, let me introduce my guest, Dr Megan Spence. Dr Spence is a licensed clinical psychologist with more than 15 years of experience. She has expertise in trauma, anxiety, depression, life transitions, and work stress. She's certified in perinatal—pregnancy and postpartum mental health. Her approach is trauma- and multiculturally informed, evidence-based, and empowering.

Welcome to the WebMD Health Discovered Podcast.

Megan Spence, PsyD, PMH-C: Thank you. I am so excited to be here to talk about this topic today.

Pathak: Before we start exploring our topic, I'd love to ask about your own health discovery in the area of perimenopause.

Spence: Yeah, so I came to this area also from more of a personal place, and it's been really interesting as I've been diving into the research around perimenopause and talking to women both in my personal life and my professional world, to just hear the misinformation that's out there. You know, I think we're at a really interesting time in history where previous generations have not talked about this. This word, perimenopause, wasn't really even known. And now we're seeing a lot of information, maybe on social media and other places, but it's not always accurate. And so people are very confused. There's a lot of information there, but they don't know what to do with it. Unfortunately, things are being missed or misdirected.

Pathak: Let's start by just taking a step back and level-setting with some definitions, so we're really clear about what we're talking about when we say perimenopause and menopause. So can you start by defining these terms for our listeners?

Spence: Yeah, so perimenopause is the period of time leading up to menopause. Menopause is defined as 12 consecutive months of not having a period. Perimenopause can be a long period of time prior to that point where women begin to experience changes to their cycles, and then a myriad of physical and potentially emotional symptoms as well.

And I'll caveat that with: some people may not realize that the symptoms have begun because maybe they're on birth control and they don't get cycles, or they're not tracking their cycle. But essentially, perimenopause can be any point when the cycle starts to shift—so the flow or the duration changes—and then up until those 12 months after the last period. Perimenopause also can last generally an average of four years, but it can last a decade or even longer. For some, it can begin as early as the mid-thirties to as late as the early fifties, mid-fifties. There's a wide range of time when this could begin for people.

And in the U.S., the average age of menopause is 51, although there's some new research coming out about how endocrine-disrupting chemicals in the environment may be prompting earlier menopause for some women.

Pathak: So I'd love to actually address one other elephant in the room when it comes to misinformation and a lot of what I'm seeing on social media and what a lot of women are sort of confused about, which is hormone replacement therapy, or hormone therapy. During perimenopause and menopause, there's so much confusion.

So give us a brief story around how we got here. Can you help us understand why views on when to use it, how to use it, and should we use it have shifted so much?

Spence: Yes. Thank you for mentioning this. This is so important. So scientists have been looking at using hormones for treatment and different medical conditions for a very long time, since the early 1900s. We see the birth control pill emerge in the ’60s, and HRT was actually initially used in the prevention of uterine cancer.

Some research was done in the ’90s—this very large study by the Women’s Health Initiative—and though the results of that study were reported on in the early 2000s, the results were widely disseminated in the media and in medical communities. The study results were presenting HRT as problematic and saying that it was causing certain types of cancer.

And so, despite decades prior to that using HRT very widely—it was super popular—at this point, HRT use decreased dramatically across the world, 46% in the U.S. It was a dramatic decrease. People were very scared. Since then, the results of that study have been reanalyzed many, many times now and have been substantiated that they were incorrect.

What was happening there was the study was looking at older women over 60, past menopause, who were using HRT, and so the sample itself was problematic. And so since then, even the investigators of the WHI studies have come out and given statements saying how problematic this was and how challenging it was that it decreased use so much for women.

But despite that, there's still a heavy stigma, and so people are still scared. They associate HRT with cancer. And the true science at this point is showing that if initiated within 10 years of menopause, HRT actually can be preventative of certain chronic conditions. So it can prevent certain health conditions.

And for the vast majority of women, it is safe to use, but there are subsets and populations where it may not be safe to use. It may be a higher risk. So it's always a delicate conversation with your provider about your own health history. But overall, this is seen as a gold standard treatment still for perimenopause.

And there's even newer research showing that it can reduce the risk of Alzheimer’s by quite a bit—20 to 30%—again, if initiated within that period of time and within certain ages in the population.

Pathak: So I'd love to sort of ask you what you think about why there may be stigma or silence within the medical community when it comes to talking to women about perimenopause in this transition.

Spence: Yeah, I mean, it's such a disservice and so unfortunate that that's been the case. And I don’t think—I mean, I don't fault OB-GYNs for that. I think it's a systemic issue, and really it needs to be looked at on a legislative level. And we've seen change in terms of postpartum depression and other areas when people have advocated for change. So I remain hopeful that there could be change, but in the meantime, it's a real disservice.

Right, and I think things get missed. Our system is very siloed, so women get kind of sent to various departments because people don't understand what's going on. I think it's really just a gap in knowledge—an innocent gap in knowledge. And so I think there needs to be change in terms of mandating that providers get training in this area.

In the meantime, for listeners who are looking for a provider, the Menopause Society has a really wonderful, robust directory of menopause-certified providers. You can search by state and different types of medical providers if you're looking for somebody who does have knowledge. Another way to do that is looking at a bio of a doctor when you're vetting them and see if they mention the word at all—like in their bio or in their training—to find out who might be able to help you.

The other piece I'll mention on stigma is there are layers here, too, around the way we think about aging, specifically in the West, and the way that we think about the value of women and fertility. And so all of that is kind of also thrown in the mix here. Aging is a tricky topic for a lot of people. For some, there's shame, embarrassment, or a sense of loss. And even for the patient, it's hard to bring some of these things up because it's an acknowledgment of where they're at in life.

Pathak: I'm so glad you brought this up. Can you talk a little bit about how these types of cultural scripts can shape our mental health as women as we're going through this transition?

Spence: I realize I haven't covered the symptoms of the perimenopause time period. So these can range from physical to emotional, mental—so anything from the classic vasomotor symptoms of hot flashes, night sweats, changes to the cycle. Also can be changes to skin, nails.
It can be weight gain specifically in the belly, most classically. Insomnia, brain fog. And then there's the whole emotional end of things, which is, um, increases in rates of depression, anxiety, rage. So in terms of the aging and stigma aspect, when we're thinking about potentially negative labels, negative ideas about what aging means and specifically what aging means about a woman's value in society, in her relationship, or even thinking about just mortality in general, right? I think oftentimes these stigmas and these darker kind of thoughts and themes can lead people into feelings of despair or feeling down, feeling ashamed. You know, if this is the first time a woman's experienced that belly weight gain in her life outside of having a child, it can feel like she's failing at something and she's doing something wrong, when really, this is just our natural biological process, right? It's sort of like we've come to accept puberty as just a normal part of life and we teach our kids about it, but we aren't quite there yet with perimenopause and menopause, and there's not really an embracing of this time period. It's more of a sense of loss and a negative change.

Pathak: How do you talk to your patients about some of these changes?

Spence: Such a thoughtful question. I like to kind of think about the word “capacity,” right? Like, in certain times of our lives, we may have less capacity to, uh, function or produce the same way that we did in our prior time. So I talk a lot about this with people who are pregnant. It's like, yeah, you can't go run your marathon. You were a marathon runner and now you're eight months pregnant. You can't run a marathon. Well, if you're in perimenopause and you are experiencing brain fog, you may have less capacity at work, and that's okay. It's challenging when you have employers who are presenting pressure to perform particular ways. But, you know, I think thinking about like the plate is full and so these physical symptoms are a large part of your plate. Maybe they're the vegetable/fruit portion of your plate, right? And so how can you take care of yourself and maybe take some of the other things off the plate so that you can really hone in on the body and do what you can to manage the symptoms as best you can.

Exercise can be really helpful in terms of mood management, sleep, lots of things, right? I think though it's really important here, again, because a listener could be hearing this and thinking, gosh, I'm not doing these things. I'm failing. I'm not taking care of myself. It's like another thing I'm not doing. Perimenopause happens at a really particular time in life, right? People are often caring for elders and they're also caring for kids a lot of times. And the kids could be young or they could be off going off to college. Like there's a lot that's happening. And so it makes it really hard to take care of oneself and also even just to notice what's going on in the body, right?

I mean, one of my friends said she didn't even notice because she's so busy focusing on other people and being of service to other people. So that's also important—to kind of just be kind to yourself around stage of life.

Pathak: So we've talked about changes in your physical health, but I'm really interested in some of the mental health pieces that come along with perimenopause. Can you talk to us a little bit about is there a higher risk for depression, anxiety, other types of mood disorders as you shift into perimenopause and meno?

Spence: Yeah, so the research around depression and perimenopause is pretty eye-opening. A huge increased risk in this time for depression. So some of the research looking at two- to fourfold increase in the risk, higher in particular populations—so higher risk of depression in Black and Hispanic populations, in populations who have a history of depression prior to perimenopause. Also populations who have a history of sensitivity to reproductive changes or hormonal changes. So people who've had PMDD or postpartum depression may be at a higher risk of depression.

I think the other thing that's kind of interesting to note about depression is I found this small qualitative study that really was looking at what's like the—how is depression different in this time. The participants described just really having a sense of just not being themselves, something being very off. And there was this, almost this existential quality to the depression around value, around who am I, what value am I bringing? What am I doing anymore with my life? So there was this really existential quality that I thought was unique compared to what we see sometimes with other forms of depression, like with postpartum depression—you don't see that, right? A lot of times women feel sad postpartum, but they wanna keep going 'cause they have their kids, they have their baby. But in this period it's more nebulous. And then the sleep and brain fog.

So the insomnia and the brain fog that can accompany perimenopause in particular can exacerbate this depression, and so can accessing the care that one needs and having healthcare providers who are providing adequate care, who are spending time to talk to this woman to really understand what's going on. So that piece is super key too, in terms of the prevention.

Pathak: That's really, really interesting. And before we get to my questions around treatment, I'd love to pull on a thread you just mentioned, 'cause I really wanna pull on that piece around health equity. So you mentioned Hispanic and Black women experience much higher rates of depression during this transition. Do we know what structural societal factors might be driving this disparity?

Spence: Yeah, unfortunately the research here is limited. I found one study, and it basically was advocating for more studies, but it was acknowledging how systems of oppression can contribute to the depression. And it was very careful to say this is not about race. This is about racism. It's about systems of oppression contributing to the mental health.

So if you think about it, someone who's facing systems of oppression on a day-to-day basis, and we have tons of research to look at how chronic stress affects the body, right? And how racism can affect people's overall health over time. It's the same thing here. It's that chronic stress adding to the overall biological changes in physical symptoms that get exacerbated.

Pathak: So then let's take all of what we've discussed and really start thinking about what we know about the best available treatments. Before we jump into HRT and then treatment and management of depression, anxiety, can we start with lifestyle changes? So talk to me a little bit about what we know about lifestyle changes and what has the best evidence base.

Spence: So, want to avoid triggers for hot flashes—so coffee, alcohol, spicy food can be triggers for hot flashes and can also get in the way of sleep. Exercise is really huge. And in particular, lifting weights can be impactful in terms of bone health in this time period, and also with weight management. Eating, you know, leafy greens. A healthy diet can be big in terms of weight management, in terms of stress management.

Another one I'd like to throw out: I found this beautiful study on how Europe has adopted these menopause cafes. So social support, right? Where women just come together—and I'm seeing, I'm heartened, I'm in the Bay Area, San Francisco Bay Area, and I'm heartened to see there's a lot more perimenopause support groups coming out or opportunities to talk about this with other women, which can be big in terms of combating that stigma and that isolation, and also helping people understand what treatments are available.

Pathak: Can you talk to us about treatments, the best available treatments for depression during this time period?

Spence: Yes, there are specific cognitive behavioral therapy protocols for menopause. There's also a pretty impactful treatment, cognitive behavioral therapy for insomnia. But I would say really therapy of any kind can be helpful. We have a lot of different theoretical orientations. There's debate in our field about what's evidence-based, what's not. You know, I think fit with your therapist is number one most important thing. So just having a therapist if that's helpful for you. Support group. And then also couples therapy.

I'll throw in the mix here because divorce rates in perimenopause are also higher, as are suicide attempts, suicidal thoughts. So specifically when there is depression on board, having therapy and potentially medication can be very helpful. And if there's marital stress, having a couple therapist to talk to, I also advocate for partners getting involved with the understanding of what's going on here, right? So I think this isn't just a women's issue, this is a family/couples issue, and we should have—we should be educating everybody about what's going on.

Just like we do with other conditions, right? If you had a partner who had diabetes, you'd wanna know what that management looks like. So same thing here. I think it's helpful to have spouses understand what's going on in this time period.

Pathak: So we touched a little on medication management for depression as well, hormone therapy. Can you talk to us a little bit around hormone therapy—not necessarily just the physical symptoms, but what do we know about using it for some of these mood disorder–type symptoms?

Spence: Yeah, so HRT can be indirectly helpful in terms of managing mood, right? Because if we can improve some of the physical symptoms, then mood will also follow. So we can help people sleep better, have cognitive sharpness, feel less irritable, then hopefully the mood would also improve.

That being said, HRT is not a magic bullet. It's not like all symptoms will be alleviated, and in some instances, even on HRT, people may still need psychiatric care in terms of additional medications or therapy to manage mood-related symptoms. But HRT is classically known to help specifically with those vasomotor symptoms and can indirectly help with some of the other physical symptoms as well.

Pathak: How do you encourage women to advocate for themselves and to have this conversation in the best way possible?

Spence: Take a breath. I would say take a breath, right? Some of that rage may show up if you're feeling dismissed, and that's a normal reaction to feeling dismissed by a medical provider. But it's your right as a patient to always get a second opinion. So maybe asking friends if they have a trusted provider or, again, kind of vetting people on the Menopause Society website or on the bios.

And so, you could get a second opinion. I think also it can come back to that same provider and, in another appointment, say—or in that appointment—say, you know, I don't feel like I'm sort of being heard. I really think this is what's happening. And then using medical jargon can be helpful.

So using the word perimenopause, naming those symptoms. So tracking your symptoms and having a good history so that you can speak the language of the medical team, right? So, hey, you know, I've had six months of disrupted cycles. My cycle used to be six days long, and now it's two days long and it's super heavy.

Or I'm having insomnia multiple times throughout the month, not correlated with my cycle. So actually using the names of the symptoms, using the names of the condition, and even asking specifically for HRT if that's the treatment that you're interested in. How can I have a discussion with you about HRT and the risks and benefits?

Spence: If you hear a provider tell you you're too young, really push back if you're experiencing those symptoms, right? It's not in your head. You're the expert of your body, and you know what's going on.

Pathak: If you had a magic wand and you could eliminate the myths around perimenopause that you are seeing on social media or that you're just seeing these misconceptions, could you share what some of those are and what would be your response to those misconceptions?

Spence: Yeah. I think a big one is just like perimenopause means that you're sort of, you know, now old and you are no longer desirable. I think that's a huge myth, right? You are no longer of value to society because you're not of reproductive age. That's also a myth. People can get pregnant in this time period, first of all.

And second of all, our values aren't tied to our ability to bear children, right? Perimenopause means that you're somehow not managing your body well or you are doing something incorrectly. Not true. I mean, hormones are such powerful chemicals in our body, right? Again, we wouldn't judge someone for being diabetic or for having asthma.

It's like that's just a medical condition. This is the same thing. But those are some of the big ones. Perimenopause means you're dementing, or you've got ADHD or something like that. Like sometimes the brain fog is confused for something else happening. For the vast majority of people, that's not true.

Not in every case. Like sometimes people do get diagnosed with ADHD late in life or maybe are having early dementia onset, but these would be really rare situations, right?

Pathak: The other myth is some women believe they start to have these symptoms and they almost like gaslight themselves, right? Of like, this isn't perimenopause. Life is just hard. I'm just in this sandwich generation. This isn't actually happening. That's a myth, right? If you're noticing cycle changes or hot flashes or brain fog that's affecting your work or rage that's affecting your relationship, those things are really happening, and it's not in your mind.

So in our last few minutes together, I'd love to cede the floor to you and ask you to talk directly to the woman who's listening right now, thinking maybe this is what's happening to me. What are some of the next steps that she can take that you would recommend to start taking care of herself on this journey?

Spence: Reading up. There's some really great resources now in terms of the Menopause Society website. There's some really solid books out there—reading up from a reputable medical source, not so much like social media world, ’cause we just don't have as much control there. Starting to track cycle—so duration, flow, as well as symptoms throughout the month.

And the thing about perimenopause is these symptoms can show up at random times throughout the month. So unlike PMDD, where the symptoms are really very specifically related to the menstrual cycle, with perimenopause, they may come out of nowhere—seemingly out of nowhere. So really tracking those, and making an appointment with their healthcare provider, someone they trust.

So most likely a primary care doctor or an OB-GYN, with the OB-GYN. And that could be a nurse practitioner, whoever's doing the OB-GYN care, you know, seeing if this person has any knowledge about perimenopause so that they don't hit that gap in knowledge. So those would be the big three things. And then maybe talking to their partner—starting to talk to their partner about, “Hey, I think this might be going on for me. You might notice I have a shorter fuse. I've been struggling with sleep. These are some of the ways you might be able to support me right now.”

Pathak: I wanna thank you so, so much for this conversation. Really, really helpful. And it certainly has helped me, and I hope it helps others that are listening. So thank you again.

Spence: Thanks for having me.

Pathak: As we wrap up, I'd like to share three key takeaways from this discussion. First, perimenopause is real, and it's a whole-body experience. The emotional and cognitive symptoms like brain fog, anxiety spikes, low mood, irritability, and even feelings of disconnection are just as valid as the hot flashes and irregular periods we so often hear about.

You're not imagining things, and you are not alone. Second, you deserve thorough, informed, and compassionate care. If you are experiencing symptoms that you think might be related to this hormone transition, and if you feel dismissed, you have every right to seek a second opinion from another healthcare provider.

Your symptoms matter, your wellness matters, your story matters, and feeling better also matters. Finally, there is hope when it comes to perimenopause and the mental health symptoms that can come along with it. More than ever before, we're starting to understand what the research is telling us about what medications are safe, when hormonal treatments are helpful, and understanding how non-hormonal treatments can play a role in managing perimenopause and menopause symptoms.

If you or someone you love is going through perimenopause, we hope today's discussion offers clarity, comfort, and the confidence to ask for support when you need it. To find out more information about Megan Spence and her work, make sure to check out our show notes.

Thank you so much for listening. Please take a moment to follow, rate, and review this podcast on your favorite listening platform. If you'd like to send me an email about topics you are interested in or questions for future guests, please send me a note at [email protected].

This is Dr Neha Pathak for the WebMD Health Discovered Podcast.