Perimenopause and menopause are often talked about in terms of hot flashes, night sweats, and irregular periods, but the emotional and psychological shifts can be just as significant. At the National Menopause Show this past October, psychiatrist Dr. Arielle Dalfen offered a simple but powerful framework: four questions every midlife woman can ask to better understand their mental health risk.

These questions don’t diagnose anything. Instead, they help you tune in, notice patterns, and understand whether you may benefit from more support — from lifestyle strategies to psychotherapy to medical care.

Past mental health challenges can resurface during hormonal change.

• Sixty percent of women with a prior mental health history experience a mood or anxiety disorder in midlife.

Perimenopause creates a dynamic hormonal environment that can expose older, vulnerable fault lines in the nervous system. This doesn’t mean something is wrong. It means your body may need more support than it did years ago.

Reflection prompts:

• Have I ever experienced anxiety, depression, panic, PMDD, or postpartum mood symptoms?
• Are familiar patterns resurfacing now?

Some brains are more hormone-responsive than others. If you notice your mood or energy shift with your cycle, birth control, or postpartum changes, you may fit this pattern.

Estrogen affects serotonin and dopamine, and progesterone influences calm and sleep quality. When these hormones fluctuate, so can your mood.

Reflection prompts:

• Did I have PMS or PMDD?
• Did hormonal contraception or postpartum changes affect me emotionally?
• Have I become more anxious, irritable, or reactive recently?

According to the SWAN study, 80-90% of women experience physical symptoms which can affect mental health. These may include sleep disruptions, fatigue, migraines, brain fog, night sweats, joint pain, or cycle changes.

Untreated symptoms can quietly influence anxiety, mood, irritability, and emotional resilience.

Reflection prompts:

• Which physical symptoms are showing up for me?
• How are they affecting my sleep, energy, or relationships?

Midlife is rarely quiet. Many women face aging parents, career pressures, teens, relationship strain, identity changes, or financial stress. Perimenopause adds another layer.

Using a biopsychosocial approach, Dr. Dalfen highlighted how life context shapes mental health.

Reflection prompts:

• What stressors are present that weren’t here a few years ago?
• What roles feel heavy or unsustainable?
• Where could I use more support?

These four questions form a roadmap that helps you understand your level of risk and why symptoms might be intensifying. They also highlight which type of support will actually help, such as psychotherapy, lifestyle adjustments, hormone therapy, or medication.

It’s common for women in perimenopause to experience mood swings, anxiety spikes, irritability, or fear that brain fog signals something serious. In reality:

• Depression risk doubles in perimenopause
• Over half of women experience anxiety
• Rage is common
• Brain fog is normal and not a sign of dementia
• ADHD traits often surface or intensify

This is physiology, not personal failure.

If these questions resonated, consider them a place to begin.

Supportive next steps may include tracking symptoms, prioritizing sleep, moderating alcohol, moving regularly, seeking informed psychotherapy, or discussing hormonal and non-hormonal treatments with your healthcare provider.

You don’t have to navigate this alone.