When something shifts – and nobody tells you exactly what
“Sometimes I don’t recognise myself.” – “I sleep badly, I’m thin-skinned and I forget words – is this just who I am now?” – “It’s probably just the hormones.”
First things first: I am a man and not a doctor, and I will never know from my own experience what perimenopause feels like. What I can do is pull the research together properly, name the medical boundary – and show what coaching can and cannot offer in this phase of life. Because the topic comes up in my practice more often than you might think.
What perimenopause actually is
Perimenopause is the transition before the final menstrual period: cycles become irregular, hormone levels fluctuate, the first symptoms appear. It ends one year after the last period. According to the WHO, most women reach menopause between the ages of 45 and 55, as a natural part of biological ageing, not a disease. Perimenopause can last several years. In Switzerland, according to University Hospital Zurich, the final period comes on average in a woman’s 52nd year of life; roughly three in four women report complaints such as hot flushes, sleep problems or mood changes. Some have hardly any symptoms, others suffer considerably.
The cycle that comes before is covered in the article Cycle and mood: PMS or PMDD? – this one is about what comes after.
What really changes: the evidence
The window of increased vulnerability is real. In 2018 the North American Menopause Society and an expert panel led by Pauline Maki published the first consensus guidelines on perimenopausal depression (co-published in Menopause and the Journal of Women’s Health). Their core message: perimenopause is a window of vulnerability for depressive symptoms and depressive episodes – even in women with no prior history of depression.
The basis for this is longitudinal research. In the Penn Ovarian Aging Study, Ellen Freeman followed 231 women without a history of depression for eight years: markedly elevated depression scores were around four times as likely during the transition as before it (odds ratio 4.29), and a diagnosed depressive disorder around two and a half times as likely (OR 2.50) – published in 2006 in Archives of General Psychiatry. The large SWAN study with more than 3,300 women found similar, though weaker, effects: in late perimenopause the odds of clinically relevant depressive symptoms were about 1.7 times higher than before menopause (Bromberger et al., 2007).
But: most women do not develop depression. The SWAN researchers state explicitly that the majority of midlife women do not have high depressive symptoms. And Maki herself stresses that although depressive symptoms are common in this phase, most of the time they do not meet the criteria for a diagnosis of depression. Elevated risk is not destiny.
Sleep and hot flushes are often the bridge. The summary of the guidelines puts it like this: around 80 per cent of women experience hot flushes; when they occur at night as night sweats, they tear sleep apart – and persistent sleep disturbance contributes to the development or worsening of depressive symptoms. In the SWAN study, women with hot flushes or night sweats had roughly 1.8 times the odds of depressive symptoms. What chronically poor sleep does to the mind is covered in Sleep and mental health.
“Brain fog” is real – and usually transient. Forgotten words, misplaced keys, thinking that feels sluggish: this is not imagination. Gail Greendale and colleagues tested more than 2,300 women in the SWAN study over four years (Neurology, 2009): during perimenopause the women improved less on repeated tests than before – processing speed and verbal memory stalled. After menopause, performance recovered to previous levels. The authors conclude that the cognitive difficulties of the transition are probably time-limited.
What doesn’t change: you are not becoming “hysterical”
The cliché of the “hysterical menopausal woman” is stubborn – and it does not survive contact with the data. The research shows no women losing control because of their hormones, but a phase in which sleep, body and hormones are all in motion at once and the nervous system has less buffer. And it shows something the cliché leaves out entirely: in the SWAN study, very stressful life events weighed far more heavily than menopausal status – two or more such events raised the odds of depressive symptoms roughly four-and-a-half-fold. Financial strain and a negative attitude towards ageing and menopause weighed more heavily too. The guidelines say it directly: life stressors, low social support and physical health problems are strongly related to depression during perimenopause.
That matches the reality of many women between 45 and 55: children move out or need a great deal right now, parents become dependent on care, the question “Is this it?” hangs over the job, the relationship gets renegotiated. Much of this is invisible organising work, the mental load. Not every change in mood is hormonal. Some of it is simply a healthy person’s reaction to too much at once. Anyone who attributes everything to hormones overlooks what could be changed.
Where the medical boundary lies
- Persistent low mood, loss of interest, hopelessness lasting more than two weeks belong with your GP, your gynaecologist or a psychotherapist, especially if you have had depression before: according to the guidelines, most women who have a depressive episode in perimenopause have had one before. An assessment covers your menopausal stage, your physical and psychological symptoms and a validated questionnaire. Established treatments – psychotherapy, antidepressants where indicated – remain the first choice.
- Severe sleep problems and distressing hot flushes are a medical matter. Alongside medical options, the British NICE guideline also recommends menopause-specific cognitive behavioural therapy here.
- Hormone therapy is a medical decision between you and your doctor, with an individual weighing of benefits and risks. It is not a standard treatment for depression: the guidelines do see evidence that oestrogen can lift mood in perimenopause, especially alongside hot flushes, but they state that oestrogen does not work against depressive disorders in women after menopause. You will get no recommendation on it from me – and none on supplements either.
- If you have suicidal thoughts: please get help immediately. In Switzerland, Die Dargebotene Hand is available around the clock on 143; in an acute emergency call 144.
How coaching and therapy differ in principle is explained in Coaching or therapy?.
What coaching can offer in this phase
Coaching treats neither hormones nor depression. What it can do is often exactly what is missing in this phase of life:
- Sorting out what is changeable and what is not. What is the body, what is lack of sleep, what is caring for your mother, what is the job? That separation alone relieves many people of the diffuse fear of “simply not functioning any more”.
- Building sleep and stress routines that fit your daily life – not as a miracle cure, but as a buffer so the nervous system has more room to manoeuvre.
- Drawing boundaries. When energy is scarcer, the question “What do I want to spend it on?” is not weakness but clarity. See Setting boundaries without guilt.
- Self-compassion instead of self-deprecation. Anyone who additionally beats themselves up over forgotten words or a short fuse doubles the load. More in Self-compassion instead of self-criticism.
- Identity in transition. Who am I when body, role and pace change? That is not a medical question. It is one that needs room.
How I work and which topics I cover is set out under life coaching in Wetzikon and online.
An evening log for three weeks
Keep a short evening log for three weeks: sleep, hot flushes, mood, what happened during the day – one word each. Afterwards you will see patterns that are invisible day to day – and you will have something concrete in hand for the conversation with your doctor.
Conclusion
Perimenopause really does change something: the risk of depressive symptoms rises, sleep suffers, thinking feels sluggish at times – all of this is well documented and not imagined. Equally well documented: most women do not develop depression, brain fog usually passes, and life circumstances often weigh more heavily than hormones. Between “it’s all hormonal” and “don’t make such a fuss” lies the honest path: look closely, differentiate, get help where it belongs.
Do you feel like a stranger to yourself right now? In coaching we sort out together what in your situation is body, what is load and what is changeable – and what belongs with your doctor. No dramatisation, no esoteric talk.
Your progress is my joy.
