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It's a regular day in her mid-40s, and Rochelle Pagano is on her way to work. But during the drive to the martial arts studio she runs with her husband on the outskirts of Philadelphia, she senses something is off. Suddenly, she feels short of breath and jittery. She’s tense and has no idea why.

A perimenopausal Pagano breathed through the episode, and her panic passed within a minute or two. But she didn’t spot the connection between her shifting hormones and the unexplained worry until years later. 

The Anxiety That Came With Menopause

As she entered her early 50s, Pagano started to feel anxious all the time, a first for her. And sometimes her heart rate would quicken. The palpitations lasted “just a couple of quick beats,” but they happened often enough to make her worry about her health.

“I remember thinking, ‘What is wrong with me? Why is my heart beating this way?’ ” Pagano says. “And that led to a vicious cycle of more anxiety.” 

After her once-high energy levels tanked, so did her mood. Then she became “a different person” and lost her motivation to exercise and often felt depressed.

Now, the 53-year-old health and wellness coach helps other women manage the changes that come with female aging. But at the time, Pagano didn’t know about the anxiety and depression that can affect people as they move into menopause. 

And like many folks, she blamed her bad mood on all the stuff that comes up in midlife. For example, you may go through menopause around the same time that your adult kids leave the house, you take on more responsibilities at work, or you need to care for aging parents. 

Pagano’s menopause mood symptoms happened alongside a global pandemic. Then her ex-husband, the father of her three sons, died suddenly. 

A deadly virus and losing a loved one can leave anyone emotionally drained. But Pagano realized something else was going on. “I wasn’t handling these things as well because of hormonal changes,” she says. “And that’s when I decided to do something." 

After working with her doctor, a nutrition coach, and making healthy lifestyle changes, Pagano feels better than she has in years. “I’m not going to say the anxiety is 100% gone, but I feel good,” she says. “I feel like me again.” 

What Causes Menopause Anxiety?

Mood changes tend to show up during “windows of vulnerability,” says Stephanie Faubion, MD, director of the Mayo Clinic’s Center for Women’s Health and medical director for the North American Menopause Society. These are times when female hormones go up and down a lot, like before your period, after you have a baby, or around the menopause transition.

When you go through menopause, your ovaries stop releasing eggs and make little to no estrogen. But hormone levels tend to fluctuate a lot during the 10 or so years before your period stops, otherwise known as perimenopause. 

“And we think it’s these hormonal shifts that cause anxiety more than the actual decline in estrogen,” Faubion says. 

Vasomotor symptoms, or hot flashes and night sweats, can also affect your mood in direct and indirect ways, says Hugh Taylor, MD, a menopause specialist and chair of the Department of Obstetrics, Gynecology, and Reproductive Sciences at Yale School of Medicine. 

When your body warms up suddenly, your heart might speed up as you start to sweat. Some people get dizzy or have chest pain. You may also have a surge of adrenaline, a hormone “designed to make you a little anxious in a stressful situation,” Taylor says.

Hot flashes can also wake you up at night. So not only are you having hormonal shifts that might affect your mood, now you’re sleep-deprived. And you might have a harder time managing stress if you’re tired or exhausted all the time.   

If you add all these physical and emotional changes together, that makes menopause “a very stressful and anxiety-producing time,” Taylor says. 

Lifestyle Changes to Manage Menopause Anxiety

Pagano talked to her doctor about her physical and emotional menopause symptoms. And while she’s not against using medication, and she may start estrogen therapy down the road, healthy lifestyle changes helped her gain control of her anxiety and stress. 

Some of her top tips for people with menopause are: 

Eat healthy foods. Pagano noticed a big difference when she cut back on processed foods high in sugar. She also added more lean meats, fish, fruits, vegetables, nuts, and seeds. “I felt 95% better just from changing my diet,” she says. 

Exercise. Regular movement is good for the body and mind at any age. But the key is to find exercise that helps you feel good, Pagano says, which may change as you go through menopause. “I love to lift weights, and my body does not like to run,” she says. 

Take slow, deep breaths. Pagano feels calmer after she inhales slowly, holds her breath for a couple of seconds, and then lets out a nice long exhale. When she does this, her worst anxiety tends to pass within “three, four, or five breaths.” 

Meditate. With the help of the Headspace mindfulness training app, Pagano tries to meditate at least 10 minutes a day. The practice doesn’t get rid of her anxiety or worrisome thoughts. “It helps you not hold on to them,” she says. 

Consider dietary supplements. There’s some evidence black cohosh may ease depression and anxiety during menopause. You can discuss that supplement with your doctor. But after talking with a health professional, Pagano added a multivitamin, fish oil, vitamin D, and magnesium to her daily routine. 

And while everyone is different, she says the herbal supplement ashwagandha helps boost her well-being. Studies show the root extract is safe and may help ease hot flashes, insomnia, and other perimenopause symptoms. 

What Are Treatments for Menopause Anxiety?

Ongoing feelings of depression, stress, and anxiety may happen during the menopause transition, but they’re not something you have to just live with. And you may need to medically manage your moods if you have negative feelings that last for more than 2 weeks or make your daily life harder. 

But there’s reason for hope: “These treatments are very effective,” Faubion says.

Tell your doctor if you have any of the following symptoms of anxiety or depression: 

  • Anger or crankiness  
  • A sense of dread
  • Memory problems or brain fog
  • A fast heart rate
  • Waking up in the middle of the night feeling anxious
  • Shortness of breath
  • Chest discomfort 

“Of course, we need to rule out other things if someone is experiencing chest symptoms, including heart disease, which is also more common after the menopause transition,” Faubion says. 

Along with lifestyle changes like eating a healthy diet, getting enough sleep, and exercising regularly, Faubion says, some of the go-to treatments for menopause anxiety and depression are: 

Antidepressants. If you have a history of mood disorders, your doctor may give you the same medication that’s helped you in the past, Faubion says. But in general, drug treatment may include: 

  • Selective serotonin reuptake inhibitors (SSRIs)
  • Selective norepinephrine reuptake inhibitors (SNRIs)
  • Other antidepressants, like bupropion, which is less likely to cause weight gain

SSRIs and SNRIs may also help with menopause symptoms like hot flashes or increased pain. 

Cognitive behavioral therapy (CBT). This is a type of time-limited talk therapy that teaches you how to reframe negative thoughts and change behaviors that may contribute to ongoing anxiety or depression. 

When it comes to the menopause transition, CBT may also: 

  • Improve sleep
  • Lessen the impact of hot flashes and night sweats
  • Help you manage stress

Hormone replacement therapy (HRT). If you have vasomotor symptoms of menopause, your doctor may suggest you replace your missing hormones. HRT may include estrogen only or a combination of estrogen and natural or lab-made progesterone. 

There are pros and cons to hormone therapy, and your doctor should go over all the health benefits and risks with you. But a short course of HRT (months or years) may get rid of your hot flashes and bring your anxiety levels back down to whatever your baseline is, “which may be zero,” Taylor says.   

“If someone is not sleeping and they’re having hot flashes, I generally think hormone therapy is the best way to get this under control,” he says. “It really has the most direct effect, and it’s the most effective option we have to offer (for menopause symptoms).” 

Looking Forward to a New Phase

Healthy habits are a key part of Pagano’s overall wellness plan. But she keeps her doctor in the loop about how she’s feeling. What’s more, she’s not against the use of medical treatment if she feels lifestyle changes aren’t enough.

For now, the behavioral health coach is happy to teach other women the skills to stay physically and emotionally strong during menopause and beyond. And she’s excited about what comes next. 

“It’s a whole different stage of life, and it’s kind of my time again,” Pagano says. “I’m much more confident and secure in who I am and what I want.”

Show Sources

Photo Credit: iStock / Getty Images

Pagano photo: Michael Miville, MM Visuals


Rochelle Pagano, health and wellness coach, Westchester, PA. 

Hugh Taylor, MD, chair, Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine; chief of obstetrics and gynecology, Yale-New Haven Hospital. 

Stephanie Faubion, MD, MBA, professor and chair, Department of Medicine, Mayo Clinic; director, Mayo Clinic Center for Women’s Health; medical director, North American Menopause Society.

American College of Obstetrics and Gynecology: “Mood Changes During Perimenopause Are Real. Here’s What to Know.”

Menopause: “Consensus Recommendations: Guidelines for the evaluation and treatment of perimenopausal depression: summary and recommendations.” 

Cleveland Clinic: “Menopause.” 

Journal of Cognitive Psychotherapy: “Does Using a Mindfulness App Reduce Anxiety and Worry? A Randomized-Controlled Trial.” 

Gynecological Endocrinology: “Black cohosh efficacy and safety for menopausal symptoms. The Spanish Menopause Society statement.” 

Journal of Obstetrics and Gynaecology Research: “Effect of an ashwagandha (Withania Somnifera) root extract on climacteric symptoms in women during perimenopause: A randomized, double-blind, placebo-controlled study.”

NHSinform: “Menopause and your mental wellbeing.” 

Climacteric: “Cognitive behavioral therapy for menopausal symptoms.”