Perimenopause, Let’s Change the Conversation

Somewhere in their early to mid-40s, many women start noticing something unsettling.

They lose words mid-sentence. They walk into rooms and forget why they’re there. They feel emotionally reactive in ways that don’t feel like them. Sleep shifts. Anxiety creeps in. Focus slips.

Increasingly, they’re asking: Is this perimenopause? Is something wrong with me?

For many women, that question becomes deeply personal. The narrative can shift from “something is changing” to “I’m not coping well” or “I should be handling this better.” That internal self-criticism can be just as distressing as the physical symptoms themselves.

The answer isn’t always simple, and that complexity reflects a larger gap in how women’s health has historically been understood. Although I’m centering women’s experiences here, it’s important to acknowledge that gender-diverse individuals can also move through perimenopause and deserve the same informed, respectful care.

So what is perimenopause — and why does it deserve more mental health attention?

Perimenopause is the transitional stage before menopause. It can begin as early as the mid-30s, though it most commonly starts in the 40s. During this time, estrogen and progesterone levels fluctuate as they gradually decline. Symptoms can include irregular periods, hot flashes, night sweats, disrupted sleep, increased anxiety, low mood, irritability, brain fog, memory lapses, reduced stress tolerance, and changes in libido — among many others.

These shifts don’t just affect the reproductive system; they affect the brain, influencing sleep, mood, cognition, and the nervous system.

Hormonal changes can heighten nervous system reactivity. Things that once felt manageable may suddenly feel overwhelming. Stress tolerance can narrow. Emotions can feel closer to the surface.

Perimenopause often brings deeper psychological shifts to the surface — questions about identity, aging, meaning, purpose, and self-worth. For many, it coincides with other life transitions: children leaving home, aging parents, career changes, evolving relationships. All of this can profoundly impact mental health and quality of life.

And yet, for some, this stage can also be an awakening. As hormonal shifts strip away old expectations and roles begin to change, many women describe a growing clarity about what matters. There can be less tolerance for people-pleasing, more willingness to set boundaries, and a renewed desire to prioritize joy, creativity, health, and meaningful change. What initially feels destabilizing can become a reorientation, an important shift toward wisdom and self-trust.

Historically, these experiences have been minimized or dismissed as “just stress” or “just aging.” Women’s health, particularly midlife health, has long been underfunded and understudied. As a result, many women and gender-diverse people enter perimenopause without clear, consistent information about what to expect and with limited support.

Treatments such as hormone replacement therapy (HRT) were clouded by misinformation and stigma, leaving many unsure about their options. In some cases, shifts in mood or anxiety were treated quickly with antidepressants, without pausing to consider whether hormonal changes might also be part of the picture. While antidepressants can be helpful, they don’t always tell the whole story.

For some women, these cognitive and emotional shifts also raise another question: could this be ADHD? Estrogen plays a role in regulating dopamine, a neurotransmitter connected to focus and executive functioning. When estrogen fluctuates, attention and clarity can shift too. The overlap can be confusing. The key is not to jump to conclusions, but to ensure that hormonal changes are part of the conversation when attention or mood concerns arise.

Thoughtful assessment matters. Conversations with a family doctor, nurse practitioner, psychiatrist, or counsellor can explore questions such as: When did these changes begin? Do they fluctuate with sleep or hormonal shifts? What other life transitions are happening at the same time? A comprehensive approach looks at biology, mental health, and life stage together.

The encouraging news is that the conversation is changing. Perimenopause is being discussed more openly. Research is expanding. Women, along with gender-diverse individuals, are finding language for experiences they once endured silently. 

More health-care providers are updating their training, and long-standing myths about HRT are being corrected. Beginning in March 2026, B.C. PharmaCare will cover hormone replacement therapy — a meaningful shift toward improving access to menopausal care for women and gender-diverse people. Eligibility will apply to residents enrolled in the Medical Services Plan (MSP).

If you are navigating midlife changes and questioning what is happening in your body or mind, you are not alone. Ask questions. Seek resources. Push for clarity. Advocate for yourself. Consider seeking out health-care professionals certified by the Canadian Menopause Society or with expertise in menopause and hormonal health. You deserve informed, collaborative care that honours your lived experience.