“I don’t feel like myself”: Recognising Perimenopause in the therapy room
With thanks to our member, Jenni Moresco, for this article.
In recent years, awareness of the physical symptoms of perimenopause has grown. However, the psychological impact remains less widely recognised, both by those experiencing it and within clinical spaces.
For many, the first signs aren’t physical at all, but a subtle and often unsettling shift in mood, anxiety and sense of self.
This became personally and professionally relevant to me when I was diagnosed with perimenopause at 35. While there was some context in terms of family history, what I hadn’t fully understood at the time was just how significantly hormonal changes could affect my mental health.
Looking back, I can see I had been experiencing symptoms for a while. Some were physical, but what felt most unsettling and far harder to make sense of was the emotional shift. That disconnect is something I now see not only in my own experience, but in the therapy room too.
“I thought I was going crazy”
There were moments where I felt entirely like myself. Then, suddenly, I didn’t.
I experienced periods of feeling overwhelmed, low or anxious in a way that didn’t feel connected to anything specific. At times, there was a sense of despair that felt disproportionate and difficult to explain. As someone with a history of anxiety, these feelings were familiar, but this felt different: more sudden, all-consuming and less predictable
There were moments of intense emotion that did not seem to fit the context. A constant internal pressure I couldn’t name. Thoughts and feelings that felt unfamiliar and at times, frightening.
There were moments I genuinely questioned what was happening to me.
From a clinical perspective, experiences like this can closely resemble or intensify presentations we might conceptualise as anxiety or depressive disorders. Without an awareness of hormonal influences, it is understandable that both client and therapist may attempt to make sense of them purely through a psychological lens.
It’s not always obvious
When we think about perimenopause, the focus is often on physical symptoms: changes in menstruation, hot flushes or sleep disturbance. While these are important, they are not always the most prominent or distressing features.
For some, physical symptoms may be minimal or overshadowed by emotional and cognitive changes. For others, it is the emotional impact that feels most overwhelming.
Hormonal fluctuations can influence mood, anxiety levels, emotional regulation and overall resilience. But if that link hasn’t been made, these shifts can feel confusing, disorientating and at times, quite frightening.
The missing link
Despite having been told I was in perimenopause, I had not initially connected the emotional intensity of my experience to what was happening in my body. Instead, I tried to understand it through a mental health framework: stress, overwhelm or a sense that I simply needed to cope better.
It was only through conversation with another woman, also experiencing perimenopause at a younger age, that something began to shift. She described her experience using almost identical language, the same language I now hear so often from clients.
It wasn't that I didn’t have information. It was that I hadn’t connected the physical and emotional pieces together.
The realisation that this might not be “just in my head” but linked to hormonal change brought a noticeable sense of relief. Not because everything changed overnight, but because it began to make more sense.
What I’m noticing in the therapy room
This is something I am increasingly hearing from clients.
They describe:
- Sudden or unexpected shifts in mood
- Increased or unfamiliar anxiety
- Feeling emotionally overwhelmed or less resilient
- A loss of identity/sense of self or a sense of not feeling like themselves
- Periods of low mood that feel disproportionate or difficult to explain
Often, there isn’t a clear external reason for these changes, which can lead to confusion and self-doubt.
It’s common to hear thoughts like:
- “I should be coping better”
- “Why am I like this?”
- “This isn’t me”
Without a wider context, these experiences are frequently internalised, which can deepen distress and self-criticism.
Clinical reflections: what therapists might notice
From a clinical perspective, there are several patterns that may be worth holding in mind:
- A relatively sudden onset or escalation of anxiety/low mood
- Emotional responses that feel out of character for the client
- Clients expressing that they “don’t feel like themselves”
- Reduced emotional resilience or increased reactivity
- Symptoms that are not fully explained by current life circumstances or history
In such cases, it may be helpful to consider whether there could be a hormonal component, particularly if the client is within the typical age range for perimenopause or, as is increasingly recognised, even younger.
This is not about making assumptions or diagnoses, but about widening our formulation. Holding both psychological and physiological factors in mind can support a more compassionate and accurate understanding of the client’s experience. Sometimes, simply holding that possibility can subtly shift the tone in the room.
The impact of not knowing
When these changes are not understood, they can be deeply unsettling. Clients may begin to question themselves, lose trust in their emotional responses or feel as though they are becoming someone they do not recognise. For some, this may also include intrusive or distressing thoughts that feel out of character, which can be particularly frightening when there is no clear explanation.
Without context, it is easy for clients to assume the worst, turning the experience inward and questioning themselves rather than considering that something else may be contributing.
The importance of being taken seriously
One of the most significant turning points in my own experience was being taken seriously by my GP. Having a doctor listen, without dismissing what I was describing or reducing it to “just stress” or anxiety, made a real difference. It helped me begin to join the dots and feel less alone in what I was experiencing.
It also opened up the understanding that there were options available to me. Not necessarily quick fixes, but different forms of support that acknowledged both the physical and emotional aspects of what I was going through.
In the therapy room, we may not be the ones providing medical guidance, but we do play a role in how seriously someone takes their own experience. As we know, being listened to, believed and not minimised can be incredibly powerful.
It can be the difference between:
- Feeling dismissed and feeling understood
- Viewing oneself as “overreacting” versus recognising a meaningful experience
- Remaining stuck versus beginning to make sense of what is happening
Supporting clients: a therapeutic approach
When supporting clients through this, it is rarely about quick solutions. Instead, the work often centres on rebuilding a sense of safety, understanding and self-trust.
This may include:
Psychoeducation
Helping clients develop language for their experience can be a powerful intervention. Moving from “What’s wrong with me?” to “This might make sense” can reduce distress significantly.
Reducing self-criticism
Supporting clients to respond to changes in capacity with compassion, rather than judgement, can help soften the emotional impact.
Attuning to changing needs
Encouraging awareness of needs such as rest, space and boundaries, which may become more important during this time.
Integrative support
Where appropriate, supporting clients alongside medical input, recognising both the physical and psychological aspects of their experience.
Sometimes, the most meaningful shift is helping a client move from:
“What’s wrong with me?”
to
“What might be happening to me?”
A therapeutic lens: the part that feels lost
From a therapeutic perspective, these experiences can often activate younger or more vulnerable parts of the self.
Parts that may feel:
- Overwhelmed
- Uncertain
- In need of reassurance
- Afraid of being “too much” or “not okay”
When these parts are met with confusion or self-criticism, the distress can intensify. But when they are met with understanding, something begins to shift and the stress can feel less overwhelming.
In this sense, the work is not only about managing symptoms, but about supporting a different relationship with the self.
A broader perspective
As therapists, we are not expected to diagnose perimenopause. However, awareness of its potential psychological impact allows us to hold a broader, more compassionate formulation. Sometimes, that broader perspective is enough to help someone feel less alone, less confused and more able to make sense of what they’re going through.
Because often, the hardest part isn’t what someone is feeling. It’s not understanding why.
