The rage hit Juliet Doherty like a train. At 48 years old, Doherty had been in perimenopause for two years, living with daily headaches, sore breasts and irregular periods. But it had been manageable.
"Naively, I believed that if that was all it was, I would be fine," Doherty said.
That suddenly changed when she began to experience anger unlike any she'd experienced before.
"Emotionally, I was a wreck," Doherty recalled. "My life spiraled out of control . . . It was like watching a car crash and you couldn't stop it."
She described her anger as "the rage": an intense burning in her stomach that didn't cease until it was released. She lashed out at family, friends — she even broke an electric fan. Afterward, she'd cry, frustrated from losing control.
Where does this anger come from?
Though menopause gets all the attention, it's even more common for women to experience mood changes during perimenopause — the transitional period before menopause that's marked by hormone fluctuation, inconsistent ovulation and irregular periods. (Some people will experience mood swings and increased risk of developing depression in the early postmenopausal period too.) Menopause isn't reached until a year after the last normal period, which occurs, on average, at the age of 51 in the U.S. Perimenopause, however, can last anywhere from four to 10 years, and begin as early as your 30s.
"Perimenopause is a time of vulnerability for women due to hormone fluctuation," Dr. JoAnn Pinkerton, medical director of Midlife Health Center and a member of HealthyWomen's Women's Health Advisory Council, told HealthyWomen.
She explained that overwhelming rage, much like what Doherty experienced, may be related to the body's changes in estrogen levels — specifically estradiol –– in combination with stressors. During the course of perimenopause, estrogen continues to fluctuate, which also affects other hormones (like serotonin and oxytocin), and frequently leaves the body with either too many or too few hormones at any given time.
Mood swings, if they're experienced, are often triggered by the body's sensitivity to this fluctuation. But, because of the constant shift, Pinkerton explained, it's not uncommon for feelings of rage to last a week or two and then disappear as the body adjusts.
According to Dr. Sheryl Kingsberg, a professor of reproductive biology and psychiatry at Case Western Reserve University and a member of HealthyWomen's Women's Health Advisory Council, poor sleep can also be a factor in mood swings.
"[During perimenopause], the decrease in estrogen is the cause of an increase in hot flashes and night sweats, [which can disrupt sleep]," Kingsberg said, adding that the shift in hormones may actually disrupt sleep itself, even without hot flashes.
Risk of depression
"Twenty-six to 33% of women exhibit significant depressive symptoms during this hormonal flux," Pinkerton said.
For women, who are nearly twice as likely as men to be diagnosed with depression, depressive episodes are often linked to hormonal life events such as perimenopause (as well as post-pregnancy and puberty).
If left untreated, anger during this transition can increase one's risk of developing depression. Women with a history of pre-perimenopause depression or who've had a history of hormone-related mood changes, such as premenstrual dysphoric disorder, are at an even greater risk, Kingsberg explained.
Both doctors stressed that if you're overwhelmed with feelings of rage, or rage is affecting your relationships, it's important to seek help so that it doesn't lead to depression.
Taming the rage
There are a number of perimenopause treatments available. According to Kingsberg, mood changes are looked at from a biopsychosocial perspective — the interconnection of biology, psychology and socioenvironmental factors. Pharmacological options include hormone replacement therapy (HRT) and low-dose antidepressants.
"There is no data that says hormones will treat major depression," Kingsberg said, "But we certainly can use them for mild mood changes. We know that it can help."
Hormones and antidepressants can provide a dual function: shift neurotransmission to restore mood and help reduce hot flashes. But HRT isn't the only option, and it may not be the right option for everyone. (Kingsberg stressed the importance of talking to your OB-GYN for shared decision-making.)
Cognitive behavioral therapy (CBT) is another effective mode of addressing perimenopausal mood changes. This popular type of talk therapy, which provides tools to shift thought patterns away from the negative and back toward the neutral and positive, is often used for depression and can address irritability. According to Kingsberg, some CBT can help with insomnia and also reduce the intensity and frequency of hot flashes.
Because estradiol fluctuations make women more sensitive to stress, Pinkerton said, experiencing stressful life events during the perimenopausal transition heightens the risk of developing depression. Therefore, it's important that women assess current life stressors to identify triggers. CBT and other mindfulness tools such as meditation can help women have a less negative emotional reaction to stress, which can decrease the development of depression.
"Mindfulness and the ability to step back are really important," Pinkerton said.
Mediation, exercise and creative outlets are all useful activities to decrease stress and irritability. But most important — especially during the COVID-19 pandemic, which has greatly increased stressors — is that it's crucial for anyone going through perimenopause who's feeling especially overwhelmed (or experiencing other physical symptoms such difficulty sleeping, loss of sex drive or pain with intercourse) to reach out for help.
Doherty finally sought help after she climbed a ladder to yell at her neighbors for painting her fence.
"I realized I had lost control of my emotions, and I called my doctor," Doherty explained.
She was put on HRT and her mood instantly changed. Today, she feels more in control of her life and emotions. Her headaches and hot flashes have also stopped.
"I am usually a very controlled, level-headed person. This hit me like lightning –– it was so fast," Doherty said. "HRT has definitely helped control my symptoms. I don't want to feel like that again."
Resources:National Suicide Prevention Lifeline: 1-800-273-8255