Mood, feelings and brain fog

Part 5 of 12 · All topics on the menopause

“I don’t recognise myself at the moment”

Sometimes a woman does not describe the menopause first in physical terms. She says: “I get irritated more quickly.” Or: “I actually love my job, but right now it is all too much.” Others notice an inner restlessness that they did not know before. Still others report a low mood, although outwardly a lot is going well. Such experiences deserve attention. But the explanation is not the same for every person.

Midlife is often very full: professional responsibility, caring work, relationships, financial pressures and changed sleeping conditions can all come together. At the same time, the hormonal situation is changing in many women. It would be just as wrong to interpret psychological symptoms solely as a result of stress as to reduce them across the board to the ovaries. The scientific question is rather which factors are connected and which treatments really help. [1]

Mood swings are not automatically depression

Being sad, sensitive or irritable for a while is not the same as suffering from a depressive illness. Depression can involve a persistently low mood or the loss of pleasure and interest, often together with changes in sleep and drive, feelings of guilt, problems with concentration or hopelessness. What matters is not whether a single symptom occurs, but its duration, intensity and effect on life.

The distinction is significant, because depression that needs treatment must not be dismissed simply with the explanation “that’s just the menopause”. Anyone who is badly affected over a longer period or feels hopeless needs professional support. If you have thoughts of harming yourself, you need help immediately, through the local emergency number or a crisis service. A person who is struggling does not first have to prove that their symptoms are hormonal in order to deserve help.

A systematic review published in 2024 evaluated 17 prospective cohorts with more than 16,000 women in total. In the meta-analysis, the risk of depression was higher in perimenopause than in premenopause; the reported odds ratio was 1.40. An odds ratio is not the same as “40 out of 100 women”, nor is it automatically a 40 per cent absolute increase. It describes a relative difference between groups. The studies used different measuring instruments and did not all have the same possibilities for comparison. [2]

What follows from this? That the menopause transition can be a phase of increased vulnerability to depressive symptoms – not that every mood swing is depression or that all women face the same danger. Earlier depression, sleep problems and stressful life events can change the situation. Good care asks about the individual history, not only about age.

Making sense of anxiety and inner restlessness

Anxiety can take many forms: constantly circling thoughts, physical alertness, tension, palpitations or sudden unease. Because hot flushes can also be accompanied by palpitations, the experiences are sometimes confused. A single symptom does not allow a reliable distinction. What matters are the course, triggers, accompanying symptoms and the question of how far the symptoms restrict daily life.

If you notice that you avoid certain situations because you fear another episode, it is worth talking about exactly that. Fear of visible hot flushes can set up a cycle of tension and avoidance. At the same time, new, unexplained racing of the heart should not be too quickly put down to anxiety or hormones. Heart and circulatory conditions, thyroid disease and the effects of medicines can cause similar symptoms.

A helpful way of putting it in a consultation might be: “For three months I have noticed a new inner restlessness. It occurs mainly at night, but sometimes also independently of hot flushes. I would like to look at possible links with the menopause as well as other causes.” This makes the picture of your symptoms more precise, without your having to make a diagnosis yourself.

Brain fog – a real impression, but not a single medical condition

Brain fog is not a clearly defined medical finding. The term covers subjective complaints such as difficulty finding words, forgetfulness, concentration that takes more effort, or the feeling of no longer being able to sort things out well when there are several tasks. Often it is everyday moments that unsettle: a name does not come to mind, a thought breaks off in the middle of a sentence or an appointment is forgotten.

Such experiences can be very distressing – especially if you need your mental performance at work. Subjective complaints are not, however, the same as changes shown in neuropsychological tests. Lack of sleep, depressive symptoms, stress, medicines, thyroid disease and other factors can affect concentration and memory. It therefore makes no sense to conclude from a moment of forgetfulness that there is a long-term neurodegenerative disease.

A meta-analysis of 34 randomised trials, published in 2024, shows that hormone therapy is not automatically a memory medicine. Across the cognitive areas evaluated, no consistent general benefit was found. This statement does not mean that an individual woman could not feel subjectively more focused with better sleep or fewer hot flushes. It means that hormone therapy should not be used with the promise of reliable dementia prevention or a general improvement in mental performance. [3]

When mood and sleep affect each other

A bad night can increase irritability and problems with concentration the next day. Conversely, a depressed or anxious mood can make it harder to fall asleep. Anyone who wants to read a single cause out of this cycle often gets nowhere. For exactly this reason it helps to name the individual problems: how many nights are affected? Does the person still enjoy activities? Is there panic, brooding or a persistently low mood? When did the symptoms begin?

Looking at them separately is not an artificial splitting-up, but protects against poor decisions. If a woman develops depression, she may need evidence-based psychiatric or psychotherapeutic treatment. If hot flushes are marked, therapies specific to the menopause can also make sense. The NICE guideline expressly stresses that diagnosed or suspected depression should also be treated according to the relevant depression guidelines – not solely as a menopause symptom. [1]

Self-observation without constant self-monitoring

A short record can make patterns visible, but should not become another burden. On a few days, note the length of sleep, mood, hot flushes and particular stresses. A single bad day says little. It is more interesting whether a recurring pattern appears over weeks. You can also record positive observations: when was concentration good? Which situations helped you feel steadier?

If you use a rating scale to assess depression or anxiety, treat the result as a starting point for a conversation and not as a self-diagnosis. Questionnaires can point to a problem; interpreting them belongs in the clinical context. They replace neither a conversation nor an examination.

And one more thing: not every burden has to be “optimised away”. It is legitimate to divide work tasks differently, to ask for breaks or to arrange support at home. These are changes to the circumstances, not treatment of a hormone level. The page Making well-informed decisions deals with such decisions in more detail.

What help there is – and where to read more

Psychotherapy, in particular cognitive behavioural therapy, can help with sleep problems and certain distressing psychological symptoms. There are also approaches specific to the menopause for the distress caused by hot flushes. If there is a depressive illness, its treatment depends on severity, history and personal preferences. Not every antidepressant used for depression is the same as the targeted use of individual active substances against hot flushes. The detailed discussion follows on the page Treatment without hormones. [1] [4]

If you have newly appearing, marked memory problems that objectively affect daily life, progress quickly or are accompanied by other neurological signs, a medical assessment is important. The aim is not to treat normal forgetfulness as a disease, but not to overlook serious causes.

When “not myself” is a helpful description

Some women report that they are more easily irritated, more tearful or less resilient than before. This can feel strange, especially if their self-image has so far been shaped by functioning reliably. But the phrase “not myself” is at first a description, not a diagnosis. It says something about the experience and the burden. For the question of causes, it is a beginning, not the end.

In perimenopause, mood swings and depressive symptoms can occur more often. A systematic analysis of prospective cohort studies found a higher risk of depression during this transition compared with premenopause. The finding does not mean that every depressive episode is caused by hormones. It shows rather that this stage of life should be taken seriously as one risk factor among several. Personal history, ongoing stress, sleep disorders, social strain and the experience of earlier depression can change the situation. [2]

It makes sense to distinguish between a mood swing and depression. With a mood swing there can be a noticeable change between good and bad days. Depression can show itself through a persistently low mood, loss of interest, changes in sleep or appetite, problems with concentration, feelings of guilt or hopelessness. The diagnosis depends on duration, severity and the overall picture. It needs a professional assessment, not just an online questionnaire. Severe hopelessness or thoughts of self-harm are reasons to seek help without delay; in an acute emergency, the local emergency and crisis services are responsible.

Why anxiety often appears as physical restlessness

Anxiety does not have to show itself as a worry that can be clearly put into words. It can be experienced as inner restlessness, palpitations, tension or constant brooding. At the same time, hot flushes themselves can come with palpitations. Some women become unsure because of the unpredictable episodes; then, on top of the original physical reaction, comes the worry about the next one. This does not mean that the symptoms are only psychological. Physical and psychological reactions can reinforce each other.

Here too, other causes belong in the picture: new heart rhythm disorders, an overactive thyroid, effects of caffeine or medicines and other illnesses can cause similar signs. Sudden severe racing of the heart with chest pain, fainting or marked breathlessness is not a situation in which to wait for the next routine appointment. The task of these pages is not to frighten you, but to show the limits of simply assigning symptoms to a cause yourself.

A helpful conversation does not necessarily begin with “I have anxiety disorders”, but perhaps with “For some months I have been waking with palpitations and I am restless during the day; I would like to know what is behind it”. This leaves room for different explanations and a proper examination.

Brain fog is an expression, not a finished theory

“Brain fog” often describes words going missing, appointments being harder to remember, or thoughts no longer fitting together as easily. The experience can be unsettling, especially for women who organise a lot and work mentally. But brain fog is not a single, medically clearly defined condition. Some of the difficulties described affect attention, others processing speed, working memory or subjectively experienced concentration.

If sleep, stress and mood impair attention, the same everyday mistakes can arise as with cognitive changes of another cause. It is all the more important not to infer a serious illness from every forgotten name – but also not to attribute all newly appearing or rapidly increasing memory problems automatically to the menopause. Persistent impairment, disorientation or clear changes in the ability to manage daily life should be examined by a doctor.

A meta-analysis of 34 randomised trials found no established general advantage of menopausal hormone therapy for the cognitive abilities studied. From this result it follows neither that a woman on hormone therapy can never subjectively think more clearly, nor that hormones would be a suitable general prevention against cognitive decline. A possible benefit through better sleep or fewer hot flushes has to be distinguished from a direct effect on memory. [3]

What a good conversation about mood can achieve

If you are preparing for an examination, you can bring three observations: when did the symptoms begin? Are they tied to particular situations or phases of sleep? And what is no longer working in daily life the way you would like? This is often more useful information than the question of whether your oestrogen is “too low”. A doctor or a psychotherapist can then ask in a targeted way about symptoms, history and possible physical causes.

Not every woman needs psychotherapy. If, however, anxiety, depressive symptoms or a stubborn sleep disorder shape daily life, psychological methods and, where appropriate, other treatments can make a lot of sense. The NICE guideline recommends cognitive behavioural therapy specific to the menopause as an option for certain depressive symptoms and sleep problems linked to vasomotor symptoms; for diagnosed depression, the relevant treatment guidelines also apply. [1]

Such a therapy does not explain “the hormones away”. It helps, for instance, to change distressing evaluations, sleep habits and the reaction to unpredictable physical episodes. This is a separate, scientifically studied treatment strategy. The decision does not have to be between “hormones” and “it’s all psychological”; some women benefit from several approaches, others prefer one alone.

Invisible work and emotional strain

Women over 40 often carry responsibility at work, in the family and for relatives at the same time. These burdens can make symptoms worse, but they are not the same for all women. A page about the menopause must therefore neither pretend that every irritable reaction is hormonal, nor that biological changes can be planned away with good enough self-organisation.

If you notice that you are constantly going beyond your limits, a simple stocktake can help: which commitment is fixed? Where can tasks be shared? When do you get real rest, and not just free minutes that are filled with further tasks? Such questions do not replace treatment of severe symptoms, but they can make visible why an improvement in one area of life alone may not be enough.

The French ELISA study and the German study of care in general practice underline that information and accessible medical support cannot be taken for granted. They do not explain why an individual woman feels the way she does, but they show that the care system and the quality of conversations can make a difference. [5] [6]

A small exercise in precision

Try to turn the statement “I can’t cope at the moment” into something that can be described. Perhaps it reads: “After two nights with frequent waking, I need longer for certain tasks.” Or: “The inner restlessness has been increasing for three months, although little has changed in my work.” Such a description is no less emotional, but it is more exact. It helps you to recognise patterns and to explain better what it is about.

If you are looking for support, you may also say clearly which goal matters to you: sleeping undisturbed again, having fewer peaks of anxiety, fewer conflicts at home or enough concentration for daily life. Good treatment is guided by achievable goals, not only by a laboratory value. This applies regardless of whether the menopause is ultimately the main trigger or only part of a larger picture.

How life history can affect the risk

A woman who has already had several depressive episodes in her life brings different starting conditions from someone who is noticing mood swings for the first time. Earlier marked symptoms around the cycle or after a birth can also be relevant for a conversation with professionals. Even so, it is not possible to predict reliably from a single feature how a person will react to perimenopause. The different stages of life share hormonal aspects, but are not identical.

Anyone who has already needed psychotherapeutic or psychiatric treatment should not end existing support merely because of a new suspicion of menopause. Genuine depression should be treated according to recognised treatment standards. If vasomotor symptoms occur at the same time, targeted treatment of these can improve the overall situation, but does not automatically replace treatment of depression. [1]

Concentrating when short of sleep: an inconspicuous problem

Many difficulties with concentration do not show up as a spectacular memory gap, but as more effort with familiar tasks. A complicated text has to be read twice; appointments are noted several times to be safe; after a restless night, an ordinary working day feels harder. In this situation it would be tempting to look specifically for a “memory remedy”. But it is worth first asking how sleep, stress, medicines and other illnesses affect attention.

Practical strategies can ease daily life without claiming a biological mechanism. Tasks that demand a lot of concentration can, as far as possible, be done at times when you feel more alert. A clear task list relieves working memory. Interruptions become easier to manage if you briefly note a thought before you switch. Such measures are organisational aids, not a therapy against dementia and not evidence of a specific menopause effect.

If the problems increase clearly, tasks that used to be routine no longer succeed or other neurological symptoms are added, a medical assessment is advisable. The fact that brain fog is often described in perimenopause does not make every change harmless.

The social effect of mood symptoms

Irritability and withdrawal affect not only the person concerned. Children, partners, friendships or teams can react with irritation. A conversation that makes sense to everyone often helps more than looking for someone to blame. You can say, for example: “I notice that after bad nights I get exhausted much more quickly. I want to take this seriously and on some days I need more quiet.” A statement like this gives direction without shifting all conflicts onto hormones.

It can also happen that a woman notices only through the new physical burden how unequally tasks had been divided until then. The question is then not whether a medicine will repair the whole relationship, but which changes are possible together. Medical treatment, practical relief and conversations in the relationship are different levels that can complement each other.

Why self-observation should not become a constant test

A symptom diary can be useful if you have a clear purpose: documenting a course of events, preparing for an appointment or assessing a treatment. If, on the other hand, you check every emotion for its hormonal meaning, attention itself can become a burden. Bad moods, joy, anxiety and exhaustion are normal human states and do not all have to be explained in a menopause app.

A simple rule is: observe what is relevant for decisions. If after four weeks you can describe more clearly how often sleep disturbances occur and what effects they have, the diary has done its job. If you feel hounded by it, less recording may be better. Self-care does not begin with the largest possible amount of data, but with a realistic way of dealing with your own burden.

When mood swings are more than a difficult phase

It is not unusual to react on some days with irritation, sadness or greater sensitivity. In the menopause transition, hormonal fluctuations and sleep problems can accompany such experiences. But when does a mental illness begin? This question cannot be answered by the strength of a single feeling. Duration, frequency and effects on life are more important. A depressive disorder can show itself, among other things, through persistent low spirits, loss of pleasure, withdrawal, difficulty concentrating and physical complaints. An anxiety disorder can be marked by worries that are hard to control, avoidance or physical tension.

This does not mean that you should diagnose yourself on the basis of a single symptom. Especially with sleep problems, exhaustion and difficulty concentrating, different causes can overlap. Good care therefore looks at the medical history, stresses and, where appropriate, physical findings. If depression or an anxiety disorder is already present, appropriate psychotherapeutic or medical treatment can remain important even if menopause symptoms occur at the same time. [1]

A woman who has never had psychological problems before can feel unsettled by new depressive symptoms. Another knows the symptoms from earlier and worries about a relapse. Both should be taken seriously. It is particularly important not to draw an automatic personal prognosis from the higher relative risk found in studies. A statistical association describes groups, not the fate of an individual.

How to read psychological studies properly

In research, mood and depression are recorded with different methods. Some studies use clinical diagnoses, others questionnaires in which participants state themselves how often certain feelings occur. These are not the same. A high questionnaire score can be an important indication, but it is not a complete diagnosis. Conversely, women may appear unremarkable in a brief survey despite relevant symptoms.

The meta-analysis published in 2024 on the risk of depression in menopausal stages included 17 prospective cohorts with more than 16,000 women in total; only some of them went into the actual quantitative summary. It found an increased likelihood of depressive symptoms or illness in perimenopause compared with premenopause. In interpreting it, one has to consider how the studies defined their groups and endpoints. [2]

A good graphic should therefore not simply claim: “40 per cent of women get depression.” That would confuse a relative measure of risk with how common an illness is. The published odds ratio of about 1.40 means a higher relative chance compared with a comparison group, not an absolute probability of 40 per cent. Such differences matter, because inaccurate figures can cause fear.

How much loss of concentration is normal?

Everyone occasionally forgets a name or searches for a word. If the same experiences stand out more often during a phase of poor sleep, that can be unsettling. But subjective difficulties with concentration are often linked to several factors. The question is not only whether a woman does badly in a memory test, but also whether she has been less rested for a longer time, is under stress or is constantly occupied in her thoughts with symptoms.

Studies of cognitive performance use various tasks, for example for attention, verbal memory or processing speed. Some measure once, others over years. A result in one domain does not automatically say anything about all abilities. The fact that the meta-analysis of randomised hormone therapy trials found no general cognitive benefit supports, in particular, caution about the promise that hormone therapy is a universal prevention of memory loss or dementia. [3]

If you notice forgetfulness in daily life, you can first look at the context: how are you sleeping? Has your workload increased? Are there new medicines? Is your mood low? If there is a marked, increasing impairment or accompanying neurological signs, a medical examination should check whether there is another cause. It would be good neither to dramatise every worry nor to dismiss it across the board as a menopause symptom.

Emotional reactions to a changed stage of life

Not all changes are symptoms. Some women experience the end of fertility as a relief, others as a loss. Some feel freer because the children are becoming more independent; others face caring responsibilities or a change in career. Such reactions are human. They do not have to be reduced to hormone levels, even if the physical stage of life changes the emotional context.

The term “menopause” can also call up cultural images: youth, attractiveness, performance and social expectations. An account that only lists medical diagnoses does not do justice to these experiences. It should explain that individual experience is socially influenced, without turning this into a new universal story. Some women find these years a particular burden, others a normal stage of life. Both may stand side by side.

The reactions of those around you also differ. A woman may hear “But that’s normal” when she talks about severe sleep disorders. Another is immediately confronted with suggestions for medicines although she is not looking for treatment at all. Good support begins with asking what she herself needs. Information and self-determination belong together.

What you can say when looking for help

Some people hesitate to mention psychological symptoms because they fear that every physical cause will then be overlooked. Others are afraid that hormonal changes will not be taken seriously. A good sentence for a medical consultation can take both into account: “Since my cycle began to change, I have had sleep problems and strong mood swings. I would like to find out which causes come into question and which treatment could help me.”

You can also ask for joint planning: what should be treated first if sleep and depressive symptoms occur together? Which measures are compatible with my other medicines? When should we review the result? Do I need psychotherapeutic co-treatment? Such questions encourage integrated care, without bringing a ready-made diagnosis to the conversation.

If you have acute thoughts of self-harm or suicide, you must not wait for a regular appointment. Then local crisis help, emergency care or trusted support should be involved straight away. A health guide can give orientation, but cannot itself treat an acute psychological crisis.

Why mental performance is not a moral duty

If you used to get many things done at once, a slower day can feel like personal failure. But attention is a limited resource. Lack of sleep, stress and physical symptoms use some of it up. It can make sense to prioritise tasks anew, to allow breaks and to arrange support. This is no proof that the body is declining irreversibly. It is a realistic reaction to a changed burden.

Many guides recommend a long list of techniques for becoming “fully productive” again. In doing so they shift the responsibility entirely onto the individual woman. A more sensible approach is to combine medical assessment, practical relief and suitable treatment. You do not have to solve every difficulty with a product or an app. Sometimes the most important progress is to take a burden seriously and to accept support.