Menopause & Mental Health: Your Questions Answered

A conversation about menopause with Dr. Sandra Dunkin, MD, of BrainWell Psychiatry — Bastrop, TX

Hormones don't just affect hot flashes and sleep — they affect the brain. Yet when women in perimenopause or menopause come in with new anxiety, mood swings, or insomnia, it's often overlooked as a hormonal issue. Dr. Dunkin sat down with Kyla, a member of the BrainWell care team, to answer the questions we hear most often about menopause, perimenopause, and mental health.

Watch Dr. Dunkin and Kyla discuss this topic: https://youtu.be/6UPKuAPvgyY

Why is menopause and mental health overlooked?

It's a good question, and there isn't one clear reason. Part of it comes down to primary care: appointments are short, and the conversation tends to focus on the most stereotypical symptoms — hot flashes and sleep problems. Anxiety doesn't get the same attention. When a woman comes in reporting anxiety, it takes time to ask the right questions: Is this new? Has she always been an anxious person, or is this a change? That kind of history-taking often gets skipped.

There's also been a cultural "suck it up" mentality around this stage of life — the idea that mood changes are just what happens as you get older, and that's just what women deal with. Historically, there hasn't been enough education around it. That's changing as women become more vocal about wanting real answers and real care, but there's still a long way to go.

How do I know if my anxiety or mood changes are related to menopause?

Perimenopause can start up to 10 years before periods actually stop, so it should be on the list of possibilities for any woman in that broader age range who's asking these questions.

A helpful place to start is history: is this new, or has it always been part of your life? It's tempting to look for an external cause — "I'm an empty nester now," or "the kids are gone" — but most of us carry roughly the same capacity to cope throughout life. We develop tools for handling stress, whether it's a toddler or a teenager, and those tools tend to keep working. When they suddenly stop working — when you're irritable, anxious, or not sleeping in a way that feels out of character — that's usually not just "a phase of life." It's often a chemical shift. Hormones have a significant effect on the brain, including serotonin, dopamine, GABA, and sleep regulation. Unless someone has dealt with these symptoms their whole life, hormonal status is one of the first things worth considering.

Interestingly, menopause timing tends to run in families. Asking your mother or an aunt when they went through menopause can actually be useful information — if a woman in her early 40s is already having symptoms and it seems early, it's worth checking whether other women in her family also went through menopause younger than average.

What happens when I come in with these symptoms?

The first step is education — helping you understand what might be going on. From there, we take a thorough history and rule out any other medical issues that could be contributing.

We also look closely at lifestyle, which is foundational to any mental health assessment: Are you getting enough sleep, and is there enough time built in for it? Do you have the support you need? Are you eating well and getting exercise? Getting a clear picture of these basics is often the starting point before deciding what else might help.

Should I see a therapist or a psychiatrist for my menopause and mental health concerns?

Therapy is a great place to start, and for many people it helps. But if you've been working with a therapist and things aren't improving, it may be time to see a psychiatrist for a fuller assessment.

A psychiatric evaluation looks at the whole picture — physiological factors, hormones, and how they may be interacting with mental health. Many medical conditions have a psychiatric component, or vice versa, and a psychiatrist is positioned to evaluate all of it together and talk through the full range of options, from lifestyle support to medication to hormone therapy.

Is hormone replacement therapy (HRT) safe?

Hormone replacement therapy can be a valuable option for the right candidate. For years, prescribing dropped off sharply after a large study was initially interpreted as showing an increased risk of heart disease and other conditions in women taking hormone therapy. In response, providers largely stopped prescribing it — and in the years that followed, we actually saw those very health risks increase.

In reality, hormones appear to be protective for the heart, the brain, and several other systems in the body. The original findings applied to a small subset of women with specific risk factors, not the majority. Most women do very well on hormone replacement therapy when it's appropriate for them, though not everyone is a candidate — that's something to evaluate individually with your provider.

I've brought this up with my doctor before and felt dismissed. What should I actually say?

Be direct. If you're noticing changes in your mood, sleep, anxiety, irritability, or emotional stability and you're in the age range where perimenopause or menopause is possible, say so plainly: "I've wondered if this could be related to perimenopause or menopause. What do you think?"

Patients sometimes hold back because they don't want to seem like they're telling the doctor what to do, or don't want to come across as demanding. But naming the possibility yourself is reasonable, and it should prompt your provider to consider it as part of a thorough assessment. It can also help to ask female relatives — your mother, an aunt, sisters — when they went through menopause, since it tends to run in families and can point to whether an earlier-than-expected transition is likely.

Can perimenopause or menopause really be connected to suicidal thoughts?

Yes, and it's something to take seriously. Recent research has pointed to a real rise in suicidal thoughts during perimenopause and menopause that often goes unrecognized. Any time a patient at BrainWell reports suicidal thoughts, it's addressed immediately — it's a sign of hopelessness, and a depressed brain can get stuck seeing a problem from only one angle, unable to see that things could look different.

Hormone replacement therapy can be an important part of treatment because it addresses an underlying cause rather than only the symptoms. But it shouldn't be the only intervention — the mental health and depression symptoms themselves still need direct treatment, whether that's an antidepressant, TMS (transcranial magnetic stimulation), another psychiatric treatment, or a combination, while hormone levels and support systems are also being addressed.

It's also worth naming the emotional side of this stage of life honestly: transitions like becoming an empty nester or a spouse retiring are real stressors. Someone might have handled that same transition fine at another point in life. When hormonal changes are also affecting brain chemistry, coping with an ordinary life transition can become much harder — and that combination is often what pushes someone into a genuinely hopeless place. Recognizing that connection is part of getting the right help.

If you're noticing changes like these

If you're in perimenopause or menopause and dealing with new anxiety, mood swings, irritability, or sleep problems, you don't have to figure out on your own whether it's "just part of getting older." A thorough psychiatric evaluation can look at the whole picture — hormonal, medical, and emotional — and help you find real relief.

If you are in crisis, call or text 988.

If you're in the Austin or Bastrop area and would like to talk with Dr. Dunkin or someone on the BrainWell team, we'd love to hear from you. Telepsychiatry appointments are also available for greater flexibility.

📞 Call us: 512-360-8488 🗓️ Request an appointment: brainwellpsychiatry.com/request-an-appointment 🌐 Learn more: brainwellpsychiatry.com 📍 909 Pecan Street, Bastrop, TX 78602

The information in this article is for educational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment. Please consult a qualified healthcare provider for guidance specific to your situation.