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What to do next · Mood, anxiety & brain fog

Mood, anxiety and brain fog: what to do next

Evidence-checked · sources listedSources

Information for better conversations, not a diagnosis. This is research with sources, not medical advice. Talk to your clinician about your situation.

What this often points to

The hormone picture. In perimenopause, the ovaries' hormone output becomes "erratic", with "less-frequent release of an egg (ovulation)", per The Menopause Society 1. The Society describes estrogen levels that fluctuate during perimenopause 1. One theory it gives for higher depression rates is a "window of vulnerability", in which some women are more sensitive to these hormone shifts 1. Over the transition, the FDA says the body "slowly produces less of the hormones, estrogen and progesterone" 2. Testosterone follows a slower path: it declines during the reproductive years 3. The Global Consensus says testosterone isn't shown to help depressed mood (Level I, Grade B) and that there's insufficient evidence for using it to improve thinking or memory 3.

Mood and anxiety: the numbers

  • A 2024 review pooled studies that followed women over time. Women in perimenopause had about 40% higher odds of depressive symptoms or a depression diagnosis than premenopausal women (OR 1.40). There was no significant increase after menopause 4.
  • In SWAN, women who started with low anxiety were more likely to report high anxiety in perimenopause or postmenopause than before (odds ratio 1.56–1.61). This held regardless of stress, finances, health and hot flashes 5.
  • The Menopause Society says women with a history of depression earlier in life are at greatest risk 1.

Worth printing before an appointment: The Menopause Society's free MenoNotes are short information sheets written by menopause experts. The one called Menopause and Depression covers the mood changes and depressive symptoms many women notice in the transition, and how to tell when they may be something more serious, like depression. It's a clear way to put words to what you're feeling and bring them to your provider.

Brain fog: the numbers

  • 40% to 60% of midlife women report cognitive symptoms such as forgetfulness during the transition. The Menopause Society says these changes are "typically mild and within the limits of normal, and dementia at midlife is very rare" 1.
  • SWAN tested 2,362 women over 4 years. Normally, people score a little better each time they retake the same test. In perimenopause that gain stalled. It returned after menopause, which suggests the effect may be time-limited 6.
  • Sleep, mood and hot flashes can all feed the fog 7. The NIA lists other causes of memory problems: thyroid, kidney or liver problems, medicine side effects, depression and anxiety, alcohol, sleep problems, and low vitamin B12 8.

Can a blood test confirm perimenopause? Usually not. ACOG says: "You probably don't need hormone testing." Your age, symptoms and period changes usually tell the story. Testing may be offered if you're under 45 with bleeding changes, especially under 40 9. NICE advises against hormone and ovarian tests to identify perimenopause at 45 or over 10.

What to track for 2 weeks

  • Mood, 0–10, and anxiety, 0–10, once a day.
  • Brain fog moments, in a few words each: a lost word, a missed step, losing your train of thought.
  • Sleep: hours, and wake-ups.
  • Hot flashes and night sweats: a tally is enough.
  • Your period: start and stop days. Note whether low days cluster around it.
  • Alcohol, big stressors, and medicines and supplements.
  • Any history of depression, anxiety, or postpartum or premenstrual mood changes.

Questions to ask your clinician

  1. "Could this be perimenopause, depression or anxiety, or a mix? Can we screen for depression and anxiety today?"
  2. "Can you refer me for CBT or another talking therapy?"
  3. "I also have hot flashes and poor sleep. Is there an option that could help with more than one?"
  4. "Should we check my thyroid, B12, or my medicines for the memory changes?"
  5. "Is hormone therapy reasonable for my hot flashes, knowing it isn't a treatment for memory?"

The options on the table

These are the authorities' own grades and words. They aren't a ranking for you.

For depression and anxiety

Talking therapies For women with a history of depression, The Menopause Society's 2022 statement says clinical guidelines recommend screening for depression, and proven psychotherapies, such as cognitive behavioral therapy and mindfulness-based cognitive therapy, for treating major depression that comes back 7.
Menopause Society: Level II
Estrogen It isn't FDA-approved to treat depression. The Menopause Society's 2022 statement gives these grades 7:
  • Estrogen therapy improved depressive symptoms in depressed perimenopausal women (Level II) 7.
  • It is "ineffective as a treatment for depressive disorders" in postmenopausal women (Level II).
  • Evidence is "not sufficient" to recommend estrogen to prevent depression.
Global Consensus: Level I, Grade B
Testosterone It isn't a mood treatment. "Available data do not show an effect of testosterone on depressed mood (Level I, Grade B)" 3. There's no FDA-approved testosterone formulation for menopausal symptoms in the US 11.
Physical activity US Physical Activity Guidelines say regular activity reduces the risk of depression and can reduce anxiety 12.

For brain fog

Menopause Society: Not recommended (Level I)
Hormone therapy isn't a memory treatment The Menopause Society's 2022 statement says hormone therapy "is not recommended at any age to prevent or treat a decline in cognitive function or dementia" (Level I) 7. The FDA says: "No, do not use hormone therapy to prevent memory loss or Alzheimer's disease" 2. Starting hormone therapy after 65 increased dementia risk in the WHI Memory Study, with an extra 23 cases per 10,000 women per year on one combined regimen 7.
Testosterone isn't a memory treatment either The Global Consensus statement says there's "insufficient evidence to support the use of testosterone to enhance cognitive performance, or to delay cognitive decline, in postmenopausal women" 3.
Treat what's feeding it Sleep, mood and hot flashes are each treatable (see the Sleep and Hot flashes paths). The Menopause Society calls hormone therapy the most effective treatment for hot flashes and night sweats for women who are candidates 7. Whether easing those symptoms also clears the fog hasn't been proven.

What the research tested

SWAN cognition (Neurology, 2009). 2,362 women took processing-speed and memory tests repeatedly over about 4 years 6.

  • Premenopausal, early perimenopausal and postmenopausal women improved with practice.
  • Late perimenopausal women's processing-speed scores didn't improve.
  • Postmenopausal women not taking hormones scored the same as premenopausal women.

What it tested: changes on standard tests over time, not how foggy women felt. Limitation: it's observational, and the differences were small.

Limitation

Most of this research measures averages in groups. It can't tell you whether your own fog is hormonal. Mood, sleep, stress and other health conditions overlap, which is why tracking and a proper screen matter more than a guess.

Supplements

Mood swings, a short fuse, and walking into a room with no idea why: these send a lot of us to the supplement aisle. Here's what trials found for mood, anxiety and brain fog, one ingredient at a time.

How we label evidence: Studied, some benefit means at least some randomized trials found a benefit, usually small or short. Mixed results means trials disagree. Little evidence means few studies, or no clear benefit over placebo. The labels describe the research. They are not recommendations, and the list is not a ranking.

The FDA doesn't approve supplements for safety before they're sold 13.

St John's wort

Studied, some benefit (for mild to moderate depression)

Safety: This is the herb with the biggest interaction warning. NCCIH says it "can interact in dangerous, sometimes life-threatening ways with a variety of medicines" and can weaken the effects of some 14.

What the research found

NCCIH says that in studies of adults in general, St John's wort worked better than placebo for mild or moderate depression. It's unclear whether that holds for severe depression or beyond 12 weeks 14. These weren't menopause-specific studies.

Saffron

Studied, some benefit

What the research found

In a 12-week randomized trial of 86 women in perimenopause, a saffron extract cut anxiety scores by 33% and depression scores by 32% from baseline, more than placebo did. It didn't help hot flashes 15. A separate 6-week trial of 60 postmenopausal women with depression and hot flashes found improvements in depression scores over placebo 16. Both trials were small, and the first was funded by the extract's maker 15.

Ashwagandha

Studied, some benefit (for stress and anxiety)

Safety: ODS says it seems well tolerated for up to about 3 months, but its long-term safety isn't known. There are reports of liver injury. It might affect thyroid function and interact with thyroid medicine, and some experts advise against it in pregnancy 17.

What the research found

The NIH Office of Dietary Supplements summarizes a 2021 review of 7 trials (491 adults in India) in which ashwagandha lowered stress and anxiety scores more than placebo over 6 to 8 weeks 17. None of these trials focused on menopause.

Omega-3 (fish oil)

Little evidence

What the research found

A 2023 systematic review of 9 randomized trials in postmenopausal women called the evidence on depression "inconclusive" 18.

Maca

Little evidence

What the research found

In a 12-week crossover trial with just 14 postmenopausal women, maca lowered anxiety and depression scores compared with placebo 19. A systematic review of 4 small trials found the evidence "limited," with too few, too-small trials to draw firm conclusions, and said safety hasn't been proven 20.

Ginkgo and soy isoflavones (for memory and focus)

Little evidence

What the research found

A systematic review of 12 randomized trials found that 5 suggested isoflavones, soy or ginkgo might help thinking in postmenopausal women. Most of those trials had serious flaws, and the reviewers concluded the evidence is "not compelling" 21.

Something to notice this week: If you're already taking one of these, write down when you started and how your mood, worry and focus have felt since. That gives your clinician something concrete to work with.

A question for your clinician: "I'm taking (name the supplement) for my mood. Could it interact with anything else I take, and should we look at what else might be behind how I've been feeling?"

The honest caveat: Most of these trials ran 6 to 12 weeks with fewer than 100 women, so we don't know how well the results hold up over months.

Worth mentioning to your provider: the National Institute on Aging lists memory changes worth a visit, such as asking the same questions over and over, getting lost in places you know well, trouble following recipes or directions, growing confusion about time, people and places, or not taking care of yourself 8.

Information for better conversations, not a diagnosis.

This is research with sources, not medical advice. Talk to your clinician about your situation.

Evidence-checked · sources listed

Talk to a menopause-trained provider

Sources (all rechecked 2026-10-15)

  1. The Menopause Society. Perimenopause (patient education; Depression and Brain Fog sections). https://menopause.org/patient-education/menopause-topics/perimenopause
  2. US FDA Office of Women's Health. Menopause. https://www.fda.gov/consumers/womens-health-topics/menopause
  3. Davis SR, et al. Global Consensus Position Statement on the Use of Testosterone Therapy for Women. J Clin Endocrinol Metab. 2019. PMID 31498871. https://pubmed.ncbi.nlm.nih.gov/31498871/ (full text PMC6821450, recs 5 and 11)
  4. Badawy Y, et al. The risk of depression in the menopausal stages: a systematic review and meta-analysis. J Affect Disord. 2024. PMID 38642901. https://pubmed.ncbi.nlm.nih.gov/38642901/
  5. Bromberger JT, et al. Does risk for anxiety increase during the menopausal transition? (SWAN). Menopause. 2013. PMID 23615639. https://pubmed.ncbi.nlm.nih.gov/23615639/
  6. Greendale GA, et al. Effects of the menopause transition and hormone use on cognitive performance in midlife women (SWAN). Neurology. 2009. PMID 19470968. https://pubmed.ncbi.nlm.nih.gov/19470968/
  7. The 2022 hormone therapy position statement of The North American Menopause Society. Menopause. 2022. PMID 35797481. https://pubmed.ncbi.nlm.nih.gov/35797481/ ; see also Maki PM, Jaff NG. Menopause and brain fog. Menopause. 2024. PMID 38888619. https://pubmed.ncbi.nlm.nih.gov/38888619/
  8. National Institute on Aging. Memory Problems, Forgetfulness, and Aging (reviewed Nov 22, 2023). https://www.nia.nih.gov/health/memory-loss-and-forgetfulness/memory-problems-forgetfulness-and-aging
  9. ACOG. Do I need to have testing of my hormone levels during perimenopause? (Sept 2025). https://www.acog.org/womens-health/experts-and-stories/ask-acog/do-i-need-to-have-testing-of-my-hormone-levels-during-perimenopause
  10. NICE NG23, recs 1.3.4–1.3.5. https://www.nice.org.uk/guidance/ng23/chapter/Recommendations
  11. ACOG. Compounded Bioidentical Menopausal Hormone Therapy: Clinical Consensus No. 6. Obstet Gynecol. 2023. PMID 37856860. https://pubmed.ncbi.nlm.nih.gov/37856860/
  12. US HHS. Physical Activity Guidelines for Americans, Top 10 things to know. https://odphp.health.gov/our-work/nutrition-physical-activity/physical-activity-guidelines/current-guidelines/top-10-things-know
  13. US FDA. Questions and Answers on Dietary Supplements. https://www.fda.gov/food/information-consumers-using-dietary-supplements/questions-and-answers-dietary-supplements
  14. NCCIH. St. John's Wort. https://www.nccih.nih.gov/health/st-johns-wort
  15. Lopresti AL, Smith SJ. The effects of a saffron extract (affron®) on menopausal symptoms in women during perimenopause: a randomised, double-blind, placebo-controlled study. J Menopausal Med. 2021. PMID 34463070. https://pubmed.ncbi.nlm.nih.gov/34463070/
  16. Kashani L, et al. Efficacy of Crocus sativus (saffron) in treatment of major depressive disorder associated with post-menopausal hot flashes: a double-blind, randomized, placebo-controlled trial. Arch Gynecol Obstet. 2018. PMID 29332222. https://pubmed.ncbi.nlm.nih.gov/29332222/
  17. NIH Office of Dietary Supplements. Ashwagandha: Is it helpful for stress, anxiety, or sleep? Fact Sheet for Health Professionals. https://ods.od.nih.gov/factsheets/Ashwagandha-HealthProfessional/
  18. Iqbal AZ, et al. Effects of omega-3 polyunsaturated fatty acids intake on vasomotor symptoms, sleep quality and depression in postmenopausal women: a systematic review. Nutrients. 2023. PMID 37836515. https://pubmed.ncbi.nlm.nih.gov/37836515/
  19. Brooks NA, et al. Beneficial effects of Lepidium meyenii (Maca) on psychological symptoms and measures of sexual dysfunction in postmenopausal women are not related to estrogen or androgen content. Menopause. 2008. PMID 18784609. https://pubmed.ncbi.nlm.nih.gov/18784609/
  20. Lee MS, et al. Maca (Lepidium meyenii) for treatment of menopausal symptoms: a systematic review. Maturitas. 2011. PMID 21840656. https://pubmed.ncbi.nlm.nih.gov/21840656/
  21. Clement YN, et al. Effects of herbal and dietary supplements on cognition in menopause: a systematic review. Maturitas. 2011. PMID 21237589. https://pubmed.ncbi.nlm.nih.gov/21237589/