When perimenopause changes our relationship with stress
I've been thinking a lot about the woman who recognises herself as being “good under pressure.” She’s often highly capable and has built a career around being able to hold a lot of complexity at once, think quickly when something goes wrong and somehow find another gear when a deadline is approaching. In my clinic, she describes herself as driven, ambitious, perfectionistic… “a bit Type A”, without ever giving much thought to what’s happening underneath because, for most of her adult life, it’s worked.
I think there can be something almost energising about pressure for this woman. She tells me that she almost feels as though a deadline sharpens her thinking; responsibility gives her something to organise herself around and being needed can generate an extraordinary amount of capacity. She’s the person who becomes calmer when everyone else is flapping, who can pull together a week's worth of work in two days, or who carries a demanding job alongside everything else that needs remembering, organising and anticipating.
She’s spent years joking that she needs a deadline to get anything done, that she is incapable of sitting still or that she functions better when she has a lot on. None of this necessarily feels problematic because these are often the same qualities that have been rewarded throughout her adult life. They helped her progress professionally, made her dependable and reinforced an identity built around being someone reliable who can cope.
When you have functioned this way for long enough, I think it’s very easy to experience it simply as personality. I've always been like this. It’s just who I am.
What becomes interesting to me is what happens when the hormonal shifts of the menopause transition begin to coincide with changes in how she responds to pressure. For many women, this is also a period when the demands of life are becoming more complex rather than less. Careers may be increasingly demanding, children are growing up with different needs, parents are ageing and she may find herself occupying that familiar position in the middle, responsible for supporting several generations while still trying to maintain everything she has built around herself.
So it isn't necessarily that nothing has changed in her external world. Quite often, a great deal has. But what can feel particularly disorientating is that the strategies she has always relied upon to manage those demands no longer seem to produce the same response. Things that previously created momentum begin leaving her overwhelmed. Several people needing something from her at once can feel physically uncomfortable. She reads an email and struggles to take in what it says, loses words halfway through a conversation or finds herself staring at a relatively ordinary task without being able to work out where to begin. A full week that she would once have moved through without much thought now requires recovery afterwards, while the quieter periods she assumes she desperately needs don't feel particularly restful once they arrive.
For some women, anxiety becomes the most disorientating part of this change. She has experienced pressure before, sometimes enormous amounts of it, but has never thought of herself as an anxious person. Now she can feel her heart racing over something she knows rationally isn't a crisis, wake in the early hours with her mind already moving or find that noise, interruptions and competing demands seem to get physically under her skin in a way they didn't before.
It can feel as though the person she has relied upon for decades has suddenly become unreliable and run off into the forest.
The obvious explanations are that she’s finally reached her limit, has burned out, has taken on too much or needs to learn better boundaries. All those things may be relevant, particularly when we consider how much many of us have spent our adult lives carrying without allowing or being aware of the physiological cost of doing so.
But I think there is another question worth asking, particularly when this change coincides with the hormonal shifts of the menopause transition.
Rather than only asking why she can no longer cope with pressure, I am interested in how pressure may have been helping her cope in the first place.
When pressure becomes part of how we function
We tend to think about coping in terms of resilience, emotional regulation, personality or the skills we develop through experience. Yet our ability to respond to demand is physiological, involving systems that regulate attention, motivation, arousal and the mobilisation of energy when something requires us to act.
For some women, urgency seems to have become particularly effective at creating that mobilisation. The deadline that has been sitting in the diary for three weeks suddenly makes thinking clearer when it’s two days away. A difficult situation at work creates a level of focus that is strangely difficult to access on a quiet afternoon. Being responsible for something, or somebody, can make it easier to find energy than having an open day in which nobody needs anything.
If that pattern has repeatedly helped her perform, there is very little reason to question it. She learned that she works well under pressure, that she’s someone who can pull things out of the bag when necessary, and perhaps that she needs a certain amount going on around her to feel properly engaged. Over time, the conditions that help her mobilise become so familiar that they are difficult to separate from her understanding of who she is.
This is where I think the overlap with neurodivergence becomes particularly interesting, without suggesting that every highly driven woman is neurodivergent or that ambition and perfectionism should automatically be reframed as symptoms.
For some women with previously unrecognised neurodivergent traits, the systems they have built around themselves may have been doing considerably more work than anyone realised. Extensive organisation may compensate for difficulties holding information in mind. External deadlines can make task initiation easier. Interesting, complex or urgent work may be much easier to engage with than routine tasks, while the expectations of other people can create a level of motivation that is much harder to generate for themselves.1
A woman can become extremely competent within that architecture. In fact, her competence may be one of the reasons nobody, including her, has ever wondered whether there is anything underneath it worth understanding.
The question becomes much more interesting when the architecture remains in place but the physiology supporting it begins to change.
When the conditions underneath her begin to change
One of the difficulties with recognising perimenopause in this woman is that she may not look particularly menopausal, even to herself. Her periods may still be regular, she may not be having hot flushes and, if she is in her early forties, it may simply not occur to her that reproductive hormones have anything to do with the anxiety, disrupted sleep or unfamiliar difficulties with thinking and concentration she’s started to experience.
We still tend to talk about the menopause transition as though oestrogen gradually declines until periods eventually stop, but the hormonal changes during perimenopause are considerably more dynamic than that. Oestradiol can fluctuate substantially during perimenopause, sometimes reaching relatively high levels as well as falling, while progesterone exposure can also become less consistent as ovulation becomes more variable.2 There is considerable variation between women in how this transition unfolds and in the symptoms they experience along the way. Some of the endocrine changes associated with reproductive ageing can begin before obvious changes in menstrual regularity, making the transition less straightforward to recognise than we might assume.3
I sometimes find it useful to draw a parallel with the hormonal unpredictability of puberty, although the underlying reproductive changes are different. Perimenopause can involve considerable hormonal fluctuation, which is why a woman can be well into the transition while still having periods and, at times, plenty of oestrogen.
That variability matters because reproductive hormones interact with the systems involved in attention, mood and our responses to stress. Oestradiol influences neurotransmitter signalling, including dopamine and noradrenaline, while progesterone metabolites such as allopregnanolone modulate GABAergic signalling.4 Changes in sleep and thermoregulation can further affect how much capacity a woman has available to meet the demands of everyday life.
Of course, reproductive hormones are only one part of the picture. She may genuinely be carrying too much. There may be difficulties in her work or relationships, unresolved psychological material, financial pressure, caring responsibilities or years of inadequate recovery sitting underneath what has finally become unsustainable. Hormonal change may affect how much physiological room she has available to accommodate those demands.
This is perhaps why I am less interested in whether a woman's symptoms are psychological or hormonal than I am in what happens when the same life begins to be experienced through a changing biological system.
There’s evidence that anxiety can become more prominent during the menopause transition, including among women who previously had relatively low levels of anxiety.5 There’s also emerging research suggesting that individual sensitivity to hormonal fluctuation may matter, rather than symptom severity being explained simply by how much oestrogen a woman has at any one point in time.6
That distinction feels particularly relevant here. Two women can be at a similar reproductive stage, with apparently similar hormone levels or menstrual changes, and yet experience the transition very differently. One notices very little beyond a change in her cycle, while another describes feeling as though somebody has changed the operating system of her brain.
And this is the part I find myself digging into: why?
Oestrogen, dopamine and the loss of the old “sweet spot”
Dopamine is often talked about rather crudely as the neurotransmitter of pleasure or reward, but its role is considerably broader. Within the prefrontal cortex, dopamine is involved in functions including working memory, attention, cognitive flexibility and the ability to organise behaviour around a goal. These are exactly the kinds of capacities our highly functioning woman may have spent years relying heavily upon.
Prefrontal cognitive function appears to depend on dopamine remaining within an optimal range, often described as an inverted-U relationship, where both too little and too much dopaminergic activity can interfere with performance. That optimal range may differ between individuals and is influenced by the wider neurochemical environment.7
Oestradiol is one of the factors interacting with that environment, with research identifying relationships between reproductive hormones and dopamine signalling, including in brain regions involved in executive function.8
Some women may have spent years becoming very good at creating the conditions that mobilise their particular nervous system. Urgency, stimulation, responsibility and external expectation may all have formed part of those conditions, alongside the psychological meaning attached to achievement and being needed.
As the hormonal environment becomes more variable, its interactions with attention, arousal, sleep and emotional regulation may also change, making her response to those familiar conditions less predictable. The woman hasn’t forgotten how to meet a deadline. She still knows how to organise the project, manage the people and do the work. What feels unfamiliar is the amount of internal activation now accompanying those familiar demands, or the fact that activation no longer reliably translates into clear thinking and productive action.
This is where the experience can become incredibly disorientating for her. She may still feel the familiar impulse to push when she is struggling, because pushing has historically brought her back online. Yet increasingly she finds herself highly activated without feeling particularly effective, tired without being able to settle, or desperate for a quiet day only to discover that her nervous system doesn’t become quiet simply because her diary has.
From the outside, it can look as though she has lost resilience. From the inside, it can feel as though she has lost herself.
When the old strategy becomes part of the problem
There’s something particularly difficult about losing access to a strategy that you didn’t realise was a strategy.
If pressure has reliably helped her mobilise for twenty or thirty years, her instinct when her capacity begins to falter is unlikely to be to question pressure itself. More often, she tries to recreate the version of herself she remembers.
She becomes more organised. She tightens the routines. She makes better lists. She works later because everything is taking longer. She exercises harder because exercise has always cleared her head. She becomes frustrated by her inability to concentrate and responds by demanding more concentration from herself. She may become increasingly protective of her time because interruptions now feel unbearable, while simultaneously continuing to take responsibility for things because being needed is one of the most familiar ways she knows how to mobilise.
For a while, this can create a peculiar experience of being both exhausted and unable to stop.
I think this is one of the places where the language of burnout can be useful, provided we do not use it to imply a single biological state. Research examining cortisol, the HPA axis and autonomic function in burnout has produced inconsistent findings, and there is no established hormonal profile that allows us to say somebody has biologically “burned out.”9
What the word often captures rather well is the lived experience of repeatedly asking for a level of output that is no longer available in the same way.
For the woman we have been describing, that can be particularly destabilising because competence may have provided much more than professional success. It may have been part of how she has created safety, self-esteem, independence and a sense of who she is.
When her body no longer responds to effort in the way she expects, she does not necessarily conclude that the conditions have changed. She concludes that she has.
The same transition, different biology
There is another layer to consider when trying to understand why these changes affect women so differently: their individual biology, including genetics.
There is no “burnout gene”, nor is there a genetic profile that can tell us which woman will struggle through perimenopause. I tend to consider genetics within the same biopsychosocial framework I use when thinking about health more broadly: one layer of information sitting alongside psychological history, neurodevelopment, current demands, physical health, sleep, nutrition, medication, relationships and social circumstances. All contribute to the person sitting in front of us, and genetics cannot be meaningfully separated from that context.
One example is COMT, the gene that provides instructions for the catechol-O-methyltransferase enzyme. COMT is involved in the metabolism of catecholamines, a family of signalling chemicals that includes dopamine, noradrenaline and adrenaline. The enzyme has a particularly important role in regulating dopamine within the prefrontal cortex. A common genetic variant of COMT, known as Val158Met, alters the activity of the enzyme and has therefore attracted considerable interest in research examining cognition, stress and dopamine-related function.8
It is tempting to turn this into the kind of genetic shorthand that circulates online: one version means “slow COMT”, another means “fast COMT”, and each supposedly explains a list of personality characteristics.
For me as a practitioner, what makes COMT interesting here is not that one variant makes a woman Type A, anxious or destined to burn out. It’s that research has demonstrated interactions between COMT-related differences in dopamine regulation and oestradiol when examining aspects of prefrontal cognition.10 In other words, the effect of changing oestradiol can’t always be understood independently of the biological system into which that change is occurring.
A woman's COMT genotype at 45 is the same genotype she had at 25. What has changed is the biochemical environment in which it is operating, alongside everything else that has accumulated across those twenty years.
Her reproductive hormones are changing. Her sleep may be different. The demands being placed upon her may be greater. The compensatory systems that once operated almost invisibly may now require considerably more effort.
Research into genetic differences offers another perspective on why the relationship between reproductive hormones, cognition and emotional regulation may vary between individuals, although translating those findings into an understanding of any one woman's experience remains considerably more complex.
The psychology and the physiology were never separate
Imagine a woman who learned very early that being capable was valuable. Perhaps competence brought approval, being useful created connection, or taking responsibility reduced uncertainty. Over time, she becomes extremely good at anticipating what needs to happen and making sure it does.
Now place that psychological history inside a nervous system that also happens to respond particularly well to urgency, stimulation or external expectation.
The meanings we attach to achievement, responsibility and control develop within a body, and the body responding to a deadline belongs to a person with a history. Neurodevelopment influences the strategies available to us, while experience shapes which of those strategies are repeatedly reinforced. Hormonal change then arrives within a system that has already been developing for decades.
For some women, perimenopause may therefore expose much more than reproductive ageing. It can reveal just how much of their lives has been organised around maintaining a particular level of functioning.
A wider formulation of the woman who “suddenly can't cope”
When a previously high-functioning woman reaches midlife and begins describing anxiety, cognitive overwhelm, exhaustion or a loss of capacity that feels completely unlike her, there are many useful questions we can ask.
What is happening in her life? What is she carrying? What has happened in her relationships? What does she expect from herself, and where did those expectations come from?
Alongside those questions, I think there is room for another set.
How has she historically mobilised herself when something needed to be done? What does she actually mean when she says she has always been good under pressure? Has urgency helped her initiate or concentrate? Has she relied on considerable structure to function as effectively as she does? Are there longstanding neurodivergent traits that have been compensated for so successfully that nobody has previously thought to look for them?
Has her sleep changed? Has anxiety appeared alongside changes in her menstrual cycle or other physiological symptoms? Might her individual biology help us understand why the transition she is experiencing looks so different from that of another woman sitting in the same waiting room?
I keep coming back to the phrase I hear so often when women describe these longstanding patterns:
I've always been like this. It’s just who I am.
I am increasingly interested in the word always.
Some of what she is describing may simply be personality. Some may reflect the psychological adaptations that have allowed her to move through the world successfully. Some may point towards neurodivergent traits, whether diagnosed or not. And some may make more sense when we understand the biology she has been working with all along.
Perimenopause does not necessarily create an entirely different woman. Sometimes it changes the conditions under which the woman who was already there has learned to function.
Perhaps the more revealing question is not simply why this woman can no longer cope with pressure, but what pressure had been making possible for her all along.
For a related exploration of the pressures shaping women's experiences of exhaustion, you might also like to read Millennial women and exhaustion.
References
1. Young S, et al. (2020). Females with ADHD: An expert consensus statement taking a lifespan approach providing guidance for the identification and treatment of attention-deficit/hyperactivity disorder in girls and women. BMC Psychiatry, 20, 404. https://pmc.ncbi.nlm.nih.gov/articles/PMC7422602/
2. Prior JC, Hitchcock CL. (2011). The endocrinology of perimenopause: Need for a paradigm shift. Frontiers in Bioscience (Scholar Edition), 3, 474–486. https://pubmed.ncbi.nlm.nih.gov/21196391/
3. Harlow SD, et al. (2012). Executive summary of the Stages of Reproductive Aging Workshop + 10: Addressing the unfinished agenda of staging reproductive aging. Fertility and Sterility, 97(4), 843–851. https://pmc.ncbi.nlm.nih.gov/articles/PMC3340904/
4. Diviccaro S, et al. (2022). Allopregnanolone: An overview on its synthesis and effects. Journal of Neuroendocrinology, 34(2), e12996. https://pmc.ncbi.nlm.nih.gov/articles/PMC9285581/
5. Bromberger JT, et al. (2013). Does risk for anxiety increase during the menopausal transition? Study of Women's Health Across the Nation (SWAN). Menopause, 20(5), 488–495. https://pmc.ncbi.nlm.nih.gov/articles/PMC3641149/
6. Gordon JL, et al. (2016). Estradiol variability, stressful life events and the emergence of depressive symptomatology during the menopause transition. Menopause, 23(3), 257–266. https://pmc.ncbi.nlm.nih.gov/articles/PMC4764412/
7. Shanmugan S, Epperson CN. (2014). Estrogen and the prefrontal cortex: Towards a new understanding of estrogen's effects on executive functions in the menopause transition. Human Brain Mapping, 35(3), 847–865. https://pmc.ncbi.nlm.nih.gov/articles/PMC4104582/
8. Jacobs E, D'Esposito M. (2011). Estrogen shapes dopamine-dependent cognitive processes: Implications for women's health. Journal of Neuroscience, 31(14), 5286–5293. https://pmc.ncbi.nlm.nih.gov/articles/PMC3089976/
9. Danhof-Pont MB, van Veen T, Zitman FG. (2011). Biomarkers in burnout: A systematic review. Journal of Psychosomatic Research, 70(6), 505–524. https://pubmed.ncbi.nlm.nih.gov/21624574/
10. Louis CC, Jacobs E, D'Esposito M, Moser J. (2023). Estradiol and the Catechol-o-methyltransferase gene interact to predict working memory performance: A replication and extension. Journal of Cognitive Neuroscience, 35(7), 1144–1153.
Evidence Note
The research cited supports the individual scientific claims discussed. The proposed connection between pressure-based coping, hormonal change and individual experiences of burnout remains an evidence-informed interpretation, not an established causal mechanism. Studies of COMT and working memory should not be taken as validation of COMT testing for perimenopausal anxiety or burnout.