Perimenopause anxiety, and where breathwork fits

Most of what people are told about perimenopause is physical. Hot flushes, irregular periods, night sweats.

What tends to arrive first, and what people find far more distressing, is psychological. Anxiety that has no obvious cause. Waking at three in the morning with a sense of dread. Rage that is out of proportion to what caused it. Losing words mid sentence. A persistent feeling of not being yourself, without being able to say what has changed.

Many people go to their doctor with those symptoms and never mention their periods, because nobody has told them the two are connected.

What is actually happening

Perimenopause is the transition leading up to menopause. It commonly begins in the early to mid forties, sometimes earlier, and often lasts between four and eight years. Hormones do not decline in a straight line during this time. They fluctuate, sometimes considerably, and the fluctuation itself is a large part of the problem.

Progesterone tends to fall earlier and more steadily. It is converted in the brain into a compound that acts on the same receptors targeted by calming medications, so as progesterone drops, many people experience more anxiety, lighter sleep and a shorter fuse, with nothing in their life having changed to explain it.

Oestrogen is involved in the regulation of serotonin and noradrenaline, both of which affect mood, and in dopamine activity, which affects motivation, attention and working memory. When oestrogen swings, mood, concentration and word finding swing with it.

Sleep then compounds everything. Broken sleep reduces your tolerance for the following day, which increases stress, which further disrupts sleep.

Why it is so often missed

Anxiety and low mood during perimenopause frequently arrive before any change to periods that would make the connection obvious. This is a recognised period of increased vulnerability to depressive symptoms, including for people with no previous history of them.

Risk appears to be higher for people who have previously experienced significant premenstrual mood symptoms or postnatal depression, which suggests sensitivity to hormonal change rather than to hormone levels themselves.

The consequence is that a lot of people are treated for anxiety or depression without anyone asking about their cycle. Antidepressants may still be appropriate, but current guidance is that they should not automatically be the first response to low mood arising during perimenopause, because hormone therapy may be more appropriate. That is a conversation worth having with a doctor who knows this area properly.

Why your stress tolerance drops

Your nervous system is continuously assessing demand and adjusting you to meet it. When a demand is temporary, activation is useful, and afterwards a flexible system settles again.

Perimenopause changes the baseline. Broken sleep, hormonal fluctuation and the physical symptoms are all additional load arriving on top of whatever your life already contains. There is less margin, so the system activates sooner and takes longer to come down.

This is why people describe reacting in ways that do not feel like them. It is not a change in character. There is less capacity available, and capacity is what allows you to pause before responding.

What the evidence says about breathing and anxiety

Research into slow and controlled breathing has found changes in measures such as heart rate variability, along with reductions in stress and anxiety across a number of studies. A review of breathwork trials found small reductions in self reported stress, anxiety and low mood compared with control conditions.

Those effects are real but modest, and the studies are mostly small. This research is also general rather than specific to perimenopause. There is very little research on breathwork for perimenopausal anxiety in particular, and I would rather say that than imply otherwise.

On hot flushes specifically, paced breathing was studied directly, the stronger trials did not support it, and menopause guidelines no longer recommend it. If flushes and night sweats are your main concern, breathwork is not the intervention with evidence behind it.

Where breathwork actually helps

Breathwork does not treat perimenopause, and it is not a treatment for clinical anxiety or depression. What it addresses is the state your nervous system is in while you go through this, which matters a great deal when reduced capacity is the central problem.

In practice, what people report is this.

• Recovering more quickly after something difficult, rather than carrying it for days
• Noticing anxiety building earlier, while there is still something they can do about it
• Being able to rest, when rest had stopped working
• Less physical bracing through the shoulders, jaw and chest
• Somewhere to put the grief and anger about the change itself

That last one is not a minor point. A significant amount of what people carry through perimenopause is not a symptom. It is the experience of a body changing without consent, often while being dismissed by people who should know better. That deserves attention in its own right, and it rarely gets any.

If you have ADHD as well

Oestrogen supports dopamine activity, and dopamine is central to attention, motivation and working memory. When oestrogen fluctuates, ADHD traits often become more pronounced.

This is why a significant number of people are diagnosed with ADHD in their forties, and why others who have managed known ADHD for decades find their existing strategies stop working during this period. Both are common, and neither means you have gone backwards.

I have written separately about breathwork and ADHD, including why standard meditation advice tends not to work.

A note on palpitations

Heart palpitations are a recognised perimenopausal symptom, and conscious connected breathwork can produce physical sensations including a raised heart rate and tingling.

If you experience palpitations, have them investigated by your doctor rather than assuming they are hormonal, and tell me before a session so I can adjust how I guide you.

Is breathwork safe?

Breathwork is not appropriate for every person or every health condition, and the way it is guided matters.

If you are pregnant, or you have a heart condition, epilepsy, high blood pressure, glaucoma or a psychiatric diagnosis, contact me before booking so we can determine whether it is appropriate, and consult your doctor if you are uncertain.

This is a wellbeing and educational practice. It is not medical treatment, psychotherapy or crisis support. If your anxiety or low mood is significant, please talk to your doctor or a psychologist. Breathwork can sit alongside that care. It is not a replacement for it, and you should not have to manage this on your own.

More on the practice itself

If you want to understand what happens in a session and how the breathing works, I have written about that separately: what breathwork is and how it works.

I am Lucine Setian. I trained through The School of Breathwork and hold the International Certificate of Breathwork Mastery, a two year training completed in 2023. I am a member of the International Breathwork Foundation and the Australian Breathwork Association, and I have facilitated at the Sydney Opera House in 2024 and 2025. I am not a doctor, and nothing here replaces medical advice.