Perimenopause can be missed, even by experienced healthcare clinicians

Teressa Barker spent more than 25 years in mental health nursing, including time as chief nursing officer, before she recognised her own symptoms for what they were. A sudden onset of severe anxiety, unlike anything she had felt before, turned out to be the kind of presentation that can hide perimenopause in plain sight, especially when clinicians have never been taught how hormone changes affect mental wellbeing.

The blind spot in everyday care

Barker’s experience is not unusual because perimenopause does not announce itself with one tidy symptom. The transition can begin several years before menopause, and it can start in a woman’s mid-30s or even earlier, long before most people expect hormone-related change to be on the table. Menopause and perimenopause usually affect women between 45 and 55, but they can happen earlier, which means the timing often collides with the years when work pressure, childcare, caring responsibilities and sleep deprivation are already stacking up.

This stage is easy to miss in routine care. If a woman presents with anxiety, low mood or panic, the default response can be to treat it as a stand-alone psychiatric problem, even when the underlying issue is hormonal transition. This is not an individual failure to spot the signs early enough. It is a system problem, built on years of thin training and a tendency to separate physical health from mental health when the two are tightly connected.

Symptoms are broader than hot flushes

Public understanding still lags far behind the clinical reality. The Royal College of Psychiatrists commissioned YouGov polling that found only 28% of women knew a new mental illness can be associated with menopause, while 93% associated menopause with hot flushes and 76% with reduced sex drive. In the same polling, only 21% of UK adults linked menopause with a new mental illness.

That narrow view is risky because perimenopause symptoms are not confined to flushing and missed periods. The physical picture can include irregular periods, itchy skin, joint pain and muscle pain. The psychological picture can include anxiety and low mood, and mood changes are a recognised symptom of perimenopause. Hormone replacement therapy is a first-line treatment for menopausal mood symptoms in appropriate cases, because women who are sent away with an anxiety label alone may never have the hormonal transition addressed at all.

Where women get missed

Primary care is often the first place the story goes wrong, because that is where symptoms are most likely to be sorted into familiar boxes. A 2026 British Journal of General Practice study found that addressing mental health symptoms during perimenopause needs a proactive and informed approach, and that better GP training on menopause plus patient education could improve consultations and management. If the clinician does not ask about cycle changes, symptom pattern, sleep, flushing, skin changes and age together, the consultation can drift toward antidepressants or anxiety treatment without ever testing the menopause hypothesis.

Mental health settings carry the same risk. The Health Services Safety Investigations Body warned in 2023 that when the impact of menopause on mental health is not considered during clinical assessments, patient safety issues can follow. Women who enter services with new anxiety or depression can go unasked whether symptoms track with their cycle, whether periods have changed, or whether they are also dealing with joint pain, skin changes or disrupted sleep. Better screening in these settings is not complicated, but it has to be routine: ask about menstrual change, ask about age, ask about physical symptoms, and ask whether the person is in the menopause transition before settling on a diagnosis.

Workplaces are another common place to miss the pattern. The Royal College of Psychiatrists polling found that just one in four UK women felt comfortable speaking to a male boss about menopause. If the conversation never happens, the woman is left to self-manage, and the employer never sees that what looks like performance decline may actually be a health issue with a recognisable clinical pathway.

What better screening looks like

The clearest fix is not more vague awareness, but more structured questioning in the places where women already turn up.

• In primary care, ask about period change, flushing, sleep disruption, anxiety, low mood and physical pain together, not as separate complaints.

• In mental health assessments, include menopause in the differential when a woman in her mid-30s to 50s presents with new anxiety, panic or depression.

• In workplace health conversations, normalise menopause as a health issue rather than a confidence problem or a private inconvenience.

• In routine health checks, make menopause part of the script instead of an optional add-on.

That last point is now beginning to move into policy. On 23 October 2025, the UK government announced that menopause questions would be included in routine NHS Health Checks for the first time nationally. In April 2026, the renewed Women’s Health Strategy for England was set to run for the next 10 years, and the government estimated that menopause questions in NHS Health Checks could benefit up to 5 million women across England.

Guidance is catching up, slowly

The clinical framework is also shifting. NICE’s menopause guideline NG23 was last reviewed on 15 April 2026 and covers identifying and managing menopause and perimenopause, including premature ovarian insufficiency in people under 40. Premature ovarian insufficiency can look even less expected than standard perimenopause, and under-40 patients are especially vulnerable to being overlooked if age becomes a shortcut for dismissal.

Professional bodies are moving too. The Royal College of Nursing updated its menopause guidance on 15 May 2026 to help health professionals renew and update their understanding of menopause’s physical and psychological impact on daily living and work life. In March 2026, the Royal College of Psychiatrists published its first position statement on menopause and mental health, stating that psychiatrists need to understand and respond to the interface of physical and mental health needs. The British Menopause Society welcomed that statement.