The Perimenopause Anxiety Fix Dr. Mary Claire Haver Says Physicians Might Be Missing
Women may be prescribed antidepressants when they really need HRT
For so many women, perimenopause brings more than hot flashes. It brings brain fog so severe some are quitting their jobs, and anxiety so intense that years of carefully managed mental health unravel almost overnight. For years, the standard medical response to anxiety and other mood changes during perimenopause has been an antidepressant prescription. But according to Mary Claire Haver, MD, a board-certified ob-gyn, Menopause Society certified practitioner and New York Times best-selling author, that reflex may be getting the treatment order backward.
In a revealing conversation on the podcast What Matters With Liz, hosted by Woman’s World editor-in-chief Liz Vaccariello, Dr. Haver laid out what she believes is a more effective approach—and explained why the mood symptoms of perimenopause deserve far more attention than they typically receive.
Perimenopause starts in the brain
Most people associate menopause with hot flashes and the end of menstruation. But according to Dr. Haver, the process begins long before those more recognizable milestones
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“What makes perimenopause so special is the process can last up to 10 years and it begins in the brain,” Dr. Haver said. “So the top two things you’re going to feel are brain fog and mental health changes.”
Rather than a brief physical transition, perimenopause is a prolonged neurological and hormonal shift that can profoundly affect how women think, feel and function in their daily lives. As Vaccariello put it when introducing the topic, perimenopause “affects every woman—and every man who loves a woman.”
Perimenopause brain fog is not dementia
For many women, the scariest part of perimenopause-related brain fog isn’t the memory blips themselves. It’s the fear of what they might mean. When you can’t recall a neighbor’s name, lose your train of thought mid-sentence or forget an appointment you’ve kept for years, the mind can spiral to a terrifying place: Is this dementia?
Dr. Haver addresses this fear directly, drawing on a distinction made by Dr. Lisa Mosconi: “Brain fog is ‘I can’t find my keys.’ Dementia is ‘I don’t know what my keys are.’”
Still, brain fog during perimenopause isn’t just a minor inconvenience. According to Dr. Haver, “Somewhere between one in 10 and one in five women are quitting their jobs because of brain fog.”
“I have incredibly high-functioning women come to my clinic who are devastated, feeling like they can’t do the life they built anymore,” she said. “For some, it gives them agency to leave a job that wasn’t serving them. But for others, this is their time. We’re supposed to be using our wisdom, leading companies, building things—and they just can’t. And then comes that devastation of what’s wrong with me?“
Dr. Haver emphasized that this perimenopause symptom is treatable and urged women not to simply accept it as inevitable. “This can be dealt with,” she said.
Is it perimenopause or anxiety?
Beyond brain fog, mental health changes during perimenopause are common and can be deeply unsettling, particularly for women who believed they had their mental health well managed.
During the podcast, Vaccariello read a question from Jenny, age 46: “I have struggled with mild anxiety for most of my life. I’ve had it managed with therapy and tools. But lately my anxiety is back with a vengeance. How do I know if this is connected to perimenopause and would be helped by hormone replacement therapy or if I need a mental health prescription?”
Dr. Haver’s answer pointed to a growing body of evidence that challenges conventional treatment approaches. “Great studies have been done on perimenopausal women with new-onset or exacerbated anxiety and depression, women who were previously well-controlled and suddenly aren’t,” she said. “For those women, starting menopausal hormone therapy in perimenopause had a better response than starting an SSRI,” or a selective serotonin reuptake inhibitor.
Dr. Haver’s approach is clear: “In my clinic, we would start her on hormone therapy and monitor her symptoms. She may still need an SSRI—we’re not dismissing that women do well with them when they need them. But it looks like first-line therapy for these patients should be hormone therapy.”
Are women in perimenopause being overprescribed antidepressants?
According to Dr. Haver, the rate of SSRI prescriptions, a common class of antidepressants, doubles across the menopause transition. “Ten percent of women are on them premenopausally, and it doubles to 20 percent postmenopausally then goes up another five percent at age 65,” she said.
Dr. Haver attributed this trend in part to the realities of a time-pressed medical system. Because a doctor hears “mood” or “anxiety,” they have 10 minutes and that’s what they’re trained to do. That’s what gets written on the prescription pad.
The implication is significant: Many women may be receiving antidepressants when menopause hormone therapy could be a more effective first option. Dr. Haver is not arguing that SSRIs have no place in treatment—she explicitly said women do well on them when they are needed. But the reflexive reach for an antidepressant may be shortchanging patients whose symptoms are being driven by hormonal changes, not a primary mood disorder.
What this means for you
For women in their 40s and 50s who are experiencing unexplained brain fog, a sudden resurgence of anxiety or mood changes that seem to come from nowhere, Dr. Haver’s guidance offers both validation and a potential path forward. The symptoms are not a personal failing. They are not necessarily a sign of a new mental health condition. They may be perimenopause, and the treatment options may be different from what a hurried appointment produces.
Dr. Haver, whose book The New Perimenopause catalogs a comprehensive list of symptoms, is leading the shift in how we approach this life transition. A key takeaway worth carrying with you: You’re not losing your mind. You’re navigating a biological process that medicine is finally learning to take seriously. And you deserve a doctor who will, too.
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