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Not all that long ago, it was fairly common to hear menopause described, often in hushed tones, as “the change.” But most of the “changes” actually happen during perimenopause, the years of transition leading up to the end of menses.

Perimenopausal symptoms can begin before your periods become irregular, according to the research of Jerilynn Prior, MD, FRCPC, an endocrinologist and the author of “Estrogen’s Storm Season: Stories of Perimenopause.”

Of course, this fact continues to perplex some doctors and gynecologists who were taught to use irregular menstrual cycles to mark the beginning of perimenopause.

Most people recognize perimenopause and menopause as entirely natural life stages, but not everyone realizes the wide range of symptoms involved.

Along with insomnia, headaches, and hot flashes, you might also experience mental or emotional symptoms, such as:

If a doctor or other healthcare professional is unable to explain your symptoms, this might only add to your distress. Know, though, that you aren’t alone: Feelings of depression and thoughts of death and dying are very normal during this time.

Our guide below can help you better understand these symptoms and get relief.

Thoughts of death, dying, and suicide often arise in response to pain and suffering, even if you don’t truly want to die.

“Perimenopause brings aging into our immediate consciousness,” says Vicki Botnick, a licensed marriage and family therapist in California. “Some meditation on death could be a healthy developmental stage.”

So, yes, it’s possible to have passing thoughts of suicide without any desire to act. You might, as Botnick explains, simply want to regain some control over your distress.

“When those thoughts become obsessive or lead to thoughts of causing your own death, you’ll want to seek support,” she cautions.

Getting support for suicidal thoughts

Talking with a mental health professional about suicidal thoughts is always recommended, but active thoughts of death, dying, or suicide are a medical emergency.

“Active suicidal thoughts take a consideration of death into the realm of action,” Botnick says. In other words, you have a plan for suicide that includes:

  • the means, or items you’ll use
  • access to those items
  • a time and place to make the attempt

During a mental health crisis, you can get help in the United States 24/7 by:

Trained crisis counselors can offer free, confidential support and connect you to additional resources.

You can get more information on crisis counseling and other suicide prevention resources here.

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Plenty of treatments can help ease symptoms of perimenopause:

Of course, it takes time to access these treatments, and they might not work right away.

Thoughts of self-harm coming up in response to emotional overwhelm? These 7 alternatives may help.

Self-care strategies to help you navigate overwhelming distress

  • Walk it out. Walking can distract you by offering a change of environment. Sunlight and fresh air can help improve your mood. Plus, physical activity can trigger the production of mood-boosting hormones, like serotonin and dopamine.
  • Phone a friend. Talking about depression and suicidal thoughts can be difficult. All the same, opening up to someone you trust often provides a measure of comfort — particularly if they’ve had similar experiences.
  • Practice yoga. This beneficial practice can help reduce stress, as well as feelings of anxiety and depression. Yoga may also improve sleep and ease some types of pain.
  • Do something that relaxes you. Relaxing activities can distract you from distressing thoughts and help you find some peace. Consider taking a warm scented bath, trying guided imagery or meditation, curling up with a favorite book or movie, or listening to a soothing playlist.
  • Get comfortable. Hot flashes, feelings of panic or doom, severe headaches, and painful or heavy periods can cause plenty of physical discomfort. Cooling drinks, soft and light clothing, cool or warm compresses, and pain relievers can help you fend off related distress and stay as comfortable as possible.
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A few of the most commonly recognized physical symptoms of perimenopause include:

These changes occur naturally as the levels of hormones in your body begin to change. They can certainly happen as part of the menopausal transition and aging process. But they can stem from other sources, too.

Stress in your personal life might leave you unable to fall asleep. This insomnia can lead to fatigue, which might drain your energy and lead to appetite and weight changes.

Some symptoms, like fatigue, aches and pain, and irregular periods, can have other medical causes.

It’s always a good idea to connect with a healthcare professional if you experience symptoms you can’t explain, even if you link them to perimenopause.

Make sure to describe all your symptoms, even ones that don’t seem relevant. Say, for example, you mention that you:

  • wake up frequently during the night
  • have headaches in the morning
  • feel exhausted during the day

This could suggest obstructive sleep apnea, not perimenopausal insomnia.

How to cope

Your healthcare professional might recommend different treatment approaches, depending on the severity of your symptoms. Some treatments include:

You can also take steps on your own to improve symptoms, by:

Perimenopause-related cognitive and mental health symptoms can also prompt mental distress, like:

While changing hormone levels can lead to imbalances that drive these symptoms, other factors can also play a part.

Perimenopause generally begins as you approach middle age, a life stage that usually includes plenty of changes, like:

  • impending retirement and other career shifts
  • children leaving home
  • noticeable differences in your body, facial features, energy, and health
  • parents or older loved ones in need of more support
  • changing romantic relationships

Any of these can add to your mental load and increase your stress, not to mention worsen existing health symptoms. You might find it tough to keep track of everything you need to do or make time for yourself. The result? A drop in well-being.

Feelings of anxiety or panic might not directly relate to hormonal changes. Still, they can tie into perimenopausal symptoms.

For example:

  • The unpredictability of your symptoms can leave you nervous and unsure what to expect next.
  • Insomnia and anxiety can play off each other, creating a cycle of anxious wakefulness that’s difficult to break.
  • Lack of sleep can worsen feelings of depression and affect concentration and memory during the day.
  • Panic attacks can trigger feelings of doom or a belief that you’re about to die.

Sleeplessness and related emotional distress can absolutely give you the impression that you’re dying. It can also make you feel like you want to die, just so it all stops.

“Physical symptoms, exacerbated by hormonal shifts that affect serotonin production in the brain, can bring on depression and suicidal thoughts,” Botnick says.

She adds symptoms can feel particularly distressing when they hang on for years, with no sign of relief.

How to cope

Talking with a therapist is a good next step, but it’s also important to connect with a healthcare professional if you’re worried about symptoms like memory loss.

They can help you rule out other possible causes, including genetic disorders or early onset Alzheimer’s disease.

Depression and other mental health symptoms might not always improve with hormone treatments that improve physical symptoms.

A therapist might not always have the ability to pinpoint the direct cause of these symptoms, but they can still offer essential support.

“Both medical doctors and therapists can offer invaluable tips for healing,” Botnick says. “A therapist can assess your level of risk and suggest methods of treating depression and intrusive or suicidal thoughts.”

You might also notice changes in your mood and emotions during perimenopause, including:

  • unusual irritability
  • feelings of sadness, grief, or loss
  • sense of helplessness
  • existential dread or depression
  • feelings of isolation
  • diminished self-esteem

Certainly, hormonal changes can prompt abrupt shifts in your mood, but plenty of other concerns can complicate emotional health.

You might, for example:

  • have difficulty coming to terms with changes in your appearance
  • fear losing control of your body and feel helpless to weather the changes
  • have difficulty with unpredictable and disruptive symptoms, like incontinence or hot flashes
  • feel frustrated by insomnia that persists despite fatigue

Emotional distress related to perimenopause could create tension in your relationships. But existing relationship concerns can also fuel conflict and worsen mood symptoms.

Narrow-minded views of aging that suggest your life is nearly over can also trigger a general sense of despair. In reality, you’re quite possibly only around the halfway mark, with plenty more to enjoy.

How to cope

Reaching out to loved ones can make a difference, especially when isolation fuels your distress.

Friends don’t understand? Consider joining a support group of others experiencing similar concerns to reduce feelings of loneliness and perhaps even form new friendships.

Mindfulness and meditation practices can also make a difference, especially in combination with therapy.

These techniques help you learn to stay present and sit with painful or unwanted emotional states without acting on them by exploding in anger, dissociating, or numbing yourself, explains Botnick.

Specific therapy approaches can also help you manage thoughts of death and suicide.

Cognitive behavioral therapy, for example, can help you identify, challenge, and replace exaggerated or distorted thought patterns.

Dialectical behavior therapy takes a similar approach, but it adds in emotional regulation techniques.

Consider existential approaches

Botnick recommends existential therapy as a helpful approach to:

  • accept fears
  • explore choices that leave you in control
  • find a sense of meaning that puts aging in a more positive perspective as a phase of a life well lived
  • build a sense of usefulness and vibrancy, even during challenging times

Mention symptoms of perimenopause to a healthcare professional as soon as you begin noticing them. This can go a long way toward helping you get relief.

That said, there’s no denying many professionals dismiss milder symptoms or seem disinterested in making the effort to understand your distress. This can be disheartening — but don’t feel obligated to continue seeing a doctor who doesn’t respect your understanding of your own body.

If possible, consider seeking out a healthcare professional you can trust who truly listens and works to help you find relief.

If that’s not an option, keep restating your concerns until they listen. Be clear and specific about:

  • symptoms you experience
  • how symptoms affect your life
  • the methods you’ve tried to find relief

It may help to keep a daily diary, noting:

  • physical symptoms
  • mood changes and mental health symptoms
  • self-care strategies or home remedies you’ve tried

Bring this diary to your appointments, so you can show your doctor.

“The most important tool for navigating thoughts of death and suicide is connection and support,” Botnick says.

Support might include:

  • family
  • trusted friends
  • crisis resources, like suicide prevention hotlines
  • counseling and support groups

Talking about suicidal thoughts may feel frightening. Still, opening up about your distress can be the key to relief.

You can start by:

  • telling a friend you’re having a hard time and asking for company
  • going somewhere safe and calming
  • calling or texting a crisis hotline
  • checking in with a counselor or support group

The changes that happen during perimenopause affect everyone differently. The most helpful treatment, generally speaking, depends on the symptoms you experience.

When your symptoms include overwhelming distress and thoughts of death or suicide, a therapist can offer compassionate guidance and support.

Unsure where to start? Here are 9 tips for finding the right therapist.

Crystal Raypole has previously worked as a writer and editor for GoodTherapy. Her fields of interest include Asian languages and literature, Japanese translation, cooking, natural sciences, sex positivity, and mental health. In particular, she’s committed to helping decrease stigma around mental health issues.