Something is shifting, and you cannot quite put your finger on it. 

You are forty something. By every external measure, life is full and functioning. The job, the kids, the house, the partner, the people who depend on you. And yet, lately, something has begun to fray. You are not sleeping properly. You snap at your children, partner or colleagues over things that did not used to bother you. There are afternoons where you sit in front of your laptop and cannot remember what you opened it to do. You feel a low background hum of anxiety that has no obvious cause. You catch yourself crying in the car for no reason you can name. 

If you are anything like the women we sit with at Centre Self Collective, you have probably tried to push through it. You have always pushed through. That is what you do. That is who you are. 

But this time, pushing through is not working. 

What Is Actually Happening 

Perimenopause is the seven to ten years before menopause when ovarian hormones are not declining smoothly but rollercoastering. It typically begins in the early to mid-forties, sometimes the late thirties. It is the trickiest stage of the menopausal transition, and the stage where mental health symptoms most commonly emerge. 

Most women do not know they are in it and it is often missed in primary care settings. Hormone blood tests during perimenopause are unreliable and can be misleading, because hormones are fluctuating wildly rather than dropping in a clean line. As a result, a huge number of women in their forties are told that their bloods are normal and offered an antidepressant for what is actually a hormonally driven process happening alongside, and intensified by, their life history. 

The Australian Menopause Society and the Jean Hailes Foundation both note that perimenopause is diagnosed clinically, based on symptoms and cycle changes, not by a single blood test. If your symptoms are being dismissed because your bloods came back fine, you are not imagining it. You may be in perimenopause. 

It is also worth holding the inverse, because both errors happen. Just as women's symptoms are often dismissed as anxiety or stress when perimenopause is the missing piece, symptoms can also be misattributed to perimenopause when something else is going on. Thyroid and parathyroid disorders, anaemia, autoimmune conditions, endometriosis, and a range of other health concerns can all share signs with perimenopause. The principle is the same in both directions. If you do not feel like yourself, you deserve a thorough assessment, not a tidy explanation.  

Why the Strategy Stops Working 

Before going further, it is worth naming something. Being 'the strong one' is rarely just an individual personality trait, and it is rarely just a family of origin pattern. It is also a role that women, in particular, have been culturally assigned for generations. Sociologists and feminist scholars have long described the unequal distribution of emotional labour, mental load, and care work that falls disproportionately on women, regardless of their paid employment, education, or income (Hochschild, 1983; Daminger, 2019). The capable, self-sacrificing, endlessly available woman is not an accident of personality. She is the product of expectations laid down across families, workplaces, healthcare systems, and culture more broadly. For women who also grew up in homes where they had to grow up early, parenting their parents, holding family stability, or suppressing their own needs to keep the peace, the cultural expectation lands on top of an already shaped nervous system. Two layers, working in the same direction. 

Being the capable one, the strong one, the person who holds it all together, has always required something specific to function. It has required a nervous system that could be kept under control. The early mornings, the late nights, the constant management of other people's emotional weather, the suppressing of your own needs to keep things moving. All of that depends on a particular kind of internal regulation. 

Perimenopause destabilises exactly that. 

Oestrogen is not just a reproductive hormone. It is a neuroprotective one. It plays a role in serotonin regulation, dopamine activity, the stress response, sleep architecture, and emotional reactivity. As oestrogen begins to fluctuate and decline, the nervous system loses one of its most important stabilisers. The body that used to absorb the load can no longer absorb it the same way. 

This is why so many women describe perimenopause as feeling like the floor has dropped out from underneath them. The strategies have not changed. The capacity to maintain them has. 

Why It Is Hitting You Harder Than Some 

Not every woman experiences perimenopause the same way. Some glide through with mild inconvenience. Others find themselves in genuine crisis. The research is becoming increasingly clear about why the difference exists, and a significant part of the answer is in your past. 

A 2021 study by Kapoor and colleagues, drawing on the DREAMS registry, found that women with four or more Adverse Childhood Experiences had approximately nine times the odds of being in the worst quartile of total menopausal symptom severity, compared with women with no ACEs. The psychological symptom burden, things like anxiety, depression, mood instability, was roughly eight and a half times higher. Even after adjusting for age, partner status, education, employment, hormone therapy, current mood, and recent abuse, the signal survived. Early adversity leaves a biological and psychological footprint that shows up decades later, exactly when the body's regulatory systems are under the most strain. 

This is not about blame, and it is not about the past being inescapable. It is about understanding why the same hormonal transition lands so much harder on some women than others. If you grew up in an environment where your nervous system never got to fully relax, the cost of that does not arrive in childhood. It arrives now. And if, on top of that, you have spent your adult life absorbing the emotional and domestic labour that culture expects women to absorb, the load is doubled. The body that has been holding all of it begins to ask for something different. 

Other research backs this up. The Penn Ovarian Aging Study (Freeman et al., 2006) and the Harvard Study of Moods and Cycles (Cohen et al., 2006) both found that women in perimenopause had two to four times higher odds of experiencing a first onset depressive episode compared with their premenopausal years. Even women with no prior history of depression are vulnerable. For women with a trauma history, the risk is significantly amplified. 

This Is Not a Typical Depression 

Professor Jayashri Kulkarni and her team at the Monash Alfred Psychiatry Research Centre have led some of the most important Australian research in this space. Their work on perimenopausal depression, captured in the Meno-D scale (Kulkarni et al., 2018), shows that this is a distinct clinical phenotype. It does not always look like classical major depressive disorder. It often presents with paranoid ideation, low self-esteem, irritability, somatic symptoms and cognitive difficulties that get dismissed or misattributed. 

This matters because it explains a very common experience our clients describe to us. They have felt depressed, but it does not feel quite like the depression they know. They feel anxious, but it is sharper, more reactive, more physical. They feel rage, which they have not felt in years. They feel deeply unfamiliar to themselves. 

They are not losing their mind. They are in perimenopause, and the strategies that previously contained their internal world are no longer enough. 

The Trauma to Menopause Overlap 

One of the more striking observations in the perimenopause literature is how closely menopausal symptoms can mirror trauma symptoms. Hot flushes can look and feel almost identical to hyperarousal. Night sweats, broken sleep and nightmares share the same physiological signature. Brain fog and dissociation are easily confused. Mood swings and emotional dysregulation overlap with classical trauma reactivation. 

For women with a trauma history, perimenopause does not just bring new symptoms. It often reactivates old ones. The body that worked hard to put things away can no longer keep them in. Memories surface. Reactions return. Feelings that had been long since neatly contained begin to leak through, often without warning. As Bessel van der Kolk has long argued, the body keeps the score, and at certain biological thresholds, the body brings the bill due (van der Kolk, 2014). 

The Cost of Suffering Quietly 

This is the part of the conversation that does not get had often enough. 

In Australia, women aged 45 to 49 have the highest rates of those taking their own life, of any female age group, with women aged 50 to 54 sitting closely behind (Australian Institute of Health and Welfare). This is the demographic intersection of perimenopause, accumulated trauma load, midlife stressors, caregiving demands, and a cultural script that still expects women to manage all of it without complaint. 

The Balance App survey, conducted by Newson Health in 2022 with over 5000 women, found that one in ten had experienced thoughts of taking their own life during their menopausal transition. One in five had felt life was not worth living. More than one in three had not sought help for their symptoms. Eight in ten had not spoken with their partner about their mental health. 

These are not numbers. These are women who look like your sister, like your colleague, like your friend. Women who are functioning, who are still showing up, who are still meeting deadlines and packing lunches and asking everyone else how they are. Women who are actually quite unwell, and who have no language and no permission to say so. 

If any of this resonates, you are not alone, and what you are experiencing is real. 

Why the Strong One Does Not Get Help 

There is a particular hardship in being the person everyone else relies on. It is very hard to ask anyone for anything. It feels exposing, even shameful. It feels like a betrayal of the role you have always played. 

This difficulty is not just personal. It is cultural. Women are still, broadly, rewarded for being capable and uncomplaining, and punished, in subtle and not so subtle ways, for being needy or vulnerable. The 'good mother', the 'reliable colleague', the 'easy daughter' archetypes are deeply embedded, and they are difficult to unhook from, even when the cost of inhabiting them is bankrupting your wellbeing. The eight in ten women who did not talk to their partner about their mental health were not necessarily unloved or unsupported. Many of them simply did not know how to be on the receiving end of care, because they have spent their lives, both individually and as women in a particular kind of culture, being the one who gives it. 

This is also why so many women come to us in this stage of life saying some version of, I do not even know who I am anymore – I feel lost. The strategy has run out of room to operate, but the identity built around the strategy is still in place. You no longer have the capacity to be the strong one, but you also do not yet know how to be anyone else. 

This is, in our experience, the moment when real change becomes possible. Not because you have failed, but because the conditions that demanded the strategy have ended. You do not need to keep being the strong one. You may finally, after a very long time, get to put it down. 

What Helps 

Many women find significant relief when it is recognised and treated appropriately. The clinical evidence supports an integrated approach across three layers: 

Medical care that takes you seriously 

A menopause-informed GP can be the difference between years of suffering and a workable plan. Menopausal hormone therapy (MHT) is first line for vasomotor symptoms when appropriate, and some research suggests that for many women experiencing perimenopausal depression, MHT may be more effective than SSRIs as a first line treatment (Kulkarni, 2022). For some women with perimenopausal depression, hormone therapy may be an important part of treatment and should be discussed with a menopause-informed GP. The Australasian Menopause Society maintains a list of menopause-trained GPs. It is worth looking up. 

Trauma-informed psychological therapy 

This is where the work we do at CSC sits. CBT, particularly menopause-specific CBT, is recognised as first line non-hormonal therapy for vasomotor and mood symptoms by NICE, the Menopause Society, and the Australasian Menopause Society. Where childhood trauma is part of the picture, EMDR offers something CBT alone often cannot: it works directly with the older material that hormonal change is bringing back to the surface. Approaches like Schema Therapy, Parts Work and somatic work all have roles to play, particularly for women whose symptoms are entangled with longstanding patterns of self-sacrifice and emotional suppression. 

Lifestyle foundations that protect the nervous system 

Sleep, movement, nutrition, social connection, structure. None of this is a cure. All of it is a buffer. The International Menopause Society has produced a substantial body of work on lifestyle medicine for menopausal mental health, and the evidence is consistent. The basics matter, particularly when the nervous system is under strain. 

The Reframe 

Being the strong one was never just a personality trait. It was a role. A role shaped by your early experiences, and a role written into the culture that surrounds you. It worked, often at significant personal cost, until the conditions changed. Perimenopause is one of those conditions changing. 

The version of you that has carried everyone else for decades does not have to keep doing it. The version of you that suppressed her own needs to keep things running does not have to keep running on empty. The story that you should be able to handle this on your own is one of the things perimenopause is, in its difficult and disruptive way, finally inviting you to put down. 

This is not the end of the strong one. This is the beginning of something else. 

Where to From Here 

If you suspect you may be in perimenopause, start by speaking with a menopause-informed GP. Jean Hailes and the Australasian Menopause Society both have search tools to help you find one. Take your symptom history with you. 

If trauma is part of your history, or if your mental health is suffering in ways that feel deeper than the physical symptoms alone, please consider working with a therapist who understands the intersection of trauma and the menopausal transition. At Centre Self Collective, our team works with this population regularly, both through weekly therapy at our Thornbury and Daylesford clinics and through our EMDR Immersives and Retreats. 

And if any part of this blog has resonated more than expected, please do not carry it on your own. There are many people who can help, and the simplest first step is just to tell someone. 

You have been the strong one for long enough. 

If you are struggling right now 

Lifeline: 13 11 14 (24/7) 

Beyond Blue: 1300 22 4636 

13YARN (for Aboriginal and Torres Strait Islander people): 13 92 76 

In an emergency, please call 000. 

References 

Australian Institute of Health and Welfare. Suicide and self-harm monitoring: deaths by suicide among women. 

Cohen, L. S., Soares, C. N., Vitonis, A. F., Otto, M. W., & Harlow, B. L. (2006). Risk for new onset of depression during the menopausal transition: The Harvard Study of Moods and Cycles. Archives of General Psychiatry, 63(4), 385 to 390. 

Daminger, A. (2019). The cognitive dimension of household labor. American Sociological Review, 84(4), 609 to 633. 

Freeman, E. W., Sammel, M. D., Lin, H., & Nelson, D. B. (2006). Associations of hormones and menopausal status with depressed mood. Archives of General Psychiatry, 63(4), 375 to 382. 

Hochschild, A. R. (1983). The managed heart: Commercialization of human feeling. University of California Press. 

International Menopause Society. (2022). White paper on lifestyle and the menopause transition. 

Irvine-Rundle, H., & Fort, K. (2025). Integrating EMDR, CBT and lifestyle medicine for perimenopause-related distress: A trauma-informed, multimodal approach. EMDR Association of Australasia Conference. 

Kapoor, E., Okuno, M., Miller, V. M., Rocca, L. G., Rocca, W. A., Kling, J. M., Kuhle, C. L., Mara, K. C., Enders, F. T., & Faubion, S. S. (2021). Association of adverse childhood experiences with menopausal symptoms: Results from the Data Registry on Experiences of Aging, Menopause and Sexuality (DREAMS). Maturitas, 143, 209 to 215. 

Kulkarni, J., Gavrilidis, E., Hudaib, A. R., Bleeker, C., Worsley, R., & Gurvich, C. (2018). Development and validation of a new rating scale for perimenopausal depression: The Meno-D. Translational Psychiatry, 8, 123. 

Kulkarni, J. (2022). Hormones and psychiatric illness. The Lancet Psychiatry. 

National Institute for Health and Care Excellence. (2024). Menopause: Diagnosis and management (NICE Guideline NG23). 

Newson Health Research and Education. (2022). Balance App menopause and mental health survey. 

van der Kolk, B. (2014). The body keeps the score: Brain, mind and body in the healing of trauma. Viking.