Psychology and Psychotherapy of Women in Premenopause and Menopause

Introduction

Menopause and the transitional period preceding it (premenopause / perimenopause) are not only physiological processes (estrogen decline, changes in the menstrual cycle) but also periods of significant psychological and socio-cultural changes. Hormonal fluctuations can exacerbate anxiety, depression, sleep disturbances, and cognitive complaints; for some women, this reduces quality of life and affects social roles.
The World Health Organization emphasizes that menopause impacts physical, emotional, and social well-being, and that manifestations vary among individuals.

Psychological Manifestations and Risks

Common psychological symptoms during perimenopause and menopause include:

• Increased general anxiety and panic attacks;
• Depressive episodes or exacerbation of existing depression;
• Irritability and emotional lability;
• Sleep disturbances and “brain fog”;
• Decreased sexual desire and satisfaction;
• Heightened feelings of loss of attractiveness or “femininity” in certain cultural contexts.

Systematic reviews and meta-analyses indicate an increased risk of depressive and anxious symptoms specifically in perimenopause compared with the reproductive period. This is related to a combination of hormonal changes, vasomotor symptoms (hot flashes and night sweats), sleep disturbances, and social factors.

Effective Approaches: Psychotherapeutic Methods and Evidence Base Cognitive-Behavioral Therapy (CBT)

CBT is adapted to the symptoms of the menopausal transition and has demonstrated effectiveness in reducing depression, anxiety, sleep disturbances, and vasomotor symptoms through work on cognitions, reactivity to hot flashes, and sleep-related behaviors.
Specific CBT protocols have also been developed for sexual problems, focusing on desire, anxiety, bodily discomfort, and interpersonal dynamics.
Randomized trials and systematic reviews support the benefits of CBT as a non-pharmacological or complementary approach, especially when hormone therapy is contraindicated or ineffective.

Other Psychosocial Interventions

Mindfulness, stress management, interpersonal therapy, and group support have shown clinical benefits in reducing anxiety, depression, and improving sleep quality in some women.
Research reviews indicate that psychological interventions generally enhance emotional well-being and help women manage the daily symptoms of menopause.

Medical and Hormonal Supports (in the context of psychotherapy)

Hormone replacement therapy (HRT) remains an important medical treatment for severe vasomotor symptoms and related depression or sleep disturbances. Treatment decisions should be individualized, balancing risks and benefits.
Psychotherapy is often effective as a standalone approach for mild to moderate depression and as a complement to medical treatment.
National guidelines increasingly recommend a balanced approach: HRT as a primary option, with psychotherapy serving as a valuable complement or alternative when HRT is contraindicated.

Sexuality: Libido and Sense of Femininity

Declines in libido during menopause are multifactorial: hormonal (decrease in estrogen and androgens), somatic (vaginal dryness, pain during penetration), psychogenic (depression, anxiety, self-esteem), and socio-cultural influences.
Research indicates that in addition to medical interventions (local therapy for atrophy, systemic HRT, in some cases testosterone therapy), psychotherapeutic approaches (CBT, sex therapy, couple therapy) can restore sexual satisfaction, desire, and bodily attractiveness.
Recent studies suggest specialized CBT protocols for sexual problems in postmenopausal women, reporting notable improvements.

Cultural Context: “Dehumanization” of Women After 50

In many cultures, stereotypes depict older women as “asexual,” “less feminine,” or “socially irrelevant,” which exacerbates internal distress and may lead to loss of meaning, reduced self-esteem, and depressive reactions.
Empirical research in various regions (e.g., Arab and conservative communities) documents negative attitudes, low awareness of menopause, and shame, which contribute to symptom suppression and barriers to seeking help.
Psychotherapy in such contexts must account for cultural sensitivity, work with internal narratives on aging, embodiment, and social roles, and involve family or community when appropriate.

Special Category: Childless Women (Voluntary or Involuntary)

For women without children, particularly those involuntarily childless or affected by infertility, menopause is often associated with additional emotional challenges: feelings of a “broken” life cycle, loss of reproductive identity, unresolved grief, and increased social isolation.
Recent reviews and policy reports indicate a higher risk of mental health deterioration in this group and emphasize the need for specialized support—psychotherapy, peer support groups, targeted programs, and clinical and social planning that acknowledges these experiences.

Practical Recommendations for PsychotherapistsCombined, individualized approach

1. Apply a multimodal principle. Assess medical (including hormonal status), psychological, and social factors; collaborate with gynecologists and endocrinologists.
2. CBT-oriented interventions. Utilize anxiety regulation techniques, cognitive restructuring regarding aging and femininity, behavioral strategies for sleep disturbances, and exposure/planning for avoidance of sexual problems.
3. Specific work with sexuality. Integrate sex therapy, mindful sensate focus exercises, couple therapy, and coordinate medical interventions as needed (local therapy, discussion of HRT with a physician).
4. Cultural and gender sensitivity. Actively explore sociocultural beliefs of the patient/community regarding menopause; use narrative and gender-sensitive approaches, prevent stigmatization.
5. Support for childless women. Recognize unique losses and uncertainties; work with grief, meaning-making, and social support.

Typical Clinical Cases (Illustrative Examples)

1. Case A — “Restoration of Mood and Activity”
49-year-old woman, perimenopause, complaints: chronic fatigue, irritability, subdepressive mood, frequent hot flashes, and poor sleep.
After 12 weeks of counseling (focus on nocturnal behavior regulation, anxiety release techniques, and restructuring catastrophic thoughts about aging), she reported reduced depression, improved sleep, and decreased subjective frequency and intensity of hot flashes.

2. Case B — “Restoration of Libido and Sense of Femininity”
54-year-old woman, postmenopause, in a culture with strong age-related taboos. Complaints: reduced desire, loss of attractiveness, avoidance of intimacy.
Psychotherapy integration (CBT + elements of body-oriented therapy and sex therapy), with concurrent treatment of vaginal atrophy in consultation with a gynecologist.
After 4–6 months: restored interest in sexuality, increased couple intimacy, and subjective return of “sense of femininity.”

3. Case C — “Childless, Expectation Mismatch”
57-year-old woman, childless for medical reasons, complaints: increased sense of “unworthiness,” chronic sadness, avoidance of relatives emphasizing “life fulfillment through children.”
Psychotherapy: grief processing, reframing personal identity, participation in a women’s support group.
After one year — sustained improvement in self-esteem and social engagement.
Emphasis: these cases require long-term, empathetic support and consideration of socio-political context.

Ethical and Organizational Considerations

It is important to avoid paternalistic narratives such as “menopause = disease”: menopause is a natural biological transition, though it may require professional support.
Ensuring access to psychotherapy and public education is crucial to reduce stigma and encourage early help-seeking.

Conclusion

Premenopause and menopause are complex biopsychosocial processes.
Psychotherapy and psychological counseling, especially within a multimodal approach, demonstrate clear benefits in reducing depression, anxiety, sleep disturbances, and restoring sexual satisfaction and a sense of femininity.
For childless women and those living in cultures with strong age-related stigma, therapeutic work must address additional layers of loss and social pressure. Clinical approaches should be interdisciplinary, culturally sensitive, and individualized.

References

1. Hunter MS, et al. Cognitive behaviour therapy for menopausal symptoms (CBT-Meno): A randomised controlled trial. 2019. PubMed. https://pubmed.ncbi.nlm.nih.gov/31453958/ 

2. Hunter MS, et al. A randomised controlled trial of cognitive-behavioural therapy for hot flushes and night sweats. PMC. https://pmc.ncbi.nlm.nih.gov/articles/PMC3191497/ 

3. Samami E, et al. The effects of psychological interventions on menopausal hot flashes. PubMed. https://pubmed.ncbi.nlm.nih.gov/35822187/ 

4. Hunter MS, et al. Is cognitive behaviour therapy an effective option for women who… PMC. https://pmc.ncbi.nlm.nih.gov/articles/PMC8453849/ 

5. Systematic review: The effectiveness of psychosocial interventions on non-physiological symptoms of menopause (Maturitas). https://www.sciencedirect.com/science/article/pii/S0378-5122(25)00130-6 

6. Digital news/overview article: Mental health and menopause: There are connections and solutions. Stanford Medicine. https://med.stanford.edu/news/insights/2024/05/mental-health-menopause-perimenopause-solutions.html 

7. Review: Psychological Changes at Menopause: Anxiety, Mood Swings, and … SAGE Journals. https://journals.sagepub.com/doi/full/10.1177/26318318251324577