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Authored by: Elizabeth DuPont Spencer, LCSW-C
Sometimes, as therapists, we have training gaps that prevent us from helping our clients live full, rich lives. Training gaps can arise from inexperience but also from limited awareness of the latest in evidence-based treatments.
I had a training gap with a client about 15 years ago, and I wasn’t the only clinician who did. This client, a 45-year-old highly educated and professionally successful woman, came to see me with a sudden onset of anxiety and major depression with psychotic features. The good news is she did fully recover, but only after nine months, which included seeing three psychiatrists and being admitted to inpatient care once voluntarily and once involuntarily. She saw a lot of mental health providers, and not one of us mentioned that this might have a hormonal component.
When Hormonal Changes Mimic Psychiatric Disorders
Emerging research over the past decade has reframed estrogen as a neuroactive hormone with significant psychiatric relevance, rather than solely a reproductive regulator. We, as therapists, have an important role in learning this new information so that we can help our clients get effective, evidence-based care to live well through this vulnerable life transition.
Approximately 50% of the population undergoes the menopausal transition, typically beginning in the 40s, though symptoms can start in the 30s and last through the 50s.
This stage of life coincides with:
- Increased incidence of depressive and anxiety symptoms
- Higher rates of psychotropic prescribing
- Greater utilization of mental health services
Recent evidence (Alsugeir et al., 2024) suggests that new-onset psychiatric diagnoses and antidepressant prescribing frequently emerge during this transition, highlighting the need for mental health care providers to be knowledgeable about treatment.
Looking back on my client’s story, I see how hormonal changes were connected to her mental health struggles, and yet at the time, none of us involved with her care thought to consider consulting with a gynecologist or menopause specialist. It was all too easy to see other possible triggers that could have led to this mental health crisis. She was under a lot of stress, including her father’s death and her mother’s declining ability to care for herself; her son’s choice of a college across the country, which felt like a rejection of her; and her husband’s unemployment and the intense pressure on her to support her family and pay for her son’s college tuition.
Her symptoms were misattributed by all her providers, which was easy to do because there can be so much overlap between hormonal changes and psychiatric presentations.
Hormonal Change: Psychiatric Presentation:
- Estrogen fluctuation - Anxiety, irritability, panic
- Estrogen withdrawal - Depressive symptoms
- Sleep disruption - Mood instability, cognitive impairment
With the new research and adequate training, clinicians can now recognize these overlaps and provide vastly improved treatment during this vulnerable time of life. There is an opportunity for targeted interventions, including SSRI’s and hormones. While SSRIs/SNRIs remain first-line treatments, emerging data support a broader, integrative approach. For example, a recent cohort study (Glynne et al., 2025) found that transdermal estradiol and testosterone therapy were associated with improvements in mood symptoms in menopausal patients.
Expanding the Treatment Conversation: A Call to Action for Mental Health Professionals
As mental health providers, we are in an important position to help our clients get appropriate care. This must start with a fuller understanding of each client’s unique mental and medical history, including menstrual and reproductive history, timing of symptom onset, sleep, and vasomotor (hot flash) symptoms. It is crucial to help our clients by normalizing this hormonal transition and the mental health vulnerability it can cause.
Mental health providers can provide psychoeducation and facilitate good care by collaborating with gynecologists, primary care providers, and/or menopause specialists. It is important to move beyond a binary distinction of “medical” vs “mental health” in considering what the best treatment is for a woman in this age range.
I wish this information had been available when my client came to see me 15 years ago, but I am thrilled that so much research has been done and that treatment has improved. Estrogen functions as a critical neuroendocrine regulator with direct implications for mood, cognition, and stress response. Failure to incorporate this understanding into clinical practice risks incomplete conceptualization and treatment of midlife clients.
Now is the time for mental health providers to step up and recognize the essential role we all play in helping our clients get the benefit of this knowledge, to prevent others from suffering without appropriate treatment. Integrating hormonal awareness into mental health care is no longer optional—it is essential for accurate, effective, and compassionate practice.
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