→Why perimenopause causes anxiety →What the evidence supports →Supplements with evidence →Product reviews →Beyond supplements →Frequently asked questions →References

Oestrogen and serotonin

Oestrogen supports the production and activity of serotonin, one of the brain’s primary mood-regulating neurotransmitters. When oestrogen fluctuates unpredictably during perimenopause, serotonin signalling becomes less stable. This can show up as low mood, irritability, and a heightened sense of anxiety that feels disconnected from circumstances.

Progesterone and GABA

Progesterone and its metabolite allopregnanolone act on GABA receptors in the brain, which are the same receptors targeted by anti-anxiety medications. As progesterone becomes unreliable in perimenopause, the brain loses some of its natural calming support. The result for many women is a persistent sense of nervous system activation, difficulty winding down, and a low-level anxiety that is present even when there is nothing obvious to worry about.

The HPA axis and cortisol

The hypothalamic-pituitary-adrenal axis governs the stress response and cortisol production. Oestrogen is understood to modulate this system, and during perimenopause as oestrogen becomes less stable, the HPA axis may become more reactive, meaning the stress response is triggered more easily and takes longer to settle. Women who describe feeling on edge, easily overwhelmed, or unable to switch off are often experiencing this heightened HPA reactivity.

Sleep disruption compounds everything

Perimenopausal sleep disruption and anxiety are closely linked. Poor sleep increases cortisol reactivity and reduces the brain’s ability to regulate emotion. Anxiety worsens sleep. The two often become self-reinforcing, which is why addressing sleep is as important as addressing anxiety directly.

For anxiety that is clearly hormone-driven, HRT addresses the root cause directly by stabilising oestrogen and progesterone levels. NICE NG23 supports the use of HRT for mood symptoms during the menopausal transition. If anxiety is significantly affecting quality of life, a conversation with a GP about HRT is worth having. The supplements covered in this article are most useful as additional support or for women who cannot or prefer not to use HRT.

A 2023 systematic review and meta-analysis found that long-chain omega-3 supplementation significantly reduced anxiety and depressive symptoms in adults (Kelaiditis et al., 2023). EPA specifically has the stronger evidence for mood regulation. For women already considering omega-3 for cardiovascular or joint health, mood support is an additional well-evidenced benefit. See our full omega-3 guide for product recommendations.

A systematic review found that magnesium supplementation reduced subjective anxiety and stress in adults (Boyle et al., 2017). Magnesium supports GABA activity in the brain, the same calming pathway that progesterone supports. For women whose anxiety is driven by nervous system activation and difficulty winding down, magnesium glycinate is a practical and well-tolerated starting point. See our full magnesium guide for product recommendations.

Ashwagandha is an adaptogen with a growing body of clinical evidence. A 2025 systematic review and meta-analysis pooling 15 RCTs with 873 patients found statistically significant reductions in cortisol levels, perceived stress, and anxiety scores compared to placebo (Bachour et al., BJPsych Open, 2025). An earlier systematic review also found a general trend toward reductions in self-reported stress and anxiety, though the authors noted variability in study design and quality across the included trials (Pratte et al., 2014). A well-designed RCT found significant improvements in stress, anxiety, and cortisol levels compared to placebo (Chandrasekhar et al., 2012). KSM-66 is the most extensively researched extract form and the one used in the majority of clinical trials.

L-theanine is an amino acid found naturally in green tea. A 2024 systematic review covering 11 RCTs with over 800 participants found that L-theanine supplementation significantly reduced anxiety symptoms compared to placebo across multiple mental health conditions (Moshfeghinia et al., BMC Psychiatry, 2024). A randomised controlled trial also found that L-theanine supplementation significantly reduced stress-related symptoms and improved cognitive function in healthy adults (Hidese et al., 2019). It promotes a calm, focused state without sedation and is well tolerated. Lemon balm has complementary calming properties and the two are often combined in supplements.

B6 plays a role in serotonin and GABA synthesis. An observational study found that low B6 intake was associated with depressive symptoms in middle-aged and older women (Odai et al., 2020). This is associational evidence rather than trial evidence, so it does not tell us that B6 supplementation improves anxiety in women with normal levels. B6 is most relevant for women with low dietary intake, those following plant-based diets, or those with high alcohol intake, as these groups are at greater risk of deficiency. A B6 complex rather than isolated B6 is generally a more practical approach.

KSM-66 · Women-focused

What we like

KSM-66 extract, food-grown formulation, women-focused UK brand, clean labelling, no unnecessary additives.

UK brand · Clean formulation

What we like

Clean Viridian formulation, two complementary calming ingredients, non-sedating, suitable for daytime use.

B6 complex · UK brand

What we like

Clean Viridian formulation, full B-complex approach rather than isolated B6, well-dosed, UK brand.

Also worth considering

Magnesium glycinate

Strong evidence for anxiety and stress via GABA pathway support. Our full guide covers five products in depth.

Read the magnesium guide →

Also worth considering

Omega-3 (EPA)

Meta-analysis level evidence for anxiety and mood. Our full guide covers five products with transparent sourcing.

Read the omega-3 guide →

Sleep

Addressing sleep disruption is one of the most effective things you can do for perimenopausal anxiety. The two are closely linked and improving one almost always improves the other. See our sleep guide for a full breakdown of what helps.

Exercise

Regular physical activity, particularly resistance training and walking, is broadly associated with benefits for anxiety, mood, and stress regulation. It does not need to be intense to be helpful.

Blood sugar

Blood sugar fluctuations can trigger or worsen anxiety symptoms. Eating regular meals with adequate protein and fibre, and reducing refined carbohydrates, helps stabilise energy and mood throughout the day.

Caffeine

Caffeine stimulates the stress response and for some women can worsen anxiety, particularly in those already experiencing heightened nervous system reactivity. Reducing caffeine, especially after midday, is worth trying if anxiety is a significant symptom.

CBT

Cognitive behavioural therapy has strong evidence for anxiety and is recommended by NICE. Understanding that anxiety has a hormonal root does not mean psychological support is not helpful. The two approaches work well together.

Is anxiety a normal part of perimenopause?

It is common rather than inevitable. Research shows the risk of anxiety and depression rises significantly during the menopausal transition compared to pre-menopausal years. For many women it is a direct hormonal symptom rather than a separate mental health condition, which is an important distinction when deciding how to approach it.

Should I take antidepressants for perimenopausal anxiety?

This is a conversation to have with your GP. For anxiety that is clearly hormone-driven, HRT often works more effectively than antidepressants because it addresses the root cause. NICE NG23 supports HRT for mood symptoms during the menopausal transition. Antidepressants are not licensed for perimenopausal symptoms in the UK though they are sometimes prescribed. Neither we nor this article are a substitute for medical advice.

Can I take ashwagandha with HRT?

There are no well-documented interactions between ashwagandha and standard HRT. However if you are taking any prescribed medication it is always worth checking with your GP or pharmacist before starting a new supplement. Ashwagandha is not suitable during pregnancy.

How long does ashwagandha take to work?

Most clinical trials showing benefits for stress and anxiety ran for 8 to 12 weeks. Give it at least 6 to 8 weeks of consistent daily use before assessing whether it is working. Some women notice changes within 2 to 4 weeks but the full effect typically takes longer.

What is the difference between ashwagandha extracts?

KSM-66 and Sensoril are the two most researched ashwagandha extracts. KSM-66 is derived from the root only and has the most human trial data for stress and anxiety. Sensoril uses both root and leaf and tends to be used at lower doses. For anxiety specifically KSM-66 is the more studied form and the one to look for on the label.