How many times have you had patients come in reporting struggles with their mental health during perimenopause and asking if this is normal? While we know this is a common experience, the lack of population-level evidence makes it difficult to validate these patients. New research from Flo Health and Mayo Clinic addresses that gap directly. Published in Menopause, the journal of The Menopause Society, as part of a landmark global perimenopause series, the study provides the evidence required to finally support patient validation. Ultimately, these findings can support patients in recognizing when they are struggling and seek the help they need sooner.
A cross-sectional study of 7,975 Flo app members aged 35 and over, across 20 countries, used the psychological domain of the validated Menopause Rating Scale (MRS) to demonstrate the psychological toll perimenopause takes on women. Participants currently using hormonal contraception or hormone replacement therapy were excluded, and reproductive stage was established by self-report, using the following definitions:
Participants also shared information about their age, education, income, ethnicity, body mass index (BMI), smoking and alcohol habits, and whether they had an existing diagnosis of anxiety or depression, allowing us to examine whether differences between groups held up after accounting for these factors.
Each of the four MRS psychological symptom domains — depressive mood, irritability, anxiety, and exhaustion — was scored from 0 (absent) to 4 (very severe), giving a combined total of 0 to 16. Using a severity scale rather than a binary presence-or-absence measure enables more clinically meaningful comparisons between groups.
Perimenopausal participants reported a mean MRS psychological domain score of 7.3, compared with 4.8 in the premenopausal group, over 1.5 times higher, with each individual symptom significantly higher in the perimenopause group.
Interestingly, while it has been recognized that women are at increased risk of anxiety and depressive symptoms during the transition to menopause, attributed to fluctuations in estradiol and declining progesterone levels,1 exhaustion showed the greatest difference (2.0 versus 1.3), followed by irritability (1.8 versus 1.2) in the perimenopause and premenopause groups, respectively.
In the Women Living Better survey, 57% of women in the late reproductive stage and 54% of women in the menopause transition reported feeling irritable, while 50% and 55% respectively reported fatigue.2 While exhaustion and irritability can present alongside and overlap with depression and anxiety, our study reinforces that these are distinct symptoms that warrant their own clinical attention and investigation.
Crucially, these differences persisted after adjustment for age, education, income, ethnicity, BMI, smoking, alcohol consumption, and preexisting diagnoses of anxiety or depression, validating that perimenopause was independently associated with higher symptom scores across all four domains, and the elevation cannot be attributed to demographic or clinical characteristics alone.
“We know that anxiety and depression get a lot of attention when it comes to perimenopause, and for good reason: They matter. But what stood out to us in this study was the scale of the difference in exhaustion and irritability between the perimenopause and premenopause groups. These are symptoms that can have a real impact on daily life and work, and they deserve to be part of the conversation,” said Adam Cunningham, PhD, lead research scientist at Flo Health and co-first author.
The study’s international scope, consisting of more than 2,000 perimenopausal participants across 20 countries, enabled an exploratory geographic analysis. Among perimenopausal participants, mean psychological domain scores ranged from 3.5 in Nigeria to 8.8 in Brazil. Scores were also high in the United Kingdom (8.4), Australia (8.1), Canada (8.0), and the United States (7.9), while lower scores were recorded in Venezuela (4.8), Chile (5.1), Germany (5.3), and Colombia (5.4).
These patterns are broadly consistent with prior evidence that perimenopause symptom reporting is shaped by sociocultural context, such as cultural openness, shame and stigma, health literacy, and access to care. A related paper in the same series found significant cross-country variation in perimenopause knowledge, with higher-income countries demonstrating greater familiarity with the full symptom spectrum, suggesting that awareness and recognition may partly drive the geographic differences observed here.³
“One of the strengths of this study is its international reach,” said Liudmila Zhaunova, PhD, director of science at Flo and senior study author. “Including women from 20 countries allowed us to begin exploring how psychological symptoms during perimenopause may vary across populations. While these findings are exploratory, they reinforce the need for more globally representative research to better understand women’s experiences and inform future education, research, and care.”
While this evidence is already pivotal in validating the psychological toll perimenopause takes on patients, it also points to some wider implications. People need better tools to track and understand the psychological changes that can accompany perimenopause, with this research providing both the rationale and the urgency. Increasing awareness of symptoms such as exhaustion and irritability may help individuals identify the menopause transition earlier and seek appropriate support, while data at this scale is essential for developing education, research, and care that reflect the diverse experiences of people worldwide.
Flo’s ‘My Perimenopause Tracker’, comprising the educational Perimenopause Score and the Menopause Timeline, provides members with a self-tracking tool to build a routine of checking in with themselves both physically and psychologically so they can track these changes and better navigate their menopause journey. These tools are complemented by perimenopause-specific educational content, helping patients improve their health literacy and better identify when they need support.
Because an informed patient is an empowered patient.