"Before the perimenopausal symptoms began, I was living my dream life. No mental health history, a thriving business, and a wonderful family. But when I hit 35, everything changed."

That's Fiona Weaver, founder of the Tasmanian adventure community Wild Island Women. Her story is why this post exists.

Most of what you'll read about perimenopause covers hot flushes, heavy periods and not sleeping. Almost none of it mentions that, for a small number of women, the hormone changes of midlife can trigger psychosis. Fiona lived it, was dismissed for years, and now wants other women to recognise the signs earlier than she could.

Before we get to her story, let's deal with the question most women are actually typing into Google at 2am.

Is it perimenopause, or am I going crazy?

If you feel like you're losing your mind in perimenopause, you're in good company.

Rage over a wet towel on the bathroom floor. Forgetting a word halfway through a sentence. Anxiety that arrives from nowhere. Waking at 3am with your heart going. These are common. They're driven by the same oestrogen and progesterone swings, they respond well to the right support, and they are not psychosis.

Psychosis is different. It means losing touch with what's real: hearing or seeing things that aren't there, holding fixed beliefs that don't match reality, or feeling watched, followed or plotted against. It's rare in perimenopause, but it's serious, and it's treatable.

Here's how I'd tell the two apart.

What is perimenopause psychosis?

Psychosis is a group of symptoms, not a single diagnosis. It includes hallucinations (seeing, hearing or sensing things that aren't there), delusions (fixed beliefs that don't shift even when the evidence does), paranoia, and disorganised thinking or speech. It can be triggered by many things, including severe sleep deprivation, infection, drugs, thyroid disease, and major hormonal shifts.

Perimenopause psychosis is psychosis that begins, or comes back, during the menopause transition. Some researchers call it menopause-associated psychosis, or MAP. It isn't yet a formal diagnosis, and the term covers a few different situations:

• A first episode of psychosis in a woman with no mental health history (Fiona's situation)
• A relapse in a woman who already lives with bipolar disorder, schizophrenia or schizoaffective disorder
• Late-onset schizophrenia, which has a known second peak in women around 45 to 50 that doesn't occur in men

What they share is timing. The symptoms arrive or worsen as oestrogen starts to swing and fall, and they often come with severe mood swings, anxiety and weeks of broken sleep.

"Here's what I want every woman to hear. Feeling like you're going crazy is common in perimenopause, and it's not psychosis. But if you, or the people around you, notice you've lost the thread of what's real, that's not something to push through. That's a GP appointment this week, not a supplement."

Sarah McLachlan, The Perimenopause Naturopath (BHSc Naturopathy), Australia

Can perimenopause cause psychosis?

Yes, though it's uncommon, and the research is clearer for women with an existing condition than for first episodes.

Women have two peaks for the onset of schizophrenia: one in early adulthood and a second around menopause. Men only have the first. A 2025 review in Current Treatment Options in Psychiatry describes psychotic symptoms arising from "the fluctuating and gradual reduction of hormones," in the same way they can after birth or in the days before a period (Reza and Ratnaparkhi, 2025).

The largest study we have followed 61,889 people with schizophrenia or schizoaffective disorder in Finland. Before 45, women were hospitalised for psychosis less often than men and needed lower doses of medication. From 45 to 50 onwards, women were hospitalised more often than men, and their antipsychotic medication became less effective. The authors describe perimenopause as "a critical period during which symptoms increase, while the effectiveness of antipsychotics declines as a consequence of estrogen deficiency" (Sommer et al., Schizophrenia Bulletin, 2023).

For mood more broadly, a 2024 meta-analysis from University College London pooled seven studies and 9,141 women. Women in perimenopause were about 40% more likely to experience depressive symptoms than women who hadn't started the transition. There was no increase after menopause (Badawy et al., Journal of Affective Disorders, 2024). That's a relative figure, and the studies don't give a clean absolute number, so read it as "meaningfully more likely," not "most women."

And it's worth saying plainly, because fear doesn't help anyone: The Lancet's 2024 series on menopause found no universal rise in mental illness at menopause. The risk concentrates in women with a history of depression, severe hot flushes, badly disrupted sleep, surgical menopause, or a pile-up of life stress (Brown et al., The Lancet, 2024).

So most women won't experience anything like this. A small number will, and they're often the women whose early signs get dismissed as "just stress" or "too young for perimenopause."

Why do hormone changes affect the brain this way?

Oestrogen isn't only a reproductive hormone. In the brain it supports dopamine, serotonin and GABA, the neurotransmitters that regulate mood, perception, and how "on" your nervous system is. When oestrogen swings and then falls in perimenopause, that support thins out. For most women that shows up as mood and sleep changes. For a few, especially when other pressures are stacked on top, it can tip into psychosis.

The same pattern shows up at the other oestrogen cliffs in a woman's life: the days before a period, and the weeks after giving birth. Postpartum psychosis is better known. This is its midlife cousin.

What stacks the odds

• A personal or family history of bipolar disorder, schizophrenia or postpartum psychosis
• Weeks of broken sleep (sleep loss on its own can trigger psychosis in vulnerable people)
• Thyroid disease
• Iron deficiency, because iron is needed to make neurotransmitters
• Some medications, recreational drugs and infections
• Heavy life stress: caring for kids and parents, work and relationship changes, illness
• A history of trauma

None of these mean psychosis will happen. They're the reasons a woman with the "common column" symptoms above deserves a proper look, not a pat on the hand.

Fiona's story: the early signs everyone missed

It started with sleep and heavy periods

For Fiona, the early signs were subtle but real. "I started noticing changes around age 35. My periods became heavier, and I was more irritable and tired than usual," she recalls.

The heavy bleeding was dismissed by her doctor despite repeated visits. Like so many women, she was told she was too young for perimenopause. It was only when she turned up with data on how much blood she was losing each month that she was referred to a gynaecologist. Fibroids and adenomyosis were diagnosed, and the fibroids were removed.

Around the same time, Fiona experienced what she now recognises as her first period of mania.

"I started waking up at about 2 or 3 o'clock in the morning and then not being able to get back to sleep. So that's kind of where it started with me, was the sleep. And then it really started with irritability."

Then the rage, and the missing filter

"I was experiencing a lot more rage. I was a very passionate person around politics and environment and the patriarchy and all those things. I got even more intense, to the point where even my husband said on tours, it was becoming a little bit uncomfortable. I couldn't really rein myself in, I had no filter. And again, like it happened over time, not straight away. The poor sleep really did exacerbate everything and then really started to quicken things up. And then, so it kind of just got worse and worse."

The escalation

By October 2022, in her early 40s, Fiona's symptoms intensified into mania. "I started having severe anxiety, trouble sleeping, and episodes of rage," she shares. These culminated in a full psychotic episode.

"It's not until I go back and just really think about where it started and when I first had the symptoms and what they were, and it looked like having a psychosis or a psychotic episode just came out of the blue for me. But now that I'm learning more about it and seeing more psychiatrists and things like that, I definitely know that there are signs and symptoms of these things earlier."

What finally helped

Fiona's psychiatrist understood the link between oestrogen and mental health and suggested hormone therapy alongside her psychiatric medication. Her psychiatric and gynaecological care providers worked together on one plan.

"It was a relief to find a team that understood the interconnectedness of my symptoms and treated me as a whole person, not just a set of symptoms."

Two other things mattered. The first was data. "Keeping a symptom diary was a game-changer for me. It allowed me to present concrete data to my doctor, which finally led to the right diagnosis and treatment." The second was people. "The community was a lifeline for me. Knowing I wasn't alone made a world of difference."

What are the early warning signs of perimenopause psychosis?

Looking back, Fiona's symptoms built over years, not overnight. That's the point of the ladder below. Each step is a chance to step in.

1. Sleep breaks first. Waking at 2 or 3am and not getting back to sleep, night after night. Do: track it and tell your GP.
2. Irritability turns into rage. No filter, and an intensity the people close to you start to comment on. Do: tell someone you trust, and start a symptom diary.
3. Wired and fast. Racing thoughts, big plans, days on almost no sleep, severe anxiety. Do: see your GP this week and ask for a referral to a psychiatrist.
4. Losing the thread of what's real. Feeling watched or plotted against, hearing or seeing things, beliefs others can't share. Do: today. GP, emergency department, or 000 if anyone is unsafe.

Early is the best time to act. This is physiology, and it's treatable.

What does treatment and support look like?

Medical care comes first

Psychosis is treated by a doctor, usually a GP and a psychiatrist together. Treatment typically involves psychiatric medication and psychological support, and for perimenopausal women it may also include menopausal hormone therapy (MHT). There's growing evidence that oestrogen helps antipsychotic medication work better in midlife women, and that MHT can reduce relapse in women with schizophrenia or schizoaffective disorder (Reza and Ratnaparkhi, 2025). Whether it's right for you is a decision for you and your psychiatrist.

If you're already on a psychiatric medication, please don't stop or change it without talking to your prescriber. Perimenopause can change how well a dose works, and that's a conversation to have with them, not a reason to go it alone.

Where naturopathic support fits

My lane is alongside your medical team, never instead of it. Once you're safe and treated, the things that make the "common column" better also make the ground under a recovery steadier:

• Sleep, protected like it's medicine (because in this context it is)
• Steady blood sugar, so your nervous system isn't running on adrenaline between meals
• Iron and thyroid checked through your GP, since both affect the brain's ability to make neurotransmitters
• Alcohol kept low, because it wrecks sleep and mood in perimenopause
• Stress load reduced wherever it's actually possible, and support asked for where it isn't

Read that list again. It's the same list that helps every woman in perimenopause. That's the point.

How to advocate for yourself (or someone you love)

Fiona's story points to something I see in clinic every week: women are still having to be their own advocates. This is what works.

• Keep a symptom diary. Sleep, mood, energy, and where you are in your cycle, side by side. Patterns are hard to dismiss when they're written down. This is what got Fiona her diagnosis.
• Ask the question directly. "Could this be perimenopause?" A lot of care providers still don't connect severe mental health symptoms with hormonal change.
• Ask for a referral to a psychiatrist with an interest in women's hormones and mental health. They exist, and they make a difference.
• Bring someone with you. A partner or friend who has seen the changes can describe what you can't.
• Get a second opinion if you're dismissed. "Too young" and "just stress" are not diagnoses.

Fiona's advice: "Don't accept dismissal from healthcare providers. Trust your instincts and keep pushing for answers."

Where to get help in Australia

• Emergency: 000, or your nearest emergency department
• Lifeline: 13 11 14 (24 hours), lifeline.org.au
• Beyond Blue: 1300 22 4636 (24 hours), beyondblue.org.au
• SANE Australia support line: 1800 187 263 (weekdays, 10am to 8pm AEST), sane.org
• Your GP, and the Australasian Menopause Society's Find a Practitioner service for doctors with menopause training

If you're outside Australia, your local emergency number and crisis line are the right first call.

Fiona's message to other women

Fiona hopes that by sharing her story, more women will recognise the signs earlier and speak openly about what they're experiencing. "Don't accept dismissal from healthcare providers. Trust your instincts and keep pushing for answers."

If your version of "going crazy" is the common one (rage, anxiety, 3am, brain fog) and you'd like a calm, personalised plan for it, the free Clarity Call is where we start. If it's the other column, please see your doctor today. Both are real. Both are treatable. Neither is your fault.

About Fiona Weaver

Fiona Weaver is an adventurer, entrepreneur, writer and speaker. In 2003, after a stint in the corporate world, she left the conventional path to pursue a life of travel and adventure. She now lives with her husband in a sustainable cabin on a permaculture property on the outskirts of Mount Field National Park in Tasmania's Derwent Valley, running her tourism business and making space for new projects and her own adventures.

After more than 10 years facilitating adventures, Fiona noticed that most women need a little extra support before trying a new outdoor activity, and that real barriers still keep women from feeling comfortable outdoors. In 2016 she founded Wild Island Women, an adventure community supporting women to break through the financial, cultural, mental and physical barriers that hold them back. Join her community on Facebook.

Frequently asked questions

References

1. Reza N, Ratnaparkhi R. Psychosis in perimenopause and beyond. Current Treatment Options in Psychiatry. 2025. link.springer.com
2. Sommer IE et al. Women with schizophrenia-spectrum disorders after menopause: a vulnerable group for relapse. Schizophrenia Bulletin. 2023;49(1):136-143. academic.oup.com
3. Badawy Y, Spector A, Li Z, Desai R. The risk of depression in the menopausal stages: a systematic review and meta-analysis. Journal of Affective Disorders. 2024. Summary via ScienceDaily
4. Brown L et al. Promoting good mental health over the menopause transition. The Lancet. 2024. thelancet.com
5. Australasian Menopause Society. Menopause and mental health (fact sheet). menopause.org.au