“Not feeling like myself” in perimenopause — what does it mean? Observations from the Women Living Better survey

The phrase “not feeling like myself” from a midlife woman was associated with anxiety/vigilance, fatigue/pain, brain fog, sexual symptoms, and volatile mood symptoms. These symptoms are not commonly associated with the menopausal transition but understanding their relationship to expressions of “not feeling like myself” may help healthcare providers respond to women's concerns.

Abstract

Objective

This study aimed to understand the meaning of the phrase “not feeling like myself” (NFLM) when used by those on the path to menopause by exploring the relationship of symptoms reported to ratings of NFLM.

Methods

Participants responded to the item “Many women report just not feeling like themselves during this phase of life. How often was this true for you over the past 3 months?” choosing from “none of the time” to “all of the time.” They rated bother associated with 61 symptoms and provided demographic information. Individual symptoms and the symptom bother scale scores were correlated with NFLM. Symptom scale scores were then entered in a two-stage multiple regression model to identify symptoms associated significantly with NFLM.

Results

Sixty-three percent (63.3%) of participants reported NFLM 50% of the time or more over the previous 3 months. Individual symptom ratings correlated with NFLM (r > 0.300) included the following: fatigue (r = 0.491); feeling overwhelmed/less able to cope (r = 0.463); low feelings (r = 0.440); anxiety, more nervousness (r = 0.398); being irritable (r = 0.380); harder time concentrating (r = 0.378); difficulty making decisions (r = 0.357); feeling like “I can't calm down on the inside” (r = 0.333); being more forgetful (r = 0.332); tearfulness/crying (r = 0.306); and worrying more (r = 0.302). A two-stage regression analysis revealed less education completed and greater overall stress ratings as significant predictors in stage 1. In stage 2, five symptom groups met the P < 0.001 criterion: anxiety/vigilance, fatigue/pain, brain fog, sexual symptoms, and volatile mood symptoms.

Conclusions

NFLM was associated with anxiety/vigilance, fatigue/pain, brain fog, sexual symptoms, and volatile mood symptoms. Recognizing symptoms associated with NFLM may allow for more accurate expectations and improve perimenopause care.

“Not feeling like myself” (NFLM) is a phrase used by midlife women on the path to menopause. It was noted in comments to the Women Living Better (WLB) Website, and it arises regularly in the clinical setting of one of the authors (M.K.R.). A google search of “I don't feel like myself” and “perimenopause” yielded 5.3 million results. A scan of the first several pages suggests that results fall in two broad categories: healthcare provider efforts to recruit new patients by demonstrating an understanding of how women feel and women, themselves, lamenting the difficulty of the menopausal transition (MT) on blogs and podcasts and in mainstream media.¹ Despite this widespread usage, no attention has been devoted to clarifying the meaning of NFLM in relationship to perimenopause. Pubmed searches using variations of this phrase revealed only two published studies^2,3 in addition to our previous work.^4,5 There are additional references to this phrase in antidepressant users⁶ and in geriatric populations.⁷

Prairie and colleagues ² explored how perimenopause symptoms that brought women to an academic midlife healthcare practice (MLP) compared with those who sought care from urban or suburban gynecology practices. They found that those who sought care at the MLP reported more nongynecologic symptoms. The symptoms were weight gain, trouble sleeping and tiredness, moodiness, and “not feeling like myself.” The authors note, “the addition of a question specifically about self-concept (ie, “I don't feel like myself”) reflected our clinical experience, and 28% of patients in the MLP reported this as a reason for their visit.” ² In the research of Prior,³ she writes about a patient surprised by perimenopausal symptoms, who shares, “I don't feel like myself — when do I get my life back”? Author M.K.R. reports that, recently, a patient shared, “I don't feel like myself. I don't know who I am. It's like an out of body experience” (M.K. Richardson, MD, July 18, 2023, oral communication).

The WLB survey of women 35 to 55 years old included a question asking how frequently participants “didn't feel like themselves” over the previous 3 months. In the following analyses, we used responses to this question to attempt to better understand the meaning of this phrase. Clarity about what symptoms or characteristics are associated with NFLM could improve the experience of perimenopause in several ways. It could help clinicians know how to respond when patients say “I just don't feel like myself” and also enable them to normalize this feeling and validate the underlying symptoms as common among other women. Improved clarity could also contribute to the general understanding of the perimenopause experience and ideally spur further research into the associated symptoms.

Our analysis aimed to elucidate the meaning of this phrase by the following:

1. Exploring correlations between bothersome symptoms reported during the late reproductive stage (LRS) and the MT and the endorsement of NFLM

2. Testing a hierarchical model relating bothersome symptom groups (anxiety/vigilance, fatigue/pain, brain fog, sexual symptoms, volatile mood, and gastrointestinal symptoms) to NFLM accounting for education level, overall stress, satisfaction with daily activities, and reproductive aging stage.

METHODS

Sampling strategy

Participants responded to the online WLB survey from March to August of 2020. Of 2,406 total respondents, 1,617 met the inclusion criteria in the study, 1,529 provided data for staging reproductive aging (946 LRS and 583 MT). Of these, 1,320 provided complete data for the correlational analysis, and 1,263 provided complete data for the multivariate analysis (Fig. 1). The WLB survey was designed to characterize participants' experience in the 10 to 15 years preceding the final menstrual period, respondents aged 35 to 55 years were recruited as a convenience sample. The timing of the survey launch with the coronavirus disease pandemic was coincidence and not a part of the study design. Most participants were from the United States and Canada. A detailed description of sampling methods is provided elsewhere.⁸

FIG. 1.

Flow diagram for derivation of study sample included in analyses. LRS, late reproductive stage; MT, menopausal transition; NFLM, “not feeling like myself”.

Inclusion and exclusion criteria

Participants were included in analyses reported here if they met the criteria for the LRS or MT using STRAW+10 criteria.⁹ Those who were using therapies affecting their menstrual cycles (eg, hormone-containing agents); have had procedures or conditions affecting menstrual bleeding (eg, endometrial ablation); and, during the past 3 months, have been pregnant or have lactated, or experienced a 20% change in body weight or a major life event, such as death of a close family member, were ineligible.

Measures

Participants rated a measure of NFLM, responding to the item “Many women report just not feeling like themselves during this phase of life. How often was this true for you over the past 3 months?” Respondents chose from a 5-point scale beginning with “none of the time” (0) to “all of the time” (4).

In addition, participants provided data about their education level, satisfaction with daily activities, overall stress, and reproductive aging stage. Women indicated whether they had completed less than college, college, or a graduate degree and whether difficulty paying for basics was very hard, somewhat hard, or not hard. They also indicated whether they were working for pay full time, part time, or not working for pay and whether they had responsibility for children/dependents and were in a committed relationship. Participants rated their overall stress on a scale from low (1) to high (5) and their satisfaction with life roles/daily activities on a scale from very dissatisfied (1) to very satisfied (5).

Participants rated 61 symptoms sometimes associated with the MT⁸ on a scale where degree of bother ranged from not at all bothered (1) to extremely bothered (7). Participants were asked to endorse only symptoms that were new to them since their mid-30s. The symptoms were summed to create symptom scale bother scores based on results of a principal components analysis for which eigenvalues of each exceeded 1.00 (Supplemental Table 1, http://links.lww.com/MENO/B211). The following symptom scales with the highest eigenvalues were used in these analyses: anxiety/vigilance (waking up in the middle of the night feeling panic, anxious, or worried; heart palpitations; feelings of anxiety, more nervousness; easily overwhelmed, less able to cope; worrying more; experiencing panic attacks; and feeling like “I can't calm down on the inside,” jumpy, startle easily), fatigue/pain (tiredness or sluggishness, joint/muscle pain, and leg pain), brain fog (being more forgetful, having a harder time concentrating, and more difficulty making decisions), sexual symptoms (pain with vaginal sex, less vaginal lubrication, less interested in sexual activities, more difficulty experiencing orgasm, more trouble feeling aroused, vaginal dryness), volatile mood (more irritable; having sudden mood changes; and experiencing sudden anger, raging feelings, and flying off the handle), and gastrointestinal symptoms (bloating; nausea; constipation; abdominal pain, heaviness, tightness) (Supplemental Table 1, http://links.lww.com/MENO/B211).

Analyses

First, we correlated the bother ratings for individual symptoms with reports of NFLM using Pearson's r. We then entered six symptom scales, five of which had shown an association with NFLM in our previous analyses⁴ (anxiety/vigilance, fatigue/pain, brain fog, sexual symptoms, volatile mood); added gastrointestinal symptoms, owing to its high eigenvalue; and included symptoms with a physiologic component, into a two-stage regression model with NFLM. Stage 1 included education level, satisfaction with daily activities/roles, overall stress, and reproductive aging stages. In stage 2, we added the symptom bother scale scores to derive a final model of NFLM. We used a P value of <0.001 owing to the large sample size.

RESULTS

With an average age of 47.3 years (SD, 4.35 y), 62% of participants were in the LRS and 38% were in the MT stages. As described elsewhere,⁸ they were well educated with 80% having completed college degrees, most not finding it difficult to pay for basics (82%), most working full time for pay (64%), having responsibility for children or dependents (67%), and living in a committed relationship (85%).

Of all participants, 16.7% said that they did not feel like themselves all of the time in the past three months. Another 18.0% said they did not feel like themselves three quarters of the time, and 28.6% said that they did not feel like themselves half of the time. In total, 63.3% of respondents said that they did not feel like themselves half of the time or more over the past 3 months (Fig. 2).

FIG. 2.

How often survey participants reported “not feeling like themselves” during the previous 3 months.

Mean bother ratings for each symptom and correlations between individual symptom ratings with NFLM scores are included in Table 1. An examination of correlations between individual symptom ratings with NFLM scores revealed a set with an r > 0.300 (Table 1). These symptoms included the following: fatigue (r = 0.491); feeling overwhelmed/less able to cope (r = 0.463); low feelings (r = 0.440); anxiety, more nervousness (r = 0.398); being irritable (r = 0.380); harder time concentrating (r = 0.378); difficulty making decisions (r = 0.357); feeling like “I can't calm down on the inside” (r = 0.333); being more forgetful (r = 0.332); tearfulness/crying (r = 0.306); and worrying more (r = 0.302). Figure 3 illustrates the different magnitude of the relationships between individual symptoms and NFLM for all symptoms with a Pearson's r >0.3. We also included hot flashes and vaginal dryness for comparison because these are known to be associated with the MT.

Table 1.

Not feeling like myself and individual symptom bother ratings: Pearson's correlations (n = 1,320)

Symptoms	Mean Bother Rating	SD	Pearson's r	P
Sleep symptomsa
Difficulty falling asleep	1.30	1.26	0.161	<0.001
Waking up in the middle of the night, back to sleep	0.88	1.65	0.053	NS
Waking up in the middle of the night, awake for an hour or more	2.17	2.74	0.167	<0.001
Waking up and panic feelings	1.22	2.32	0.219	<0.001
Early am awakening	0.82	1.71	0.084	0.002
Vasomotor symptoms
Hot flashes	1.60	1.26	0.277	<0.001
Night sweats	1.88	2.34	0.237	<0.001
Palpitations	1.29	2.26	0.285	<0.001
Mood symptoms
Irritable	2.66	1.26	0.380	<0.001
Anxiety, nervous	2.45	2.77	0.398	<0.001
Overwhelmed, less able to cope	2.12	2.77	0.463	<0.001
Worry more	1.45	2.41	0.302	<0.001
Low feelings	2.01	2.69	0.440	<0.001
Sudden mood changes	1.40	2.43	0.264	<0.001
Panic attacks	0.94	2.17	0.279	<0.001
Sudden anger, rage	1.54	2.62	0.246	<0.001
Tearfulness, crying	1.38	2.30	0.306	<0.001
Can't calm down on the inside	1.31	2.41	0.333	<0.001
Brain fog
More forgetful	3.00	2.75	0.332	<0.001
Difficulty concentrating	2.68	2.80	0.378	<0.001
Difficulty making decisions	1.79	2.64	0.357	<0.001
Dizziness	0.95	2.04	0.253	<0.001
Vertigo	0.70	1.85	0.188	<0.001
Light-headed	0.91	2.04	0.219	<0.001
Headaches and sore breasts
Tension headaches	1.53	2.29	0.252	<0.001
Migraine headaches	0.98	2.22	0.144	<0.001
Breast tenderness	1.59	2.12	0.195	<0.001
Skin dryness, itchiness, acne
Dryness	1.87	2.33	0.255	<0.001
Itchiness	1.51	2.28	0.258	<0.001
Breakout	1.12	2.22	0.143	<0.001
Dry eyes	1.66	2.40	0.250	<0.001
Vaginal and urinary changes
Vaginal dryness	0.96	2.06	0.205	<0.001
Vaginal itchiness	0.78	1.93	0.160	<0.001
Vulvar pain without intercourse	0.17	0.98	0.096	<0.001
Urine leakage with cough/sneeze	2.08	2.71	0.209	<0.001
Urine leakage without cough/sneeze	0.91	2.16	0.095	<0.001
Urinary frequency	1.19	2.19	0.226	<0.001
Urinary urgency	0.89	2.09	0.142	<0.001
Digestive symptoms
Bloating	1.63	2.50	0.271	<0.001
Heartburn	0.90	1.96	0.169	<0.001
Nausea	0.57	1.65	0.207	<0.001
Constipation	0.75	1.86	0.178	<0.001
Diarrhea	0.54	1.62	0.140	<0.001
Abdominal pain	1.00	2.10	0.258	<0.001
Pain and fatigue
Joint/muscle pain	1.68	2.53	0.272	<0.001
Back pain	1.01	2.12	0.196	<0.001
Leg pain	0.77	1.93	0.238	<0.001
Neck pain	0.68	1.83	0.190	<0.001
Shoulder pain	0.72	1.86	0.105	<0.001
Joint/muscle stiffness	1.40	2.39	0.296	<0.001
Fatigue	2.67	2.91	0.491	<0.001
Painful sex/libido
Pain with vaginal intercourse/penetration	0.71	1.94	0.149	<0.001
Decreased vaginal lubrication with arousal	1.40	2.36	0.203	<0.001
Less interest in sexual activities	2.51	2.71	0.281	<0.001
More interest in sexual activities	0.13	0.53	0.024	NS
Difficulty experiencing orgasm	0.92	2.13	0.210	<0.001
Difficulty feeling aroused	1.69	2.62	0.257	<0.001

NS, not significant.

^aSymptoms grouped by categories from Women Living Better survey.

FIG. 3.

Correlations between individual symptoms and “not feeling like myself.” NFLM, “not feeling like myself”.

When we included predictors of NFLM from our previous analyses⁴ and the GI symptom group (for reasons stated previously) in a two-stage regression model, we found that the best set of predictors included in stage 1 were as follows: education completed, satisfaction with the mix of all the activities in which you are engaged, overall stress rating, and reproductive aging stages (LRS, MT). Each met the criterion for statistical significance of P < 0.001. In stage 2, we added the symptom scale scores (anxiety/vigilance, fatigue/pain, brain fog, sexual symptoms, volatile symptoms, and GI symptoms). Significant predictors included education completed and overall stress rating, but satisfaction with the mix of activities and reproductive aging stages were not significant at the P < 0.001 level. Stage 2 analysis included symptom groups meeting the P < 0.001 criterion: anxiety/vigilance, fatigue/pain, brain fog, sexual symptoms, and volatile mood symptoms, but gastrointestinal symptoms did not meet the P < 0.001 criterion. The R² for stage 1 of the model was 17.1% and, for stage 2 of the model, was 41.8% (stage 1, F_{4, 1,259} = 64.97 [P < 0.001]; stage 2, F_{10, 1,253} = 90.03 [P < 0.001]) (Table 2).

Table 2.

Symptom groups associated with NFLM: hierarchical multiple regression results (B; SE; β; t; and R², F, and df) (n = 1,263)

Predictor variables	B	SE	β	t	R2, F, and df, p
Stage 1					0.171; 64.971; 4, 1,259; <0.001
Constant	1.424	0.225		6.337	<0.001
Education	−0.299	0.044	−0.176	−6.829	<0.001
Satisfaction	−0.126	0.034	−0.101	−3.702	<0.001
Overall stress	0.357	0.034	0.282	10.395	<0.001
Reproductive aging stage	0.326	0.068	0.124	4.809	<0.001
Stage 2					0.418; 90.026; 10, 1,253; <0.001
Constant	0.839	0.192		4.363	<0.001
Education	−0.146	0.038	−0.086	−3.861	<0.001
Satisfaction	−0.057	0.029	−0.046	−1.996	0.046
Overall stress	0.141	0.031	0.111	4.501	<0.001
Reproductive aging stage	0.158	0.058	0.060	2.705	0.007
Anxiety/vigilance	0.024	0.003	0.220	7.884	<0.001
Fatigue/pain	0.043	0.006	0.192	7.294	<0.001
Brain fog	0.023	0.005	0.123	4.716	<0.001
Sexual symptoms	0.015	0.003	0.121	5.190	<0.001
Volatile mood	0.016	0.005	0.083	3.345	<0.001
GI symptoms	0.014	0.005	0.061	2.483	0.013

B refers to the unstandardized coefficient.

β is defined as the standardized regression coefficient.

β indicates the relative contribution of a variable, for example, education, when considered along with other variables in the model.

NFLM, “not feeling like myself”.

DISCUSSION

To elucidate the meaning of the phrase “not feeling like myself” when used by midlife women, we looked at correlations of individual symptoms with NFLM and the associations between NFLM and groups of symptoms from the WLB survey. The individual symptoms most highly correlated with NFLM were the following: fatigue, feeling overwhelmed/less able to cope, low feelings, anxiety/more nervousness, irritability, difficulty concentrating, harder time making decisions, feeling like “I can't calm down on the inside,” being more forgetful, tearfulness/crying, and worrying more. Including symptom scale scores in a two-stage hierarchical model, accounting for education level and overall stress ratings, NFLM was most strongly predicted by the following symptom groups: anxiety/vigilance, fatigue/pain, brain fog, sexual symptoms, and volatile mood symptoms. These reflect changes to emotional response and stress tolerance (anxiety/vigilance and volatile mood), cognitive changes (brain fog), and mind/body changes and responses (fatigue/pain and sexual symptoms). Because these symptom groups have not been typically associated with the MT, they may represent inexplicable and unfamiliar feelings and responses for which women lack an explanatory model and thus use the phrase, “I'm not feeling like myself.”

Anxiety/vigilance symptom group

Although prevalent among women, anxiety during perimenopause has received less attention from researchers than depressed mood symptoms.^10,11 Penn Ovarian Aging Study (POAS) participants reported an overall prevalence of anxiety symptoms of 10%, with 19% reporting severe anxiety during premenopause, 24% in the early MT, and 16% during postmenopause.¹² Measuring anxiety with a psychologic distress scale that included symptoms of being tense or nervous, irritable or grouchy, or heart pounding at baseline, Bromberger and colleagues¹³ found an overall prevalence of 24% among the Study of Women's Health Across the Nation (SWAN) participants. WLB participants' reports of individual symptoms of “feeling overwhelmed/less able to cope,” “new anxiety/nervousness,” “feeling like I can't calm down on the inside,” and “worrying more” were all significantly correlated with NFLM.

Interviews with postmenopausal women about their anxiety experiences indicated that their experience differed from the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) criteria used to diagnose generalized anxiety disorders. None of the participants described their experience as “excessive anxiety and worry occurring more days than not for at least 6 months or as being difficult to control the worry.”¹⁴ Rather than Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) generalized anxiety disorder, Bremer and colleagues ¹⁴ hypothesized that a domino effect of changing reproductive hormones and related effects on the neuroendocrine system were adversely affecting women's response to stress, which study participants described as “insignificant things become major stressors” and “decreased tolerance for stress.” Although it is unclear whether study participants were referring to their experiences during perimenopause or only postmenopause, fluctuating hormone levels during perimenopause¹⁵ may contribute to a similar lowered tolerance for stress.¹⁶

Anxiety-like behaviors have been linked to changes in estrogen levels across the lifespan. ¹⁷ Assays from Seattle Midlife Womens Health Study (SMWHS) participants' overnight urine samples across the MT stages indicated a significant relationship between cortisol levels and estrone and follicle-stimulating hormone, as well as both epinephrine and norepinephrine.¹⁸ The relationship between fluctuating estrogen levels and cortisol and catecholamines during the MT stages may be operative in or relevant to the symptoms Bremer and colleagues describe. The recent work of Gordon et al ¹⁹ suggests that exaggerated perimenopausal estradiol fluctuation may play a role in increased sensitivity to psychosocial stress. Specifically, the urine metabolite estrone-3-glucuronide fluctuation was associated with increased heart rate in stress testing (the Trier Social Stress Test) as well as increased rejection, anger, and sadness. ¹⁹ These examples of estrogen-mediated change in sensitivity to stress are neither familiar to nor expected by women, which could lead to the descriptor, “not feeling like myself.”

Volatile mood symptom group

Volatile mood symptoms (irritability, sudden mood changes or mood swings, and feelings of sudden anger or rage) are also indicators of emotional arousal. ²⁰ Each of these was significantly related to NFLM in the analyses presented here. de Wit et al ²¹ found that, whereas irritability has usually been associated with depression during perimenopause, irritability was linked to different patterns of changes in estrogen levels compared with estrogen levels in depression, and this suggests that irritability may be a standalone symptom for some women in perimenopause. Expression of sudden anger, a part of the volatile symptom mood group, is less socially acceptable for women and, in general, poorly tolerated. ²² In our prior analyses, volatile mood symptoms were significantly related to interference with activities of daily living and relationships and to women's negative ratings of their health.⁴ Taken together, these symptoms may contribute to a woman's feeling of a loss of control over her expression of emotions, interfering in her in everyday life and leaving her feeling “not like herself.”

Brain fog symptom group

Reports of brain fog at midlife were documented by Mitchell and Woods,²³ but relationships to hormonal changes associated with perimenopause have not yet been established.²⁴ In both the POAS cohort²⁵ and the SWAN cohort,²⁶ verbal memory changes were associated with reproductive stage but not linked specifically to hormonal changes.²⁴ The suggested link between changing estrogen levels and cognition is supported by studies in which the ovaries are removed or suppressed.^27-29 In our previous work, forgetfulness was the most frequently reported symptom by those in the LRS, before notable menstrual irregularity, as well as after, during the MT. ⁸ It was also the most bothersome for both the LRS and MT groups.⁸ A visitor to the WLB site made this comment about brain fog: “Brain fog seems to be extreme for me. I normally forget little and stay very organized, but I'm not myself anymore. This is extremely frustrating and very concerning. I'm a professional and feel like I've been compromised.” ³⁰ This quote links cognitive changes to “not feeling like myself.” As with anxiety/vigilance and volatile mood symptoms, brain fog symptoms are frequently not expected and generally not known to be linked to the MT, so when women experience forgetfulness, a harder time concentrating, or more difficulty making decisions, it may feel unfamiliar and unsettling.

Fatigue/pain symptom group

Fatigue is widely reported by midlife women. ^31,32 In our previous work, fatigue was endorsed by 50% of participants in the LRS (−3A STRAW stage) and 55% in the MT.⁸ A study of 308 Turkish women about the effect of menopausal symptoms on daily activities revealed that sleep problems and mental and physical exhaustion were the two most frequently reported symptoms.³³ A recent study of the impact of menopause at work in 407 women found that menopausal symptoms affected employees more than 50% of their work time and the most prevalent symptoms reported were fatigue (54%) and difficulty sleeping (47%).³⁴ Fatigue is not commonly acknowledged as associated with the MT despite its prevalence among midlife women. However, sleep disruption is associated with the MT and clearly contributes to fatigue. ^35,36 Also heavy bleeding, common during perimenopause, can lead to anemia, which causes fatigue.³⁷ Considering the multiple responsibilities of midlife women as parents, partners, and workers, it is not surprising that fatigue is prevalent among this age group of women.³⁸ Nonetheless, when newly diminished levels of energy to complete the many tasks associated with midlife feel unfamiliar, women may report “not feeling like themselves.”

Sexual symptom group

Although none of the individual sexual symptoms was correlated strongly (r > 0.300) with NFLM, the sexual symptoms scale score (which includes pain with vaginal sex, less vaginal lubrication, less interested in sexual activity, more difficult experiencing orgasm, more trouble feeling aroused, vaginal dryness) was significant in the two-stage model indicating that these symptoms contributed to reports of NFLM. Various aspects of sexual changes at midlife have been studied with sometimes conflicting findings. Dennerstein et al³⁹ found a decline in sexual responsivity associated with both the MT and aging. In the POAS, Freeman et al⁴⁰ found that vaginal dryness was not associated with menopause transition stage. Other research from POAS documented an increase in sexual dysfunction during the MT, such as issues with lubrication, orgasm, and pain.⁴¹ The SMWHS documented a decrease in sexual desire during the late MT.⁴² From SWAN, Avis et al⁴³ reported an increase in pain during sexual intercourse and a decrease in sexual desire over the MT, whereas the MT was not associated with reports of sexual arousal. Although it's well documented in the literature that sexual changes begin before menopause, women are not educated to expect these various changes. Like mood changes, which confer a new, unfamiliar emotional reaction and brain fog that makes women feel different in their cognitive responses to situations, changes to sexual response also make women “not feel like themselves.”

Low feelings, experiencing tearfulness/crying spells

Although low feelings and tearfulness/crying spells were strongly correlated with NFLM, they were not a part of a symptom groups identified in our factor analysis. Unlike anxiety, depressive symptoms during the MT are well documented, ^44-47 enough so that, in 2018, Maki et al⁴⁸ published the first guidelines for evaluating and treating perimenopausal depression. Most research has linked depressive symptoms to declining estrogen, but more recently, Joffe et al⁴⁹ documented perimenopausal depression as linked to fluctuation in both estrogen and progesterone during this phase. Sander and Gordon⁵⁰ raised the possibility that the hormonal changes in the MT may exacerbate menstrually related mood disorders. Although better studied than anxiety, depressive mood in perimenopause is not expected. For those who experience low feelings and are more tearful and cry more easily, “not feeling like myself” may become a way to explain these new, unfamiliar emotional responses.

Women are generally ill-equipped for the transition from their reproductive to their nonreproductive years. Anticipatory guidance about puberty⁵¹ and pregnancy⁵² are imbedded in our healthcare and educational systems, but not so for perimenopause. Women know to expect hot flashes and vaginal dryness with menopause, yet expect these to begin around age 50.⁸ When instead experiences related to stress tolerance (anxiety/vigilance), low energy or pain with movement (fatigue/pain), feeling less sharp cognitively (brain fog), changes to sexual interest and response (sexual symptoms), and new sudden anger and irritability (volatile mood symptoms) arise earlier, women lack an explanatory model for how they feel. This can lead to concern about what is happening to them. In the absence of appropriate anticipatory guidance, which women have been requesting⁵³ and previous research has repeatedly recommended,^54-56 these new unexpected and unfamiliar feelings are communicated by the phrase, “I'm not feeling like myself.”

These unfamiliar responses can have variable but significant effects on the multiple roles that midlife women assume. In all roles, increased irritability, feeling less able to cope, and fatigue present challenges. In the caregiving domain, sudden rage is particularly problematic. In the workplace domain, cognitive challenges can lead to a loss of confidence and ability to perform. In addition, in spousal relationships, changes to sexual response, as well as the previously mentioned symptoms, can have a negative impact.

Aside from difficulties associated with roles, these changes may produce a fundamental challenge to one's self-image and clash with behavioral norms. For example, those who identify as independent and brave find new feelings of being less able to cope, being more tearful, and more anxious as particularly difficult. Whereas, for those who prioritize strength and fitness, new fatigue is problematic. For those rely on their intellect, cognitive challenges are most worrisome. In addition, new emotional volatility, not seen culturally appropriate for women, can be most disconcerting.

Establishing certain NLFM symptoms as linked to perimenopause will not eliminate the experience of not feeling like oneself. However, it could go a long way to normalizing NFLM as appropriate and framing it as a temporary aberration during a transitional time.

CONCLUSIONS

“Not feeling like myself,” a phrase used by women in the MT, was most strongly associated with the symptom groups: anxiety/vigilance, fatigue/pain, brain fog, sexual symptoms, and volatile mood symptoms and the individual symptoms of low feelings and tearfulness/crying. These symptoms describe changes in emotional, cognitive, and sexual responses, and changes to energy levels and stress tolerance that feel unfamiliar. Because these symptoms are not expected in perimenopause, women lack an explanatory model for why they are arising. Until new research establishes a fuller picture of the path to menopause, the symptoms associated with NLFM presented here can offer healthcare providers cues to help them respond to expressions of NFLM right now.