For many high-functioning women in their 40s, perimenopause does not simply affect periods. It can affect sleep, mood, focus, appetite, confidence, and the body’s stress response and anxiety can become the loudest symptom. Many women seek perimenopause anxiety therapy in London when symptoms begin to affect confidence, sleep, and performance at work.
This can be particularly unsettling if you have always been the “capable” one. The person who can present, lead, travel, problem-solve, and stay calm under pressure. When panic-like symptoms arrive out of the blue, heart racing, dizziness, breathlessness, a sudden urge to escape — it can feel like you have lost your edge, or worse, lost yourself.
As a Senior Psychotherapist who has previously led teams at South London and Maudsley NHS Foundation Trust, I have worked with many women who appear fearless from the outside but privately feel frightened by what is happening in their body. Therapy can help you make sense of the symptoms, reduce panic and claustrophobia, and rebuild confidence at work and in daily life.
Why can perimenopause trigger palpitations and panic symptoms?
Perimenopause involves hormonal fluctuation (often unpredictable), and this can change how the nervous system responds to stress. Many women experience symptoms that are very real and very physical — and unfortunately, they can overlap with the sensations of anxiety.
Common perimenopause-related drivers include:
- Palpitations and adrenaline surges: sudden pounding heart, fluttering, or racing sensations that can feel alarming
- Hot flushes and temperature shifts: sensations that can trigger “I need to get out” feelings
- Sleep disruption: waking at 2–4am with a racing mind and an activated body
- Increased sensitivity to stimulation: caffeine, alcohol, sugar dips, intense workouts, and screens can have more impact than before
- Brain fog and concentration changes: which can undermine confidence at work
- Changes in body composition/weight gain: often accompanied by self-criticism and a sense of losing control
- High responsibility loads: senior roles, leadership visibility, parenting, and caring responsibilities
A key part of therapy is helping you separate symptoms from meaning. Symptoms are not proof that you are unsafe or incapable. They are signals from a system under strain. This is often the point at which women begin looking for therapy for perimenopause anxiety to better understand what is happening in their body.
Meet Rachel (name changed) – previously fearless, now avoiding lifts, meetings, and being “seen”
Rachel came to therapy in her mid-40s. She was a high achiever in a senior role, known for being calm, direct, and unshakeable. She had always been someone who could walk into a room, lead a meeting, and handle pressure. People often described her as fearless.
Privately, Rachel had started to feel something change. It began with sleep. She would fall asleep exhausted, then wake in the early hours with her heart thudding. Some nights she would lie there bargaining with her body: “Please just settle.” Other nights she would get up, check emails, scroll, or plan the next day, as if productivity could outrun panic.
Then the palpitations started happening during the day. Not only when she was stressed — sometimes in the supermarket, sometimes on a train, sometimes sitting at her desk. The unpredictability was part of what made it frightening. She began to scan her body, checking whether her heart felt “normal,” and she became more cautious about coffee, meetings, travel, and anything that might tip her over.
The claustrophobia crept in quietly. Rachel began to dread situations where she felt “trapped”: packed meeting rooms, long presentations where she couldn’t step out easily, lifts, crowded trains, busy theatres. What she feared was not the place itself, but the possibility of having symptoms in front of other people — and being seen as not coping.
This hit at the core of her identity. Rachel did not only fear panic; she feared the humiliation of not being the person everyone relied on. She worried: “If I panic in a meeting, my confidence will be gone. People will see it. I’ll never get it back.”
In response, Rachel did what many high-functioning women do: she managed, masked, and controlled. She started arriving early so she could choose a seat near the door. She avoided lifts. She rehearsed more. She spoke less spontaneously. She kept water, mints, and “just in case” items close by. These behaviours helped in the short term, but gradually her world began to shrink — and her confidence went with it.
Assessment and formulation
In our early sessions, we focused on mapping the cycle clearly and compassionately.
For Rachel, the cycle looked like this:
- Baseline vulnerability: perimenopause symptoms + broken sleep + high workload
- Body sensations: palpitations, heat, breathlessness, dizziness, tension
- Meaning-making (the scary part): “Something is wrong,” “I’ll lose control,” “I’ll be trapped,” “People will see”
- Protective behaviours: monitoring, over-preparing, choosing exits, avoiding certain environments, suppressing emotions, pushing through
- Short-term effect: a temporary sense of safety/control
- Long-term effect: increased fear of sensations, increased claustrophobia, reduced confidence, greater performance anxiety
In perimenopause anxiety, this cycle can become particularly intense because hormonal shifts amplify the body’s stress response.
The key point with Rachel was that she wasn’t “becoming weak.” Her nervous system was increasingly sensitised, and her coping strategies — although understandable — were accidentally reinforcing the threat response.
Therapy focus – safety in the body, confidence at work, and reducing the fear of being seen
Therapy aimed to help Rachel feel steadier physiologically and psychologically, and to rebuild the sense of “I can handle this” without requiring her to be perfectly calm.
Perimenopause-specific psychoeducation: palpitations and the threat response
We spent time understanding what palpitations can be in perimenopause: a symptom that can feel dramatic and frightening, especially when sleep-deprived or under pressure.
In therapy, we focused on two parallel aims:
- reducing alarm (so the body is less likely to escalate into panic)
- reducing catastrophic meaning (“this means I’m not safe” / “this means I’m losing it”)
This shift alone often reduces symptom intensity, because the nervous system stops treating sensations as emergencies.
Claustrophobia: fear of being trapped, and fear of losing control in public
Rachel’s claustrophobia was less about enclosed spaces and more about not having an escape and being witnessed. We explored what it meant, emotionally, to go from “fearless” to feeling vulnerable.
We worked on:
- recognising the moment the “escape urge” appears
- grounding in the present rather than racing ahead to humiliation
- building tolerance for the sensation of “I want to leave” without automatically obeying it
- developing a calm, internal script that was firm and kind (not a pep talk, but reality-based)
Workplace and performance: identity, visibility, and the pressure to be composed
For Rachel, work was not just work. It was an identity. She prided herself on composure. Perimenopause symptoms threatened that, so she tried to control everything more tightly — which increased the sense of pressure and reduced spontaneity.
Therapy focused on:
- reducing perfectionistic over-preparation
- shifting from “I must not show this” to “I can still lead while anxious”
- strengthening her ability to stay present when adrenaline rises
- practicing communication that was confident and boundaried, rather than over-explained
We also explored something many high achievers carry quietly: the belief that being respected means being unflappable. Rachel learned that steadiness is not the absence of symptoms; it is the ability to remain anchored whilst symptoms pass.
Sleep and nervous system stabilisation
Because sleep disruption was amplifying everything, we worked on realistic changes that supported regulation:
- reducing late-night scrolling and “work thinking”
- creating a wind-down routine that signalled safety (not productivity)
- building a plan for waking in the night that did not involve spiralling or self-monitoring
- adjusting stimulation (caffeine, alcohol, intense evening exercise) that was increasing palpitations
This was not about becoming perfect. It was about creating enough stability that her nervous system could settle.
Rebuilding confidence through consistent behavioural shifts (not “experiments”)
Rather than framing therapy as “tests,” we focused on the behaviours Rachel wanted to shift:
- not always sitting by the door
- taking the lift when she could, without forcing or fighting herself
- staying in meetings even when sensations rose (and noticing they fell again)
- speaking up again rather than shrinking to avoid scrutiny
- reducing body-checking and reassurance seeking
Over time, the message her brain absorbed was: “I can feel this and still function. I am not in danger. I am not failing.”
Outcomes – palpitations less frightening, claustrophobia reduced, confidence returning
As therapy progressed, Rachel became more able to:
- respond to palpitations with less fear and less monitoring
- reduce claustrophobic avoidance and regain freedom in daily life
- sleep more consistently and stop “working” through the night
- feel steadier in meetings and presentations
- tolerate being seen and stay connected to her authority
- treat herself with more respect during a major life transition
Rachel’s work highlights something important: perimenopause can be destabilising, especially for women who are used to being strong and composed. But with the right support, it is possible to reduce panic and claustrophobia, rebuild confidence, and feel like yourself again — not by forcing calm, but by creating safety and self-trust.
If you recognise yourself in Rachel’s story — palpitations, sleep disruption, anxiety, claustrophobia, and the fear of not being “the fearless one” — therapy can help.
Contact
You can connect with Tara O’Donoghue, a therapist in London, Marylebone, 10 minute walk from Bakerloo station, by clicking here. Home-based sessions are also available.
To discuss therapy options, book a Zoom session or in-person home visit by clicking here or emailing: info@homebasedtalkingtherapy.com.