The Menopause Conversation Still Has One Major Blind Spot

So some data exist. What doesn’t exist, with anything close to the same rigor, is a guideline, a diagnostic category, or even a name for perimenopausal rage on its own terms. 

The 2018 Menopause Society consensus guidelines on perimenopausal depression, the most recent dedicated clinical guidance on mood from any major U.S. professional body, direct clinicians to screen for depressive symptoms using validated instruments and treat them with antidepressants or psychotherapy. And in the research that does measure irritability, including the SWAN analysis, it appears as one component inside a composite anxiety measure, studied alongside nervousness, fearfulness, and a racing heart, never examined as its own clinical subject. 

Researchers are now beginning to change that. A federally funded clinical trial currently underway at the University of North Carolina, supported by the National Institute of Mental Health, is specifically investigating the neurophysiology of irritability during perimenopause, because, as its researchers note, most perimenopausal women with affective symptoms report that irritability, not depression, is their primary source of distress. But rage specifically—the symptom my patients actually describe, the one sharp enough to make a woman get off a plane because she worries she’ll have an outburst in an environment she can’t escape, or step back from a promotion she spent years working toward—has no equivalent guideline. It has been studied just enough to confirm it’s real, but not nearly enough to be treated as its own clinical problem.