The Emotional Storm Nobody Warned You About: A Conversation with Dr. Deborah Wagner

What inspired you to write The Fifth Decade: Is It Just My Life or Is It Perimenopause?

I became inspired to write The Fifth Decade when I saw women struggling with the perimenopausal transition without the benefit of understanding what was happening to them. There was some information available on the physiological changes women experience, but too many people thought of menopause as something that happens to older women and is primarily about hot flashes.

Women, and their families, need to know that this transition can start as early as the late thirties, can take ten or more years to complete, and has an enormous psychological impact. It can disrupt sleep, cause anxiety and depression, and can significantly reduce overall quality of life. That combination — the suffering without context — is what compelled me to write this book.

Why are depression and anxiety so closely associated with perimenopause?

Depression and anxiety have always been associated with times of significant hormonal change in women: puberty, pregnancy, and the premenstrual period. We are now beginning to realize that the perimenopausal transition is no different.

During perimenopause, estrogen levels are vacillating wildly — sometimes very high, other times very low, often swinging from one extreme to the other within hours. In the meantime, progesterone, the hormone that tends to balance the effects of estrogen, is steadily declining throughout perimenopause.

The erratic hormones alone create risk for anxiety and depression, but that risk increases substantially when women are not aware of what is happening physiologically and why they feel so out of sorts emotionally. They are suffering without a framework. In addition, perimenopause brings significant sleep disruption. When women are exhausted and sleep-deprived, they are far more vulnerable to anxiety and depression — and a painful spiral can take hold.

Do you think most women are aware of their options for managing well-being during this time, or do many suffer in silence, thinking they just have to "deal with it"?

Far too many women suffer in silence — and I have witnessed this firsthand throughout my clinical career. One of the most striking moments I can recall was with a patient we’ll call Lori, who came to me at forty-five.  She was severely depressed, highly anxious, unable to sleep, and convinced she was simply falling apart. She had taken sick leave from work. When I began to explain perimenopause to her — the mood swings, the insomnia, the relationship shifts, the identity struggles — I watched the shock and simultaneous relief move across her face. She recognized herself in every word.

At the end of that first session, Lori looked at me and asked: "Why doesn't everyone know about all of this?"

That question has stayed with me…because she was right. Most women don't know. They attribute what is happening to stress, to aging, to their marriages, to their children — to anything except the profound hormonal transition unfolding in their bodies. The women who suffer most are often those who are completely unaware that what they are experiencing is normal, that it has a name, and that it does not have to be endured alone. Knowledge, it turns out, is one of the most powerful treatments we have.

What do you suggest women do to explain their symptoms to doctors and loved ones to ensure they receive the care and support they need?

This is critically important, and it begins with the recognition that navigating perimenopause often requires a team approach. No single practitioner has all the answers. A psychiatrist can address medication for depression and anxiety but may not be equipped to evaluate hormonal or thyroid-related mood issues, that often present during perimenopause.  An endocrinologist can treat thyroid dysfunction but little else. A gynecologist may not fully understand the psychological complexity. And while psychologists are trained to help women cope with anxiety, depression, and major life transitions, many are not well versed in the physiological underpinnings of the perimenopausal transition.

Women need to feel empowered to seek care from multiple providers — and to advocate for themselves in doing so. Research has shown that male physicians are significantly less likely to identify depression in female patients than are female physicians, which means some women's symptoms are being missed entirely. That is a sobering reality that reinforces the importance of speaking up clearly and persistently.

When talking with loved ones, I encourage women to share information rather than simply share feelings. Giving a partner or family member language and context — explaining the hormonal shifts, the disrupted sleep, the emotional volatility — can transform misunderstanding and frustration into genuine support. Part IV of my book is dedicated entirely to helping the men in women's lives understand what is happening and what they can concretely do to help. Informed support from those closest to a woman is, in my experience, of immeasurable value.

What ideas, advice, and stories will women find in your book to help them?

The Fifth Decade offers women something I believe they are desperately hungry for: a map.

Through real clinical stories, readers will meet women like Sari, who woke each morning fighting tears with no explanation for her misery; Christine, who was blindsided by severe panic attacks on a tropical vacation despite being an avid, experienced traveler; Tara, a medical professional who had been in denial about her own changing cycles until an unmistakable moment with a patient forced her to reckon with the truth; and Catherine, who found that once she had a framework for understanding her experience, the chaos began to lift.

The book explores the four psychological stages of perimenopause I have identified through my clinical work: Perimenopausal Initiation, Emotional Disruption, Turbulence, and finally, Quietude — the calm, clear, often surprisingly liberating chapter that waits on the other side of the storm.

It reviews a full range of treatment options — from bioidentical hormone therapy to psychotropic medications, from supplements and acupuncture to yoga, meditation, and psychotherapy — so that you and your healthcare team can make informed decisions together.

And it ends, as I believe every book about this transition should, with hope. Because there is real, evidence-based reason for hope. The instability of perimenopause is not permanent. The women who fare best are those who face it with understanding, support, and the right tools — and that is exactly what this book aims to provide.

Deborah R. Wagner, Ph.D. is a licensed psychologist in private practice in Ridgewood, New Jersey, with more than thirty years of clinical experience working with women, couples, and families. She is the author of The Fifth Decade: Is It Just My Life or Is It Perimenopause?

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