Is stress making menopause worse? If you have started hormone therapy and still do not feel like yourself, or if your sleep, patience, appetite, and body composition all seem to have changed at once, that question can land hard.
It is not a question meant to blame you. Midlife is already full. Work, caregiving, relationships, grief, a body that will not follow its old rules, and the relentless pressure to handle all of it can make a woman feel as though she has to push harder just to stay even.
In this Menopause Mastery conversation, Dr. Betty Murray makes a bigger point: the body is a system and a symphony. The stress-response system, the hypothalamic-pituitary-adrenal or HPA axis, does not sit in a separate room from your sleep, blood sugar, thyroid, mood, or menopause symptoms. It sits above them. And when it runs high for long enough, it can actively make your perimenopause worse. This is why, as Dr. Murray puts it, stress physiology matters more in perimenopause and menopause than at almost any other time of life.
That does not mean every hot flash is stress or every unfinished response to hormone therapy has one hidden cause. It means we need a better question than “Is this just my hormones?” or “Why can’t I get it together?”
Medical note: This article is for education, not diagnosis or individualized treatment. Do not change hormone therapy, thyroid medication, or supplements based on an article. Persistent or disruptive symptoms deserve an individualized clinical review.
The ovaries cannot be replaced by willpower, wellness, or “adrenal support”
One part of the conversation deserves to be said plainly, and Dr. Murray says it from experience. In her 30s she had, in her words, the audacity to think she would manage her own perimenopause naturally with the right diet and lifestyle. After a PhD spent digging into hormone metabolism, she is now blunt: there is no way to restore hormone function at the level the ovaries performed through adrenal support. Not with a perfect diet, not with a supplement cabinet, not sitting on top of a mountain doing Buddhist meditation. The ovaries produced important hormones in a cyclical pattern at high levels for decades. The adrenals set the pace and offer a little support, but they do not recreate that.
That is why a woman does not have to “earn” menopause treatment by first fixing every habit in her life. Systemic hormone therapy is the most effective treatment for bothersome hot flashes and night sweats for appropriate candidates, and the right choice depends on symptoms, medical history, risks, and preferences.[1]
And here is the boundary Dr. Murray draws hard: “adrenal fatigue” is really HPA axis dysregulation, and it is how your body tries to bring balance back to an out-of-whack system. Your adrenals never get so tired that they stop working. What actually happens is HPA-gonadal dysregulation. Under chronic stress, you develop receptor resistance, just like insulin resistance, and the cortisol levels that used to shut the system off no longer do. The clinically useful term for the cumulative wear and tear is allostatic load, not adrenal fatigue.[3] Fatigue is real, and it has real contributors worth chasing: insomnia, depression, sleep apnea, anemia, medication effects, thyroid problems, or another condition.
When the stress system runs high, menopause gets louder, and here is the mechanism
This is the heart of the episode, and it is a mechanism, not a vague correlation. The HPA axis sits upstream of your thyroid, your blood sugar, and your sex hormones. When stress activation never fully downshifts, the brain does something protective and costly: it suppresses the pulsatility of GnRH, the signal that tells your ovaries what to do. That drops LH and FSH, which lowers ovarian production of estrogen and progesterone. In Dr. Murray’s words, this is literally the mechanism that bridges stress and hormones, and it suppresses ovarian function in a way that makes perimenopause worse.[2]
Progesterone is the most stress-vulnerable hormone in early perimenopause, especially in cycles where you do not ovulate, which become more common under stress. So the woman who has been under sustained stress often has more severe perimenopausal and menopausal symptoms, not because she imagined them and not because she lacked discipline, but because the regulatory machinery behind her hormones is being pushed around.
One myth worth correcting while we are here: this is often called the “pregnenolone steal,” as if stress literally steals the raw material for your sex hormones. Dr. Murray is clear that this is a simplified teaching model. You do not deplete pregnenolone or progesterone like a gas tank. The real mechanism is upstream signaling and receptor regulation by the hypothalamus and pituitary, not substrate depletion. The distinction matters because it points you toward calming the system, not toward megadosing a precursor.
The trap is trying to out-discipline a stressed body
When the body changes in perimenopause, many women respond exactly as they were taught: cut more carbs, skip meals, add more high-intensity classes, demand faster results from the scale. Dr. Murray names this directly. We see the metabolic changes, we panic, we double down, more HIIT, more Orange Theory four times a week, more skipped meals, more rules.
The problem is that this feeds the fire. Chronic cortisol keeps blood sugar elevated and drives compensatory high insulin. Then the blood-sugar swings themselves become stressors that trigger more cortisol. You end up burning 800 calories, eating 1,000, and still not losing weight, and the law of thermodynamics seems broken, because your hormones will down-regulate metabolism when the system believes you are in danger. This is where the bro science falls apart.
So carbohydrates are not illegal. Fruit, beans, whole grains, root vegetables, nuts, seeds, and vegetables all bring carbohydrate to the table, and in a stressed, insulin-resistant body, having some carbohydrate to use is often better than forcing keto. If skipping meals leaves you shaky, ravenous later, or unable to think, a regular, satisfying meal pattern is support, not weakness.
And this is one place Dr. Murray does give a number, because it matters for a stressed body: aim for a protein-forward breakfast of about 40 to 50 grams within the first hour of waking. That breaks the overnight fast, steadies blood sugar, supports muscle protein synthesis, and keeps you off the glucose-cortisol roller coaster. She is a fan of fasting in general, but a chronically stressed perimenopausal woman is not who should be fasting.
Exercise follows the same logic. Strength training and movement are powerful in midlife, but high-intensity cardio, long HIIT, and heavy strength work without recovery all push the HPA axis the wrong way. Her approach: strength train with real recovery between sessions, often using bodybuilding-style splits (legs one day, back one day, chest one day, with active rest) precisely because the value is in the recovery. On off days, do zone 2 cardio, which for most midlife women means keeping your heart rate around 135, since training too high keeps you catabolic and raises cortisol, and too low heart rate does not improve the cardiovascular fitness. If you are overdoing it, retool rather than quit. If you are doing nothing because life is too full, you still need to move, because your body needs a physical outlet for a stress response that has nowhere to go. Exercise snacks count, a few squats between meetings, a short walk in the morning light.
Less is not always more, and more is not always better. The real question is what kind of movement helps you feel stronger and more capable of living your actual life.
You cannot always think your way out of stress, so work bottom-up
This may be the most human part of the episode. Dr. Murray says it plainly: “I tried for so long to like logic my way out of stress, and it just doesn’t do it.” Most of the stress response is not under conscious control, so cognitive tools alone will not reset it. You have to back into it with somatic, bottom-up practices that tell the nervous system to stand down by working on the body first.
The ones she highlights tone the vagus nerve and shift you toward parasympathetic recovery:
- Physiological sighs and extended-exhale breathing. A double inhale and a long exhale, or box breathing with the exhale stretched to six to eight counts, sends a downshift signal up and down the vagal nerve. Your dog does the physiological sigh without thinking about it. In a one-month randomized study, five minutes a day of structured breathing, including cyclic sighing, improved mood and lowered respiratory rate more than mindfulness meditation. It is not a menopause-treatment trial, but it is a real, repeatable downshift.[5]
- Heat and cold exposure. Deliberate temperature change gives the nervous system a hormetic reset. Cold for women does not need to be brutal, closer to the high 50s in water than near-freezing. If you live somewhere you move from one climate-controlled room to another, you give your system less to adapt to.
- Humming, chanting, or yodeling. These stimulate the vagus nerve through the throat and help re-regulate the HPA axis. You can do them anywhere.
- Progressive muscle relaxation or yoga nidra before bed. Even starting with squeezing and releasing your hands and forearms helps down-regulate the nervous system. You do not have to do it perfectly.
The point is not a flawless routine. It is to give your body real signals of safety where you can.
Circadian anchoring: the lever most women skip
Dr. Murray treats morning light and a consistent wake time as foundational, not optional. Getting outside as the sun rises resets the cortisol awakening response and regulates melatonin at night, and almost everything, down to your gut bacteria, runs on that clock. If your sleep is wrecked, that disruption alone will make you feel terrible.
If you are staying up until 4 a.m., you are usually not a true night owl, a real night owl runs only 30 to 40 minutes off. More often you pushed past the sleepy window into a late cortisol-release zone. Her fix is to move the schedule back an hour every few days until you land near a 10 p.m. bedtime, get early light without blue-blockers, and keep your wake time consistent. If your work and daylight don’t line up, even catching the sunrise on your commute or using a daylight-spectrum lamp can help. This same light anchoring also helps stabilize blood sugar.
A 3 a.m. wake-up is a clue worth reading
Waking in the middle of the night on repeat is maddening, and Dr. Murray gives a specific way to read it. If you wake around 3 a.m. and you are hot and sweaty just around your neck, like you put on a scarf, while the rest of your body is not hot, that pattern is often a sign of a blood-sugar and cortisol release, a central-nervous-system response to chronic stress activation, rather than a hot flash from shifting sex hormones. It fits the larger picture, because as cortisol stays dysregulated it disrupts the cortisol-melatonin balance that is supposed to let you stay asleep.
That is a clue, not a self-diagnosis, so bring the whole pattern to a clinician. Night sweats, worry, alcohol, pain, medications, and sleep apnea can all wake you too. Sleep apnea deserves particular attention, because women often do not fit the loud-snoring stereotype and instead report insomnia, fatigue, morning headaches, anxiety, or frequent awakenings, and upper-airway resistance affects women at much lower thresholds than is usually assumed.[6] If you regularly wake unrefreshed or feel sleepy during the day, get that evaluated. For chronic insomnia, cognitive behavioral therapy for insomnia, CBT-I, is a recommended first-line treatment, and if hot flashes are what keep waking you, that is a menopause-care conversation, not a personal failing.[7]
If hormone therapy is helping, but not enough, widen the lens
“I feel better, but not really” is a valid thing to say, and Dr. Murray calls the stress-and-HPA picture one of the primary reasons hormone therapy underdelivers. Addressing it is often the step that lets the hormones finally work. So if you have done the circadian, food, movement, and nervous-system work and you still feel off, the next question is whether the dose and delivery are right for you.
Two women can take the exact same patch or pill and get completely different results because it depends on how your body absorbs and metabolizes it, and whether cream, patch, or pill suits you. This is also why Dr. Murray pushes back on the idea that menopause is the one place we should not test. We test insulin when the pancreas fails, we test the thyroid before prescribing, we test a man before and after starting testosterone. Sex hormones are no different, and a provider working from symptoms alone is partly guessing. Symptoms of perimenopause and menopause are ENOUGH to warrant treatment, blood work identifies if your estradiol and testostereone levels are in researched ranges to provide benefit, and 24-hour urine testing of free hormones and hormone metabolites identify if you have enough free levels and how you biotransform hormones for excretion. This is longevity science in action, this is where inidividualized treatment is done,
That testing includes the thyroid, and here Dr. Murray parts ways with the TSH-only approach. Cortisol suppresses TSH and the peripheral conversion of T4 to the active T3, so a woman can have a normal-looking TSH and T4 and still be functionally low in T3. Elevated reverse T3, which she describes as a skeleton key that fits the lock but will not turn it, can block the T3 you do have, and it rises under chronic stress. This is exactly why she tests free T3 and reverse T3 rather than stopping at TSH, because so many women are functionally hypothyroid with “good labs.” The stress, thyroid, and sex-hormone systems each suppress the others under sustained threat, so looking at only one leaves you treating a fraction of the picture.
A systems approach is not an endless scavenger hunt for obscure labs. It is careful listening and targeted testing that actually changes the plan. But for this cluster of symptoms, the fuller thyroid panel earns its place.
Supplements come last, after the foundation is in
The question everyone eventually asks is “What can I take?” Dr. Murray’s answer is steady: supplements supplement. On their own, short of swallowing an arsenal, they are not strong enough to make up for chronic stress, poor sleep, over-exercising, and a 30-year stress load. Paired with the foundational work, they help.
- Magnesium, almost always. She rarely meets anyone who is not supplementing and has enough, serum testing misses most of it, and magnesium bis-glycinate before bed helps calm the nervous system and support sleep. The honest safety note: too much causes diarrhea, and high doses can be a real problem for anyone with impaired kidney function, so clear your dose with a clinician if that applies to you.
- Phosphatidylserine, which she says does not get enough attention. It can lower cortisol in the brain and help down-regulate the stress response without acting as a direct sedative. She likes PS150 by Designs for Health, though there are many options.
- Adaptogens, the herbs and medicinal mushrooms such as ashwagandha, rhodiola, lion’s mane, and holy basil, which help re-regulate the stress response. They can interact with medications or be unsuitable for some conditions, and they are an add-on, not a replacement for the foundation.[10]
Add these after you have dialed in the circadian, food, movement, and nervous-system work, because that is where the real change happens.
A better place to start this week
You do not need to overhaul your life while exhausted. Pick one or two things that lower the pressure rather than raise it.
Maybe it is getting outside into morning light. Maybe it is a 40-to-50-gram protein breakfast within an hour of waking. Maybe it is trading one punishing workout for zone 2 and real recovery. Maybe it is a few long exhales before bed, or writing down the one symptom you most want help with.
And maybe it is saying this out loud: I do not have to think my stress away before I deserve care.
At Menrva, we believe women deserve more than a narrow answer or a quick dismissal. They deserve care that sees the whole symphony, hormones, thyroid, blood sugar, sleep, stress, and daily life, because the body is a system, not a silo. If this gave language to something you have been carrying, share it with the friend who needs to hear it. Together we rise.
Frequently asked questions about stress and menopause
Does stress cause menopause?
No. Menopause reflects the natural aging of ovarian function. But chronic stress can genuinely worsen the transition by suppressing GnRH pulsatility and lowering ovarian estrogen and progesterone output, which is why a stressed woman often has harder symptoms.[2][4]
Can cortisol cause a 3 a.m. wake-up or a hot flash?
A 3 a.m. waking with sweating just around the neck, while the rest of you stays cool, is often a cortisol and blood-sugar pattern rather than a hot flash, as Dr. Murray describes. It is a clue to bring to a clinician, not a self-diagnosis, and bothersome hot flashes and night sweats have their own hormonal and nonhormonal treatment options.[1][10]
Will reducing stress make hormone therapy work?
Often, yes, more than people expect. Dr. Murray calls unaddressed stress and HPA dysregulation one of the primary reasons hormone therapy underdelivers, so calming that system, alongside checking your dose, delivery, thyroid, and blood sugar, is frequently the step that lets the hormones do their job.