When Your Tried and True Coping Skills Stop Working: Why Perimenopause Anxiety Needs More Than a 50-Minute Hour

Perimenopause Anxiety Support:

Why Standard Therapy Isn't Always Enough

By: Edwige Theokas, LPC, EMDRIA Certified | Planting Seeds Counseling in Bordentown, NJ

*This is Part 2 of a two-part series. Part 1 covers how to tell whether what you're experiencing is anxiety, perimenopause, or both.

So, you've started to piece it together. The anxiety that showed up out of nowhere in your 40s, the coping strategies that suddenly stopped working, the sense that your nervous system is operating by a different set of rules than it used to.

You're starting to understand that what you're navigating isn't just stress, and it isn't just anxiety, it could be both.

Now comes the harder question: “What do I actually do about it?”

I want to share honestly about this, not just about what types of treatment help, but about something that doesn’t often get discussed: the format of support.

When you are in the middle of a significant neurological transition, or just a life transition period, a standard 50-minute therapy session may not be the right container for the work.

When you are learning about how your hormones have shifted, navigating your nervous system, and dealing with unresolved trauma, while you are simultaneously trying to function as a mother, a partner, a professional, and a person, it can be hard to unpack all of that in 50 minutes.

"Just Treat the Hormones" Isn't Always Enough

Hormone therapy (HT) can be a valuable tool for many perimenopausal women.

It has been a great tool in my own toolbox to help balance the upheavals.

I consistently encourage women I work with to evaluate it with a menopause-informed physician or OB-GYN.

For some women, stabilizing hormones meaningfully reduces anxiety, especially if the hormonal volatility was the primary driver of the anxiety.

But for many women, particularly those with any history of anxiety, trauma, or chronic stress, hormone therapy helps but doesn't fully resolve the psychological symptoms.

Here's why: When the nervous system has been in a state of chronic vigilance for years, that state becomes the nervous system's default setting.

Think of it like a car alarm that has been going off for so long that the system is simply always in alarm mode, even when there's no trigger.

Hormones can quiet some of the triggers. But they don't necessarily recalibrate the alarm system itself.

That recalibration is where therapy does the work that hormones cannot.

But not all therapy, and not in any format, gets there.

What Getting Support Actually Looks Like

The most effective approach for women in perimenopause dealing with anxiety addresses both the biological and the neurological dimensions.

Here is what I've found helps:

1. A Hormonal Evaluation (With the Right Provider).

If you haven't yet, seek out a physician who is genuinely informed about perimenopause, not just menopause.

Many women are told their hormone levels are "normal" based on tests that don't capture the volatility of perimenopause, or are not offered HT because they "don't have enough symptoms yet."

And in many cases, reluctance to prescribe hormone therapy is based on outdated studies from over 20 years ago.

Advocate for yourself. Seek a second opinion if needed.

The Menopause Society maintains a directory of certified menopause practitioners if you need help finding someone who actually speaks this language.

2. Nervous System Regulation - As a Foundation

Specific nervous system regulation practices like extended exhale breathing, orienting, grounding, somatic tracking, etc., help manage acute anxiety and build capacity for deeper work.

I want to be clear that these are not the same as generic "relaxation tips."

They are targeted tools for the nervous system, partnered with an understanding that your body needs to reset from a system that has learned to default to high alert.

The tools help you function and become a part of your lifestyle.

They don't address what's driving the alarm.

3. Trauma-Informed Therapy - To Address What's Underneath

When anxiety has roots in past experiences, accumulated stress, or a nervous system shaped by difficult history, the work that produces lasting change happens at the nervous system level, not just the cognitive one.

Whether through EMDR or other trauma-informed modalities, this work helps the brain complete the processing of experiences that got stuck.

And when that happens, the alarm system recalibrates in a way that no amount of breathing exercises alone can produce.

*A Word on Medication: SSRIs and SNRIs are legitimate, evidence-based treatments, and there are perimenopausal women for whom medication is an important part of the picture.

I am not anti-medication.

I am pro-comprehensive care.

What I want to gently push back against is the immediate and automatic prescribing of antidepressants to women in perimenopause without a full evaluation of the hormonal picture, and without a comprehensive look at the potential side effects.

Unfortunately, this happens frequently, and it means many women spend years on medication that's managing a symptom whose underlying cause was never addressed.

Don’t get me wrong, when you are in the midst of a breakdown, and you do not think that there is any other way out, you will take whatever it takes to ease the symptoms and feel better.

I understand this and have been there.

If you are on medication that's helping: good.

But if you are being offered medication without any discussion of perimenopause, at some point when you’re stabilized, it is worth asking if this could be hormonal?

Why the Format of Support Matters. What Extended Sessions Make Possible

Here is the part of this conversation I want to focus on a bit, because it's the thing I wish someone had told me. Getting a new diagnosis, or a new framework for understanding symptoms you've been living with for months or years, can be disorienting.

Your life may have been upended by these symptoms (some theorize that the rise in divorces later in life may be loosely correlated to perimenopause).

There is a lot to absorb if life changes are all coming together at the same time.

There are questions you don't even know to ask yet.

There is grief mixed in with the relief of finally having a name for what's been happening.

There is the work of figuring out what this means for how you're going to take care of yourself going forward.

That process does not fit inside 50 minutes.

It has been my experience that a typical therapy session is designed for maintenance work, processing what happens in the week, for developing skills, and for gradual and incremental movement in making change.

It is not designed for the kind of deep, concentrated work that a significant transition requires.

When you are in the middle of an upheaval, when your life and your nervous system is genuinely different from what it was a year ago, what you often need is more time, more continuity, more space to actually go somewhere and stay there long enough for something to shift.

This is where extended sessions and intensives come in, and this is why they have become one of the cornerstones of the work I do with women in midlife.

What Extended Sessions and Intensives Actually Look Like

An extended session is longer than a standard appointment.

They are typically between 90 minutes and two hours.

Instead of spending the first 10 minutes re-establishing context and the last 5 wrapping up, you have time to actually go somewhere.

You have the space and time to follow a thought and an insight all the way through.

For women in middle age, navigating perimenopause, this can look like:

• Taking the time to actually map out what's happening in your life, along with the accompanying parts. We get to not just be curious about experiences, but possibly label it, and understand it well enough to work with it.

• Processing the grief that often lives underneath the anxiety and possible trauma. Acknowledging loss, and the grief of a body that feels unfamiliar, exploring coping strategies that no longer work, and grieving a version of yourself that feels inaccessible.

• Begin to address the deeper patterns (the early experiences, the maladaptive coping skills, the adaptations that perimenopause is unmasking and pulling to the surface.

An Intensive is a more concentrated version of this.

A half-day or full-day format (sometimes spread across two days) that allows for the kind of deep, uninterrupted processing that weekly sessions may take months to reach.

Intensives are not crisis intervention.

They are for women who want to do the work, who have a limited window of capacity in a demanding life, and who want to make meaningful progress without the work stretching across an entire year.

For women in perimenopause specifically, intensives offer something that is hard to get in any other format: the experience of actually unpacking something and healing parts of it before going back into the real world.

Why Extended Sessions During Perimenopause Can Make A Real Difference.

Your hormones are fluctuating, sometimes day to day, sometimes week to week.

Your nervous system has good weeks and harder weeks.

Your bandwidth and your capacity are not predictable or fixed.

What this means practically is that the slow, incremental model of therapy (a little bit of work every week, for a long time) often gets derailed by the very instability that makes the work necessary.

You make progress in one session, and then you have a difficult hormonal stretch, and much of what you gained feels inaccessible.

You start to wonder if it's working.

You lose momentum.

The work stalls.

A concentrated intensive creates a better opportunity for processing difficult things in one sitting.

Based on what I was seeing with my trauma therapy clients, I saw how much improvement occurred from week to week when we incorporated extended sessions.

And when I started offering the extended session to non-trauma clients, I saw the same kinds of improvements.

It has been my experience that many clients have benefitted from beginning with weekly extended sessions for a period of 3-6 months and then reducing to monthly extended sessions or bi-weekly 50-minute sessions until termination

 If you're in New Jersey and you're ready to explore what that kind of support looks like, whether that's extended individual sessions, an intensive, or a combination, I'd love to talk.

Learn more about extended sessions and intensives

Daily Practices That Actually Help (Beyond the Therapy Room)

Good support doesn't only happen in sessions.

Here are some lifestyle practices I recommend, (both personally and in my work with clients) that help regulate the nervous system during this transition.

None of these are revolutionary. But done consistently, they make a real difference.

1. Protect your sleep like it's a second job. 

I know this feels impossible when perimenopause is ruining your sleep, and you’re waking up at 3 AM every night.

But the practices around sleep matter even when sleep itself is disrupted.

Consistent wake time (yes, even on weekends).

No screens for 30–60 minutes before bed.

Cool room. Blackout curtains if you can.

2. Magnesium supplement before bed.

This has been one of the most consistent recommendations I've seen across menopause researchers, functional medicine practitioners, and women in the trenches (including myself).

Magnesium glycinate (not oxide - the glycinate form absorbs better and is gentler on digestion) supports sleep, reduces muscle tension, and helps calm the nervous system.

Many women are deficient without knowing it, and the deficiency worsens in perimenopause.

Personally, I use Magnesium Breakthrough, and I like it.

Always check with your doctor if you're on other medications. 

3. Limit alcohol.

I know! This is a big one for many, but alcohol genuinely worsens perimenopause sleep and increases night sweats.

I mention this not to be a Debby Downer, but many women don't realize just how significant the connection is.

Sleep deprivation amplifies every anxiety symptom.

Protecting your sleep is nervous system care. 

4. Get outside, even briefly, every day. 

Natural light in the morning helps regulate cortisol rhythms, which are already disrupted in perimenopause.

Time in nature, even a 10-minute walk around the block, has documented effects on the nervous system that indoor movement doesn't replicate.

This helps indicate to your nervous system that you are safe.

This is not about getting your steps in. It's about giving your nervous system the input it evolved to receive.

Make it a requirement, not a bonus, or a “if I have time”.

5. Reduce your load before you improve your coping.

This is the one nobody says out loud.

We spend so much energy trying to cope better so that we can continue on the hamster wheel of an overloaded life.

But if your nervous system is already at capacity because of the hormonal transition, adding more coping strategies on top of a full schedule isn't the answer.

What can you put down?

What are you doing out of obligation or habit that you no longer have the bandwidth for?

This is not a productivity question. It is a nervous system health question.

One thing off the list is worth more than three new coping tools. 

6. The extended exhale 

When the wave of panic or dread hits, your breath is the quickest lever you have.

Inhale for 4 counts, exhale slowly for 7 or 8. Focus on making sure that your belly expands and contracts. If you’re breathing through your chest, you are not getting the full benefit

Do this for 5 cycles.

The extended exhale directly activates the parasympathetic nervous system - the part of your body that tells your alarm system that you are safe.

Practice this before you need it so it's available when you do.

7. Find your information sources carefully.

There is a lot of perimenopause content right now - which is wonderful, because awareness around this issue is finally growing.

But not all of it is accurate, and some of it is genuinely scary in ways that aren't helpful.

Because I am new to this whole world, I am lucky not to be consumed by competing and controversial content.

I am also lucky to have actual people in my life who I trust to guide me through the process.

I like: Dr. Mary Claire Haver's work, Dr. Lisa Mosconi, Dr. Kelly Casperson's podcast (*You Are Not Broken), and Dr. Jen Gunter's books.

These are evidence-based, woman-centered voices. Add them to your rotation.

Knowledge is genuinely regulating.

Understanding what's happening in your body reduces the sense of chaos and helps you make informed decisions.

8. Find predictable sources of enjoyment 

In a phase of uncertainty, having something to look forward to every day can help.

Whether it be a daily dose of cat videos, or baking once a week, maybe even folding laundry, train your body to look for things that signal safety.

For me, it the daily 5:30PM Bluey episode while scouring my sink.

Everyone can watch it.

It makes me laugh, nothing bad happens, and it acts as a transition from the day to the evening.

Find yours and stick it into your day.

9. Let yourself be a work in progress.

You're not supposed to have this figured out yet.

Perimenopause is new information for most of us because it's been under-researched, under-discussed, and wildly underestimated in its impact.

Give yourself the opportunity to learn as you go.

The fact that you're reading this, paying attention, trying to understand what your body is doing, that is half the battle.

Be patient with yourself the way you would be with someone you love who's navigating something hard for the first time.

Extended sessions may be what you need

Frequently Asked Questions About Extended Sessions

1. What is an extended therapy session, and how is it different from a regular session?

An extended session is typically 90 minutes to two hours, compared to the standard 50-minute hour.

The additional time changes what's possible: instead of touching something and running out of time, you can follow a thread all the way through.

For women navigating perimenopause, who often come in carrying months or years of confusion, and accumulated nervous system load, this makes a significant practical difference.

2. What is an EMDR Intensive, and is it right for me?

An intensive is a concentrated format - a half-day (3-4 hours) or full-day (4-8 hours) session, sometimes across two days.

This allows for deep, uninterrupted processing work.

It's not a crisis intervention; it's for women who are ready to do meaningful work and want to make significant progress in a concentrated period rather than gradually across many months of weekly appointments.

For women in perimenopause whose capacity is variable and whose lives are full, it can be a particularly efficient and powerful option.

3. I'm not sure I have enough "trauma" for intensive work. Is this still relevant to me?

Yes. You don't need to have experienced a dramatic traumatic event for intensive work to be valuable.

Many of the women who benefit most from this format are navigating the cumulative weight of being a high-functioning woman for decades (i.e. chronic stress, a nervous system shaped by early childhood experiences, grief that never got processed, anxiety that was always managed and masked rather than addressed).

4. I already have a therapist. Do I have to stop seeing my regular therapist?

No! In fact, I love it when a client who is interested in intensives is already working with a current therapist.

You may have already established a relationship with a therapist, but they are not trained in EMDR or trauma therapy.

A one-time intensive can be a great supplement to help you address deeper issues and then bring those insights into therapy with your weekly therapist.

5.     Can I do extended sessions alongside hormone therapy?

Absolutely. Extended sessions and intensives work well alongside hormonal treatment.

For many women the two approaches are most effective in combination.

Stabilizing hormones can make the nervous system more accessible for therapeutic work; intensive processing can address the dimensions of anxiety that hormones alone don't reach.

6. What if I'm in the middle of a difficult perimenopause stretch? Is this a good time to do intensive work? 

It depends on where you are.

Some instability is normal and doesn't preclude intensive work.

In fact, the intensive format can be particularly supportive during a difficult period because it provides a structured, held space for the overwhelm rather than leaving you to manage it alone.

If you're in acute crisis or in a particular phase of your menstrual cycle, we'd talk through timing.

But for most women, "the middle of a difficult stretch" is exactly when more support, not less, is what's needed.

How do I know if I need weekly sessions, extended sessions, or an intensive?

The best way to figure that out is through a consultation.

We'd talk about what you're navigating, what your schedule and capacity look like, and what kind of support would actually be useful for where you are right now.

There's no one-size-fits-all answer, but the question worth starting with is: Is the current way of doing things working for you?

Edwige Theokas, LPC, is an EMDRIA Certified therapist and the founder of Planting Seeds Counseling in Bordentown, NJ. She specializes in EMDR and EMDR Intensives for women in midlife and perimenopause. She is currently pursuing Certified Menopause Practitioner training. Learn more at https://www.plantingseedscounselingnj.com.