I was leading a workplace session on menopause, screens full of faces from the same company. We’d covered the standard symptoms: hot flashes, sleep loss, the cognitive fog that shows up uninvited. Then I said something not on the agenda. I told them the emotional volatility of perimenopause can carry different professional consequences for women of color, because of the layers of bias they already navigate before they walk into any room.

A woman closed her eyes. Then another. Then another, until heads were nodding across the screen, quietly, almost in unison.

That moment crystallized something I’ve known for years in clinical practice but hadn’t found quite the right way to say out loud: we have built an entire public conversation about menopause around the symptoms that are easiest to name, and left out the one doing the most damage.

To be clear, institutional momentum is finally building around menopause, including some of its mood symptoms. In June, Melinda French Gates announced a $215 million commitment to women’s health research and advocacy. That same month, Washington Governor Bob Ferguson signed an executive order directing state agencies to build menopause accommodations into workplace policy, and Illinois lawmakers advanced the bill that would require employers to provide reasonable accommodations for menopause-related conditions. 

But almost none of that momentum has reached the one mood symptom doing the most damage. The word we’ve settled on is irritability. The word my patients use is rage.

Women in my practice describe something sharper than short-temperedness: an emotional intensity disproportionate to the moment. What scares many of them is the loss of predictability, the sense of no longer recognizing their own reactions.

The science on this has existed for decades, but it has seldom entered the clinical conversation in language women can recognize in themselves. Estrogen plays a central role in regulating the neurotransmitter systems that govern mood and stress response, and as it fluctuates during perimenopause, those systems are disrupted, often abruptly.

The Study of Women’s Health Across the Nation (SWAN), the largest and longest-running study of the menopause transition, shows women are significantly more likely to report high depressive symptoms during perimenopause than before it. A separate analysis tracked irritability specifically, as one symptom in a four-part anxiety cluster alongside tension or nervousness, feeling fearful for no reason, and a racing or pounding heart, in nearly 3,000 women over 10 years. Women with no prior history of anxiety were significantly more likely to report high levels of that cluster during perimenopause and beyond, even after adjusting for hot flashes, stress, and overall health.

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.

I think of a white patient who sat across from me several years ago and stared at the floor. For years she’d been one of the most animated people I knew, full of stories about work travel and her family. That day she barely looked up.

“I’m scared to get on a plane,” she told me. “I feel like I’m exploding inside.”

She had stepped back from a leadership role that required frequent travel, not because she couldn’t do the work, but because she no longer trusted what she might feel at 30,000 feet. The rage came without warning and without proportion, and what frightened her most was that she couldn’t see it coming anymore. She hadn’t connected any of it to perimenopause, because no one had ever suggested she should. 

As a clinician, I see this pattern—mood disruption mistaken for personal failure, real professional decisions made in response to something a woman has no name for—all the time. Women rarely raise it unless I ask directly.

But the silence isn’t distributed evenly, and that’s where any policy response built on this moment will either hold up or fall apart.

Another patient, a Black woman in her mid-40s who had built a career on moving through professional spaces with precision, described the same sudden rage, the same anxiety. Then she said something I’ve never forgotten.

“I can’t be perceived as angry,” she said. “Ever.”

Black women are held to a different standard than their white colleagues, even in workplaces where anger and aggravation are otherwise treated as normal parts of the culture. Sociologist Adia Harvey Wingfield spent years documenting racialized feeling rules: the uneven, unspoken boundaries around who is permitted to express emotion and at what professional cost. Wingfield’s research has found that Black women in particular learn to deploy anger selectively and strategically, calculating when it might help them be taken seriously rather than confirm doubts already stacked against them.

Washington’s new directive and the Illinois bill focus primarily on accommodations for the physical symptoms of menopause: temperature control of workplaces, flexible scheduling, occupational health access. These are necessary and overdue. But they are not sufficient if another symptom driving significant professional disruption, one with no clinical guideline at all, stays outside of the frame.

Women are stepping back from leadership roles, withdrawing from opportunities, and quietly losing trust in their own judgment in response to a biological event nobody told them was biological. Research on how rage specifically affects women’s careers is thin, partly because research on women’s occupational health during midlife is thin across the board, and partly because rage so infrequently has been studied on its own. 

Rage deserves to be treated with the same seriousness now finally being extended to other menopause symptoms.