Stories of menopause: ACT in action

Menopause is not simply a collection of symptoms. It is a biopsychosocial transition involving fluctuating hormones, disrupted sleep, shifts in cognition, changing identity, and powerful cultural narratives about ageing and worth. For many, this period interacts with longstanding patterns of self-criticism, anxiety, or striving.

Acceptance and commitment therapy (ACT) does not aim to eliminate menopausal symptoms. Instead, it offers a framework for responding flexibly to the physical and emotional changes of this life stage; making room for discomfort, loosening rigid identity stories, and reconnecting with what matters.

The following mini case examples illustrate how ACT principles can be applied in menopause-informed practice.

Client 1: Linda – struggling with identity and self-worth

Background

Linda is 50 and has recently started experiencing hot flushes, disrupted sleep, fatigue, and strong emotional swings linked to menopause. Even before this transition, Linda tended to measure her worth through performance and productivity. Being capable, reliable, and “on top of things” had always been central to how she saw herself. As menopausal symptoms began affecting her energy and concentration, her mind quickly interpreted these changes as signs of personal failure and decline. She says she feels like she’s “losing herself” and worries she’s no longer the person she used to be.

Formulation

Linda is particularly hooked by self-evaluative stories about competence and worth. Thoughts such as “I’m past my prime” and “I’m not good enough anymore” show up automatically and feel deeply convincing because they fit long-standing beliefs about needing to perform well to have value. When fused with these thoughts, Linda either overworks to prove herself or withdraws when she feels she has fallen short. Both patterns increase exhaustion and strengthen the narrative that something is wrong with her.

Conceptualisation

Menopause has introduced genuine physiological shifts, including disrupted sleep, fluctuating oestrogen affecting mood and concentration, unpredictable waves of heat and fatigue. Yet Linda’s mind interprets these changes not as biological transition, but as evidence of personal decline. The body’s variability collides with a long-held identity organised around competence and control. Normal bodily changes have become evidence in her mind’s court case for decline. Her struggle is less about symptoms themselves and more about what they seem to mean about her as a person. Alongside this frustration, there is a quieter grief, for the predictability of her younger body, for the ease of mental clarity she once relied upon. This grief has little space to be acknowledged, as her mind pushes her to “keep performing” instead. The ongoing fight to maintain her old standards has narrowed her life and increased emotional distress.

ACT recommendations

• Working with self-judging narratives: Linda learns to notice when “the not who I was story” shows up, for example when she feels tired in class or makes a small mistake. Instead of arguing with the thought, she practises acknowledging it (“There’s my mind telling the not who I was story again”) and gently returning her attention to what she’s doing.
• Reconnecting with a broader sense of self: Through perspective-taking exercises, Linda explores the part of her that has been present across different life stages, helping her experience herself as more than her current symptoms or performance.
• Making space for bodily discomfort: Rather than overriding fatigue or battling hot flushes, Linda practises responding with attuned flexibility; sometimes slowing down, sometimes adjusting expectations, sometimes continuing gently. Acceptance here is not endurance, but wise responsiveness to a changing body.
• Values-led activity planning: Together they identify what brings Linda a sense of purpose, such as connecting warmly with students, mentoring colleagues, or enjoying creative hobbies. She begins scheduling these intentionally, even on lower-energy days.
• Sustainable self-care and movement: Linda experiments with gentle exercise like walking, yoga, or stretching to support energy levels and wellbeing, focusing on caring for her body rather than pushing it to perform.

 

Client 2: Amara – managing anxiety about the future

Background

Amara is 47 and has always described herself as a “worrier.” Even before perimenopause, she tended to anticipate problems and seek reassurance when uncertain. The onset of irregular cycles, mood swings, and brain fog has intensified this pattern. Physical changes have made her more aware of ageing and vulnerability, triggering familiar anxiety about what might go wrong in the future. She now spends large amounts of time researching menopause and health concerns online, hoping to feel more in control.

Formulation

Amara becomes easily fused with future-oriented worry thoughts that predict negative outcomes. These thoughts trigger anxiety, which she tries to manage by seeking certainty through information and reassurance. While this brings short-term relief, it teaches her brain that anxiety must be eliminated before life can feel safe, strengthening the worry cycle.

Conceptualisation

Perimenopause has increased bodily unpredictability, including irregular cycles, sudden mood shifts, cognitive fog — creating fertile ground for Amara’s pre-existing sensitivity to uncertainty. In a cultural landscape saturated with alarming health narratives, her nervous system is repeatedly cued toward threat. Researching menopause briefly reduces anxiety, but it also teaches Amara’s brain that uncertainty is intolerable. The more she searches for guarantees, the less capable she feels of living alongside ambiguity; a particularly challenging task in a life stage defined by hormonal fluctuation. Her attempts to control fear through thinking and researching keep her stuck in a loop of worry, pulling her away from present-moment living and valued activities.

ACT recommendations:

• Learning to stay with anxiety sensations: Amara practises noticing tightness in her chest, racing thoughts, and urges to research, allowing these sensations to be present while breathing slowly and grounding herself in the room.
• Reducing reassurance behaviours: Together they set gentle limits on research time, such as checking reliable sources once a day rather than constantly and noticing how anxiety rises and falls without acting on it.
• Defusing from worry stories: Amara learns to label thoughts as “worrying about the future” and bring attention back to what she can see, hear, and touch in the present moment.
• Rebuilding meaningful routines: She identifies valued activities that anxiety has crowded out, such as exercise, social time, and creative hobbies, and intentionally schedules them into her week.
• Movement for wellbeing: Amara begins incorporating regular physical activity she enjoys, like swimming, walking, or fitness classes, using exercise as a way to support mood and presence rather than to manage anxiety away.

 

Client 3: Sarah – coping with social withdrawal and isolation

Background

Sarah is 53 and recently retired after many years working in a helping profession. Earlier in life, she had experienced periods of health anxiety following physical illness, which made her particularly sensitive to bodily changes and vulnerability. As menopause brought joint pain, fatigue, and mood shifts, these sensations were quickly interpreted as signs that her health was deteriorating. At the same time, she began feeling more self-conscious about ageing and believed she needed to look and feel well in order to socialise comfortably.

Formulation

Sarah becomes hooked by thoughts about being unwell, ageing poorly, or being judged by others. These thoughts trigger fear, shame, and physical discomfort, which she attempts to avoid by withdrawing from social situations. Avoidance provides short-term relief but leads to isolation and low mood, reinforcing the belief that she cannot cope with social engagement while feeling this way.

Conceptualisation

Menopause has reactivated earlier fears about health and vulnerability, while also challenging Sarah’s self-image. Physical sensations are interpreted as signs of irreversible decline rather than fluctuating physiological changes that can be understood, monitored, and supported. This catastrophic framing intensifies fear and narrows her life. Her life has gradually become organised around staying safe and avoiding discomfort, which has reduced connection and joy. Sarah has also absorbed subtle cultural messages that ageing women should remain energetic, slim, and composed. When her body feels different, shame arises – not just fear of illness, but fear of being seen as diminished.

ACT recommendations

• Practising openness to physical sensations: Sarah learns to gently notice joint pain, tiredness, and emotional discomfort during daily activities, allowing them to be present without immediately retreating.
• Stepping back from judgement thoughts: She practises recognising thoughts about ageing or being judged as mental events, sometimes thanking her mind for trying to protect her before refocusing on what she’s doing.
• Values-based social reconnection: Together they identify how important relationships are to her and plan small, manageable social activities, such as short walks with friends or brief coffee meetups.
• Gradual increase in activity: Sarah slowly builds up her level of social and physical activity, noticing that discomfort can be carried while still enjoying connection.
• Gentle movement for health: Low-impact exercise such as swimming, stretching, or group fitness for older adults helps support joint health and confidence.

Client 4: Priya – feeling overwhelmed by responsibilities

Background

Priya is 48, works part-time, and has two teenage children. Throughout her life she has held very high standards for herself and taken pride in being organised, capable, and dependable. She tends to measure success by how much she can manage and how well she meets others’ needs. With the onset of perimenopause, fatigue, irritability, and brain fog have made it harder to maintain these standards, which has triggered intense self-criticism and pressure to try even harder.

Formulation

Priya is fused with perfectionistic “should” rules about what a good mother, partner, and employee must do. When she experiences tiredness or frustration, these thoughts escalate, driving overworking and self-neglect. Difficult emotions are treated as signs of failure that must be corrected through doing more, deepening exhaustion.

Conceptualisation

Perimenopause has exposed the limits of a lifelong strategy of striving and self-sacrifice. Fatigue and emotional reactivity make it harder to sustain relentless productivity, yet her internal standards remain unchanged. The collision between biological limits and rigid “should” rules creates constant tension. Her life is increasingly organised around meeting impossible expectations rather than caring for herself and connecting meaningfully with others. At this stage of life, Priya is also navigating the demands of teenagers, work responsibilities, and ageing parents; pressures common in midlife that magnify exhaustion. Menopause does not occur in isolation; it unfolds within already full lives.

ACT recommendations

• Noticing and softening “should” thoughts: Priya practises identifying perfectionistic rules as they arise and gently loosening her grip on them, choosing more flexible responses.
• Allowing emotions without fixing: She learns to sit with guilt, frustration, and tiredness through breathing and grounding rather than immediately compensating by doing more.
• Values-based time use: Together they map how she wants to spend her time in ways that support health, family connection, and enjoyment, rather than constant productivity.
• Building self-care into routines: Priya schedules regular activities such as walking, yoga, reading, or quiet time, treating these as essential rather than optional.
• Setting practical boundaries: She experiments with saying no to extra tasks, delegating responsibilities, and creating protected rest time to prevent burnout.

Menopause as identity transition

Across these examples, a common thread emerges; menopause is not simply physical. It often involves a renegotiation of identity. Fertility ends. The body behaves differently. Cultural narratives about youth and value become louder.

ACT offers space for this transition. It allows grief for what has changed, openness to what is emerging, and movement toward values that extend beyond appearance, productivity, or control.

The menopause can bring a range of challenges, from physical symptoms to shifts in identity and emotional well-being. ACT enables clinicians to target key maintaining processes in menopause-related distress: fusion with decline narratives, experiential avoidance of bodily sensations, rigid rule-governed behaviour, and identity contraction. When these processes soften, behavioural flexibility increases, even in the presence of ongoing symptoms.

Read more about Menopause, common symptoms and how ACT can support women through menopause on our knowledge hub.

You can also download these 4 cases studies as a reference tool from our resource hub: Client case studies: Menopause and ACT

We are really excited to have Natasha Lazareski joining us for “Navigating menopause with ACT” in April, helping therapists and other practitioners to bridge the gap between hormonal understanding and evidence-based psychological strategies.

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