Your client is 42.
What do you ask next?
She has never struggled significantly with anxiety. Now she says she doesn’t feel like herself.
Get the free toolkit ↓Sarah has been your client on and off for several years. She came back three months ago because, in her words, everything feels like too much.
She isn’t sleeping well. She’s more anxious than you’ve ever seen her — and she has never been an anxious person. She’s snapping at her partner and her children, then lying awake feeling ashamed about it. Work, which she has always been good at, suddenly feels harder. She loses her thread in meetings.
She has started to wonder aloud whether she’s developing depression.
Near the end of the session, gathering her coat, she says:
You have four minutes left.
What would you do next?
Decide before you scroll. There is no trick answer here — every one of these is defensible.
- AReflect the shame she’s carrying about snapping at her family.
- BAnswer her question: yes, sudden heat can be part of a panic response.
- CScreen more formally for a depressive episode.
- DAsk whether anything has changed with her cycle, sleep or temperature regulation.
- EExplore the psychosocial load — work, partner, children, caregiving.
- FRefer her to her family doctor for bloodwork.
Show the one clinicians most often miss
D. Not because it matters more than the others — but because it is the only one that brings new information into the room, and because Sarah handed you the opening herself, at the door, framed as an aside.
A, B, C and E are all good clinical practice. That is exactly the problem: a competent, thoughtful session can be built entirely out of those four, and perimenopause never enters the formulation at all.
Two or three questions. Costs a minute. And it can be asked without stepping outside your scope.
The question is not: “Does my client have perimenopause?” That is not ours to answer.
The question is: “Should perimenopause be part of my clinical formulation — and does this warrant further medical assessment?”
The “Something Feels Off” Toolkit
Fifteen pages for the clinician sitting in that room. Everything the page above stops short of — the other five options and what each one does to the formulation, plus the questions, the differential and the referral guidance.
- 01What are you hearing in your therapy room? — a listening checklist across eight symptom domains, and how to read what you’ve ticked
- 02The full Sarah case — all six options, each with an honest debrief of what it does and what it closes off
- 03Five questions to consider asking midlife clients — conversational, and none of them require any endocrinology
- 04Don’t assume it’s perimenopause — overlapping presentations from thyroid dysfunction to late-recognized ADHD, and when to actively encourage medical assessment
- 05What belongs in therapy, what needs referral — a clear scope-of-practice split, plus a five-step script for helping a client advocate for themselves in a seven-minute appointment
A note on language. The research cited here largely studies cisgender women. Perimenopause is also experienced by transgender men, non-binary people and others who may face additional barriers to recognition and care. Where sources say “women,” we’ve kept their wording; where we speak in our own voice we mean anyone moving through this transition.
Every statistic is sourced to The Menopause Society or ACOG, with links, on the final page.
For educational purposes only. This toolkit is not a diagnostic or screening instrument and does not provide medical advice. It is intended to support clinical formulation, conversations with clients, and appropriate referral decisions. It does not diagnose perimenopause, replace medical assessment, or substitute for a clinician’s professional judgment, scope of practice, or applicable professional standards.
She has heard the word. She just hasn’t said it to you.
A 42-year-old client has been hearing about perimenopause for months — from a podcast, from her feed, from a friend at work. She has never once said it in your office. What she says is that she can’t sleep, can’t concentrate, and doesn’t feel like herself.
Meanwhile most of us were trained thoroughly in mood, anxiety, trauma and attachment, and barely at all in what happens to mood, sleep and cognition across the menopause transition. That isn’t a personal failing. The Menopause Society named it directly in July 2026: “Clinicians typically receive inadequate training and education on perimenopause and menopause care.”
The survey behind that release — more than 7,600 US women aged 35 and older — found 34% were unsure of their own reproductive stage, and that the most common difficulty, reported by 56%, was distinguishing perimenopause from other causes. So the client is uncertain, and the clinician was never taught. That is a lot of uncertainty in one room.
Supporting Women Through Perimenopause
Clinical approaches and interventions with Kara Cruz, MA, LMFT, PMH-C, EMDRIA Certified Therapist™ — a Licensed Marriage and Family Therapist, Certified Perinatal Mental Health Professional, clinical supervisor and educator with over a decade of experience. Her practice spans perinatal mental health, postpartum adjustment, perimenopause, trauma-informed care, women’s mental health and ADHD. She founded Kara Cruz Psychotherapy & Wellness and co-founded Women’s Support Circle.
By the end of the training you will be able to
- Describe the differences between perimenopause, menopause and post-menopause
- Identify common physical, emotional and psychological symptoms
- Determine how the transition can affect mental health, mood and overall wellbeing
- Explain how clinicians can promote client self-advocacy and make appropriate referrals
- Identify key considerations when working with cisgender and transgender clients
- Use appropriate screening tools, interventions and referral strategies for anxiety, mood and sleep concerns
October 29–30, 2026 · 1:00–4:15 pm ET each day · 6 CE hours · Live webinar · Includes 1-year recording access
$219 CAD early bird (regular $259)