“I am not someone who screams or loses my temper easily,” says Christine Rale, a project manager in Cedar Park, Texas. “But since I’ve been in menopause, I’m more irritable, quick-tempered, and stressed. Every little thing is magnified. One day, I was arguing with my husband and I got so angry and frustrated, I took my hairbrush and smashed it into a painting on the wall. This was a rage that I couldn’t suppress or deal with logically.”

When usually calm people start becoming diva-like ragers, hurling hairbrushes around, you have to wonder what is going on. The answer just might be: a big drop in estrogen, that’s what.

Most of the conversation around menopause and the big hormone shift centers around hot flashes and bone loss. But a seismic shift in emotional health can happen, too, although it is less recognized or accepted by—well, almost anyone, except those of us experiencing it and a handful of menopause specialists.

That’s a huge problem when you consider that by the year 2020 an estimated 50 million women will be menopausal. A survey from Johns Hopkins found that across the country, half of the fourth-year ob-gyn residents who responded said they needed more education about menopause medicine. These are doctors who are about to go out into the world and begin practicing and who will be expected to treat all us menopausal women.

It’s clear that the perception, the reality, and the openness surrounding menopause aren’t in a good groove. Lest you have any doubts, check out the results of another recent survey conducted by the American Association of Retired persons (AARP). Of the 500 women between the ages of 50 and 59 who were surveyed, 85 percent said they never discussed menopause with a health provider.  (Keep in mind it’s likely that the majority of those health professionals wouldn’t know how to treat them, even if they had asked.). And only one in five of those who asked for medical help were given a referral to a menopause specialist. The reluctance to be open and honest about the emotional effects of menopause is reflected in the unwillingness of some of the women I spoke with to use their real names—or  even access help. Only one of the women I interviewed had sought help from a health professional.

Read More: 7 Things I Feared About Menopause that Didn’t Happen (and One that Did!)

When Your Moods Go Haywire

Image: sdominick/E+/Getty Images

For some women, negative feelings that descend during menopause are the garden-variety angst over the loss of youth, a sense of quickly declining visibility and sexual allure, and the end of childbearing years. However, the drop in estrogen that happens during perimenopause (the gradual drop in estrogen leading up to menopause) and menopause itself can, in a very small group of unlucky women, trigger far more serious mental health issues, ranging from clinical depression and panic attacks to first episodes of schizophrenia.

Jane Simpson of Connecticut knows about this kind of major mood shift. When perimenopause began, a depression descended. “It was like nothing really mattered and everything about me was withering,” she recalls. That mindset came on even stronger as she entered menopause.

“When I was alone, I’d find myself getting desperately melancholy and feeling as if all the good memories had been made—getting married, raising kids, having career recognition. I’d start getting teary and think all that was ahead was decline and death. I’d sit in the dark, tears rolling down my face. I began to think not exactly about ending things, but deeply questioning the road ahead. I saw a therapist, then a psychiatrist, who put me on meds, which have helped somewhat. No one has ever said it was due to the hormonal changes I was dealing with, but I wonder …”

I began to think not exactly about ending things, but deeply questioning the road ahead.

According to Philip Sarrel, MD, professor emeritus of obstetrics, gynecology, and reproductive sciences and psychiatry at the Yale School of Medicine, “Women with a history of depression are at the greatest risk for dramatic shifts in mental health. Anxiety disorders, such as panic attacks related to hormonal changes, can be debilitating. About a third of women experience depression and/or anxiety states when they are having hot flashes,” he says. “About 10 percent have suicidal thoughts.”

For most women, however, the emotional fluctuations experienced during perimenopause and menopause are disconcerting rather than dangerous. Still, they are enough to affect your interactions with family and friends. And even your relationship with yourself.

“My poor husband!” says Kathy Lester, an author and business owner in South Carolina, thinking back on her perimenopausal mood swings. “I’d stop half-way across the kitchen to sob … or laugh. And I didn’t know why. Two minutes later, it would be like nothing happened.”

This is hard for me to admit, but I had my own unique brand of “mentalpause,” as retired psychologist Mary Kinder refers to it. When my hormones started doing a do-si-do, I became rather enamored (I hesitate to say obsessed) with a young celebrity, who shall remain nameless. I read about him online. I watched all his movies. If I learned he was reading a book, I read that book. I was more than 30 years older than the poor boy, but that didn’t put a dent in my enthusiasm. I was fully aware of what I was doing and how odd it was, but my thoughts were out of my control. I felt just like I did when I was in the sixth grade and I had an excruciatingly intense crush on a classmate.

My crush on the object of my menopausal affection faded with time, just as my junior-high infatuation had. But I still wince at how the roiling emotions destroyed my focus on work—due, in part, to my constant Googling said celebrity’s name—and family—“Mom, where are you??? You were supposed to pick me up half an hour ago!”

Getting Grounded Again

While experts have laid out theories as to why a precipitous drop in hormones during perimenopause and menopause can drastically alter your mood and behavior, the bottom line is nobody knows for sure.

One prominent theory points a finger at the interplay between estrogen and the neurotransmitter serotonin, which functions as a calming chemical. Neurotransmitters are chemical messengers the body produces that send signals to neurons—signals that pretty much dictate whether you’re happy or sad, anxious or serene. Or whether you fixate on a young celebrity less than half your age.

One theory looks at the interplay between estrogen and serotonin, a calming chemical.

The hormone estrogen may both increase serotonin levels in the brain and strengthen serotonin’s action, which, in theory, makes you a happier, more serene camper. When estrogen levels plummet, so can your mood.

Lack of sleep is also a possible contributor. As hormones shimmy and shift, sleep becomes your “frenemy,” wonderful when it shows up, but more often than not, snubbing you. Regardless of your age, lack of shut-eye can wreak havoc with your mental health. When you’re menopausal, it can be the proverbial straw.

Read More: What Every Woman Needs to Know About Hormone Replacement Therapy and Bioidenticals

Magic Bullet, Wherefore Art Thou?

So what to do to get relief? It’s not a one-size-fits-all prescription. That’s because no two women experience the emotional shifts of menopause on the same timeline and in the same way. How long it takes to get to menopause once perimenopause sets in and how severely it affects mental health varies tremendously from woman to woman. Obviously, if you are in psychic pain, a referral to a mental health professional for an evaluation is a must. Counseling and antidepressants, which boost serotonin levels, might be warranted.

Some women swear by natural therapies, including herbals, vitamins, acupuncture, meditation, and massage for their mental health. The answer for other women is HRT, or hormone replacement therapy, to compensate for the estrogen your body is no longer making. HRT may help keep you sane, but it also carries well-recognized health risks, and those have to be weighed against the potential benefits to your mental health.

The answer for some women is hormone replacement therapy.

Jill Anderson of Minnesota was one of those women who started experiencing symptoms of perimenopause in her late 30s. “Too young for menopause, right?” she asked, rhetorically. She had remarried at 41, right around the time her periods stopped altogether, and she endured horrible mood swings. “I didn’t like anyone, including myself, and my husband was clueless as to what was had happened to his new wife. Add to that the fact that we had five of our six blended-family kids living with us at the time—ugh!” She said she started taking hormones to “save my sanity and my marriage.” After 18 years of slowly weaning herself off of hormones, she’s finally stopped for good and, yes, she’s still married.

To get an expert opinion of the best path forward, a menopause practitioner can provide guidance. The North American Menopause Society offers a searchable database of menopause practitioners. There are also some excellent and informative blogs written by women who speak from personal experience. They’re not experts—just women like you and me who are sharing their experiences and letting other women know they’re not alone.

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Densie Webb is a freelance editor and writer, mainly on health and nutrition topics. She has written for a wide range of publications, including The New York Times, Parade Magazine and Berkeley Wellness Letter, and has provided consulting for a number of public relations firms. She has recently added fiction to the mix and is working on completion of her third novel.