The 5 Midlife Crises No One's Talking About

Midlife Women Take Their Own Lives at the Highest Rate of Any Female Age Group

Women aged 45 to 64 take their own lives at a higher rate than any other female age group. 8.6 per 100,000.

According to the National Center for Health Statistics, Women in this age range held that position every single year from 2002 to 2022.

Behind that number are Women who often look, from the outside, like they are holding everything together.

Women raising teenagers, or watching grown children leave. Women caring for aging parents. Women at the height of their careers, or starting over after a marriage or a job has ended.

Suicide always has many threads: depression, grief, trauma, isolation, money, pain, access to means. Midlife physiology is 1 thread that almost never gets named.

The hormonal transition itself raises the risk of depression. In the Study of Women's Health Across the Nation, known as SWAN, researchers followed Women for 10 years through the Menopause transition. Women were 2 to 4 times more likely to have an episode of major depression during Perimenopause and early post-Menopause than in the years before it.

Progesterone is part of why. Your brain turns some of your progesterone into allopregnanolone, a calming compound that acts on the same GABA receptors that help your Nervous System settle.

In Perimenopause, ovulation becomes irregular, progesterone swings and then falls, and that steady calming signal swings and falls with it. Medicine takes this signal seriously: the first medicine approved in the United States specifically for postpartum depression, brexanolone in 2019, is a form of allopregnanolone itself. Postpartum is another steep hormonal drop, and the same brain is on the receiving end.

Then there is sleep. Night sweats and the 3 AM wake-up can fragment sleep for years, and research links insomnia to a higher risk of suicidal thoughts and behavior, often even after depression is accounted for.

There is also a gap in how this gets caught. In 2018, The Menopause Society, then called the North American Menopause Society, and the National Network of Depression Centers published joint guidelines naming Perimenopause as a window of vulnerability for depression and asking clinicians to recognize it. In the stories Women bring to me, a Woman describing low mood is rarely asked when her cycle started changing, how she is sleeping, or what her hormones are doing.

What can you do, and what can the people around you do?

• If you are struggling, tell 1 person today, and tell your practitioner about your sleep and your cycle alongside your mood.
• Ask for your physiology to be checked alongside any counseling or medication: your sex hormones, your morning cortisol, your full thyroid panel, your ferritin, your vitamin D, and your B12. Physical care and mental health care work together.
• If you love a Midlife Woman who has gone quiet, pulled away, or talks about being a burden, ask her directly how she is doing, and ask directly about suicide if you are worried. Research shows that asking does not plant the idea, and it can bring relief.

1 of the reasons I teach this material as freely and as often as I do is that I want to reduce the suicide rate among Women in this season. Every one of these Women was somebody's whole world.

If you are having thoughts of ending your life, please reach out today. In the US and Canada, call or text 988. Elsewhere, findahelpline.com lists the line for your country.

1 in 5 Midlife Women Takes an Antidepressant, Often Before Anyone Checks Her Hormones

1 in 5 Women aged 40 to 59 took an antidepressant in the last 30 days. 20.1 percent, rising to 24.3 percent among Women 60 and older.

Across all adults in the same national survey, Women used antidepressants at about twice the rate of men, 17.7 percent against 8.4 percent.

An antidepressant prescription can be written without anyone ever checking her sex hormones, her full thyroid panel, her ferritin, her vitamin D, or her cortisol. Nothing in the system requires it.

Why does this matter so much? Because in Midlife, several of the most common physical shortfalls look and feel exactly like depression and anxiety.

• Low ferritin looks and acts like depression, everything a constant push no matter how much you rest.
• Low progesterone looks and acts like anxiety, because it is the hormone of calm.
• Falling estrogen affects serotonin and dopamine, the brain chemicals behind mood and reward.
• Low testosterone looks like flatness, the 'I just don't care anymore' feeling.
• A struggling thyroid can look like every one of these at once.

The chapter 'The Mimics' in Part 2 walks through each of them by name, with the labs that tell them apart.

There are good reasons a doctor may reach for an antidepressant. Real clinical depression is common in Perimenopause and deserves real treatment. Some antidepressants also calm hot flashes, and a low-dose form of paroxetine is approved for exactly that, which matters for Women who cannot take estrogen.

The gap is the order of operations: the prescription comes first, and the physiology is often never checked at all. The 2018 Perimenopausal depression guidelines also note that estrogen therapy has shown antidepressant effects in Women in Perimenopause, though it is not approved as a treatment for depression. That is a conversation for a prescriber who knows the current evidence.

Now, I'm also not telling anyone, stop your antidepressants, okay? They save lives. Some Women need them, okay? What I'm saying is that a lot of Women were never given the chance to find out whether their sadness has a root cause, sitting in their blood work.

If you take an antidepressant now, keep taking it as prescribed while you investigate. Stopping suddenly can cause real withdrawal symptoms, and any change belongs with your prescriber.

What you can do is ask for the labs that were skipped. If your ferritin is 17, your progesterone has gone quiet, or your Free T3 sits at the floor of its range, you and your practitioner will want to know that, whatever you decide about the medication.

Gray Divorce Is Rising Fastest in the Very Years It Falls for Everyone Younger

Between 1990 and 2023 divorce fell for every age group under 45, and rose for every age group from 45 up. The steepest rise of all is among Women 65 and older, where the rate went from 1.4 to 6.7 per 1,000 married Women, more than 4 times over.

Sociologists call this gray divorce. Between 1990 and 2010, the divorce rate among adults 50 and older doubled, and by 2010 roughly 1 in 4 people divorcing in the United States was 50 or older.

These are often Women in marriages of 20, 30, and 40 years. The children have left, the house is quiet, and 2 people look across the table at each other in a new way.

Some marriages in this season genuinely need to end, and a Woman's reasons are her own. And some of what is happening in the Relational layer is physiology that nobody has checked.

• Testosterone. When it drops, desire drops, and a Woman often has no idea why. Patience, playfulness, and the wish to be touched can go with it.
• Estrogen. As it falls, vaginal tissue thins and dries, and sex that used to be a pleasure can start to hurt. Local vaginal estrogen treats this, often with an outsized effect.
• Progesterone and sleep. A Woman who has not slept through the night in 2 years may have very little patience left for anyone.
• Depletion. Low ferritin, a struggling thyroid, and a flattened cortisol curve leave nothing extra to give the people she loves.

In research on heterosexual couples, Women initiated about 2 out of every 3 divorces. In unmarried couples, Women and men initiated breakups at about the same rate. I wonder how many of those decisions were made from inside a temporary, treatable physiological state, by a Woman who was never told there was a physiological state.

In the appointments Women describe to me, libido and painful sex are rarely raised by the practitioner, so they go unmentioned for years. A Woman may carry her loss of desire as a private shame, and her partner may carry it as rejection.

Before you make anything permanent in your relationships in Midlife, get your system replenished where it has run dry. Then decide whatever you decide, from a place of clarity and strength.

If you are the partner of a Midlife Woman, this chapter is for you too. What looks like withdrawal may be a body with nothing left in the tank.

Divorce after 50 also carries a financial cost, and it lands hardest on Women. 'Work, Money, and Purpose: Finding Meaning in the Second Half' explains it, along with the Social Security rule every Woman in a long marriage should know.

About 1 in 8 Women Is Living With a Diagnosed Autoimmune Condition, and More Go Undiagnosed

About 1 in 8 Women carries a diagnosed Autoimmune condition, and more are building 1 that nobody has named yet. That 1 in 8 comes from a 2023 study of 22 million patient records in the United Kingdom, published in The Lancet. In the United States, about 1 in 6 people aged 12 and older test positive for antinuclear antibodies (ANA), a sign of immune activity against the body's own tissue that can appear years before a diagnosis, and that does not by itself mean disease.

Many Women with an Autoimmune process already underway have simply never been checked.

The first comprehensive count in the United States arrived only in January 2025. A team led by Dr. DeLisa Fairweather at Mayo Clinic studied the health records of more than 10 million people across 6 large medical systems, and estimated that about 15 million Americans, 4.6 percent, have been diagnosed with at least 1 of 105 Autoimmune conditions.

Across all 105, including type 1 diabetes and psoriasis, which affect men and Women more evenly, 63 percent of the people diagnosed were Women. Counts differ with the method and the list of conditions, which is why a study in the United Kingdom and a study in the United States land on different figures. Every count points the same way: Autoimmunity is 1 of the most common kinds of chronic illness there is, and it lands on Women most.

In many single conditions, such as Hashimoto's, lupus, and Sjögren's, the share of Women climbs to 80 percent or more. Female immune systems are more reactive, and estrogen amplifies immune activity, which helps a Woman fight infection, and also leaves more room for crossed signals.

Perimenopause is often the moment when an Autoimmune process that has been building quietly for years finally tips into view. The hormonal shift is itself 1 of the triggers in the 3-factor model developed by Dr. Datis Kharrazian: genetic susceptibility, a permeable gut barrier, and a trigger.

So the Women in this gap are often Women in their 40's and 50's. 1 of the most common Autoimmune conditions of all, Hashimoto's, is also the most common cause of an underactive thyroid in the United States.

It gets missed because the symptoms are the very ones this book opened with: fatigue, hair loss, weight that will not move, brain fog, joint pain, bloating, low mood. Every one of them is easy to file under stress, Perimenopause, aging, or being a busy Woman.

And the standard screen often cannot see it. TPO and thyroglobulin antibodies, the markers that show a Hashimoto's attack, can rise years before TSH moves, and many thyroid checks run TSH alone.

So many Women are walking around with misdiagnosed and undiagnosed Autoimmune conditions.

It matters because Autoimmune conditions tend to travel together. Roughly 1 in 4 people with 1 Autoimmune condition goes on to develop another. In the model this book teaches, that is because the terrain that allowed the first one, the permeable gut, the inflammation, the unaddressed triggers, is still there.

What can you do? Ask for a full thyroid panel with both antibodies, TPO and TGAB, and ask for inflammation markers such as hs-CRP.

If your joints, skin, or gut point elsewhere, ask your practitioner whether other Autoimmune markers make sense for you. The Lab Wish List in Part 2 lays out every one.

No One Is Designated to Guide Her, and Her Care Declines After 35

Only 6.8 percent of medical residents surveyed felt adequately prepared to manage Women in Menopause. That was 12 out of 177 residents in family medicine, internal medicine, and OB-GYN training programs.

There's nobody designated to guide someone properly through all that unfolds in this guide in the Midlife journey. There's nobody that's looking at the thyroid properly, the sex hormones, the gut, the adrenals, and your liver health, how much you're exercising, your level of inflammation, your sugar habits, and how all of this operates together. There's nobody that's trained in this conversation, which is an imperative conversation for every Midlife Woman to be having with a skillful practitioner. So quality of care for a Woman, once she hits 35, rapidly declines, and misdiagnosis upon misdiagnosis happens.

That survey, published by Dr. Juliana Kling and colleagues at Mayo Clinic in 2019, asked residents in exactly the fields that become your primary care physician, your internist, and your OB-GYN. About 20 percent said they had received no Menopause lectures at all during residency.

The survey also asked about a Woman newly in Menopause, with symptoms and no medical reason to avoid hormone therapy. 34.4 percent of the residents said they would not offer her hormone therapy, even though current guidelines consider her a good candidate.

A 2023 survey of 99 OB-GYN residency program directors found that only 31.3 percent of their programs had a dedicated Menopause curriculum. The gap reaches even the specialty most Women assume has this covered.

Why 35? Perimenopause can begin as early as 35, and it can run for up to 17 years. Nothing in routine care changes to meet it.

A Woman's checkups stay organized around Pap smears, mammograms, blood pressure, and cholesterol, and routine care has no step for her sex hormones, a full thyroid panel, her ferritin, or her cortisol curve.

In practice, declining care looks like 1 reasonable appointment at a time.

• The symptoms get split across specialists. Hair loss goes to a dermatologist, bloating to a gastroenterologist, aching joints to a rheumatologist, and low mood to a psychiatrist, each seen on its own.
• Each lab is read alone, in 15 to 18 minutes, without the rest of the picture on the table.
• The thyroid is checked by TSH alone.
• A normal-range verdict. Every number sits inside the conventional range, so the visit ends with 'your labs look fine'.
• An antidepressant or a sleep aid, as the first and sometimes only step.
• 'It's just age.' Or stress, or being a busy mother, or 'welcome to your 40's'.

Each of those doctors may be doing careful, conscientious work inside their own scope. The problem is that nobody's scope is the whole Woman.

Autoimmune care shows the cost. In a 2017 patient survey by the Autoimmune Association, then called AARDA, people with Autoimmune disease saw an average of about 4 physicians over about 3 years before they were diagnosed. That was an improvement over 1996, when it took about 6 physicians over about 5 years.

A 2025 national survey of more than 1,000 US Women aged 30 to 60, commissioned by the hormone therapy company Biote, found that nearly 40 percent felt misdiagnosed during Perimenopause, often treated for depression or anxiety.

Only 42 percent said their primary care provider or OB-GYN had started a conversation with them about Perimenopause. A company with a stake in the topic paid for that survey, so read it with that in mind. It points in the same direction as the independent research above.

What can you do? Until you find a practitioner who can hold the whole picture, you hold it.

• Know your numbers. Your ferritin, your vitamin D, your B12, your full thyroid panel with antibodies, your sex hormones, and your cortisol.
• Keep your own file, every result with its date, so the pattern across years and across specialists lives in 1 place.
• Bring the whole list of symptoms to every appointment, even the ones that seem unrelated.
• Look for the rare practitioner who is trained in this conversation, and for someone who can walk beside your care between appointments.

This is the crisis that sits underneath the other 4. When nobody is designated to guide a Woman, her depression, her marriage, and her undiagnosed Autoimmunity all have more room to grow.

It is also the one I built this book to answer. You deserve 1 place where all of it is held together, and until the system builds that place, this guide is here to be it.

What connects these 5 crises?

All 5 of them cluster in this 1 season of a Woman's life, a season when her hormonal baseline resets more completely than at any time since adolescence.

In this same age range, a Woman is more likely to take her own life than at any other stage of life. 1 in 5 is on an antidepressant. Autoimmunity often tips into view here, frequently without a diagnosis. And divorce rises here, in the very years it falls for everyone younger.

And in the very years she needs the most skillful care, no one is designated to guide her, and misdiagnosis follows misdiagnosis.

Why is no one putting these facts in the same room and shouting them from the top of a mountain?

This guide puts them in the same room. It was my personal saving grace as I found my way through all of these symptoms in my own Midlife, and it is my privilege to help Women address all of them, because each 1 has physiology underneath it that can be addressed, and to support you in getting the right medical care, the way I did for myself.