We explore the unique considerations surrounding menopause, periods and contraception for people with intellectual disability (ID), the barriers they face and how to achieve ‘equal outcomes of care’. A complex interplay of communication differences, societal assumptions and stigma, diagnostic overshadowing, physical accessibility challenges, and gaps in healthcare providers’ understanding of ID, create these barriers. Aspiring to achieve equal outcomes of care requires early and adapted communication about menopause, periods and sexual health. Clinicians need to adapt clinical care to embed enquiry about menstruation and menopause and use systematic tracking tools to understand a woman’s periods and associated psychological and behavioural changes and then offer the whole range of treatment options. The responsibility lies with professionals to be aware of the barriers, provide reasonable adjustments to overcome them, and to advocate for equal outcomes around menopause, periods and contraceptive health for people with ID. The chapter includes insight from ‘experts by experience’, and each section provides practical suggestions for professionals working with people with ID.

The perimenopause is an individual experience, influenced by life circumstances, cultural context, family history and narrative. The perimenopause can last many years and women, as well as health professionals, can be poorly prepared for this potentially challenging period. Most people know to expect hot flushes, and maybe genitourinary symptoms. However, if the emotional symptoms, such as, reduced ability to cope, irritability and sudden anger, arise first, years before the expected hot flushes, it can be difficult to understand and have a detrimental effect on a woman’s life. We explore widespread physical symptoms of perimenopause and highlight symptoms that are regulated in the brain: hot flushes, body temperature regulation, sleep disturbances, libido. We focus on emotional symptoms, such as mood changes, depression, anxiety, agitation, irritability, a sense of overwhelm and losing the ability to cope, and explore their impact on suicidality. We briefly look at cognitive symptoms and explore the influence of trauma and the differences in experience by ethnicity and cultural influence. Finally, we look at the experience of premature ovarian insufficiency.

This chapter summarises current guidelines for the assessment, investigation and management of menopausal symptoms and its pertinence to psychiatry. We explain the use of hormone replacement therapy including oestradiol, progesterone and testosterone to manage common symptoms of perimenopause and menopause. Reference is made to the current NICE prescribing guidelines and consideration given to management of genitourinary symptoms of menopause (GSM) as well as surgical menopause and primary ovarian insufficiency (POI). Specific attention is given to the management of menopause in breast cancer. Other hormonal treatments, non-hormonal treatments, psychological and lifestyle interventions are also reviewed. Overall, this chapter emphasises the importance of taking a holistic, patient-centred approach to the management or menopause. Through knowledge of treatment options and evaluation of individual risk factors, patients can be empowered to make decisions regarding preference and choice of treatment in order to create individual treatment regimens that optimise symptom management.

Women’s mental health has long been misunderstood, misrepresented and mistreated. Historically, women have been institutionalised, dismissed and subjected to clinical models that fail to account for the dynamic nature of female biology. The reliance on male-centric research and clinical guidance in mental healthcare is dated; we seek new models that incorporate and validate a woman’s experience of menstruation, menopause and other hormonal changes. Understanding the interplay between hormones and mental health, on biological, psychological and social levels, offers a vital lens through which to understand the complexity. Through explanation of the scientific underpinnings by experts in the field and real stories of women who have endured misdiagnosis, poor treatment and disability, this book exposes the consequences of neglecting to understand a woman’s hormonal experience, and the transformative potential when care is hormonally informed. We stand at the cusp of a revolution in women’s health. Emerging research and innovation promise a future where care is compassionate, evidence-based and attuned to women’s lived realities of menstruation, menopause and mental health.

Women’s mental health has been shaped by patriarchal societal biases in science, medicine and society. Early medical texts attributed women’s distress to their reproductive system or sexual deprivation. In the Middle Ages, mental illness was often misinterpreted as witchcraft, reinforcing harmful beliefs about female autonomy, and in the nineteenth century, male-dominated medical science pathologised women’s independence with diagnoses such as ‘moral insanity’ to justify institutionalising women who defied social norms. Twentieth-century feminism underpinned advances in medicine and social reform, shaping health policy and psychiatric practice, although controversies around research into hormone replacement therapy (HRT) disrupted momentum. Despite progress, persistent gender bias in research and access to mental health care persists, particularly for marginalised groups, although initiatives like the Women’s Health Strategy offer hope for a more equitable future.

This chapter examines the bi-directional relationship that exists between the menopause and society. It reflects on how a woman’s perception of the menopause is influenced by societal and cultural ideas about menopause, ageing and gender. It reviews how Western societal attitudes towards the menopause have developed over time, in response to scientific developments and medical trends. It also considers the viewpoint that this natural life transition has been over medicalised, and looks at how this life stage is viewed in other cultures. The chapter looks at how an individual woman’s experience of the menopause has an impact on her wider society. It considers the impact that menopausal symptoms can have in the workplace, and in personal relationships including partners, children and other family members. It also speculates about how health economics are affected by women in this life stage.

The menstrual history is a key feature of a psychiatric assessment and must be approached with sensitivity, recognising that cultural beliefs surrounding menstruation and menopause may pose barriers to open discussion. A structured framework is outlined, including suggested questions, designed to simplify the process and support identification of links between hormonal fluctuations and psychiatric symptoms and to glean information about the practical management of menstruation. We suggest a culturally sensitive, trauma-informed approach to enquiring about female genital mutilation (FGM) and its psychological impact. By adopting a life-course approach and routinely incorporating menstrual history into psychiatric assessment, clinicians can provide more holistic, personalised care.

This chapter explores the interplay between common gynaecological conditions and mental health, focusing on polycystic ovary syndrome (PCOS), endometriosis and adenomyosis. It also examines the psychological impact of infertility, subfertility, miscarriage and baby loss: experiences that are often overlooked in psychiatric assessments but carry significant emotional weight. Drawing on the latest research, the chapter highlights the increased prevalence of mental illnesses in women with these reproductive health conditions. Designed for psychiatrists and mental health practitioners, this chapter provides evidence-based insights to support a comprehensive biopsychosocial approach to care. Each section concludes with practical, clinic-ready guidance to improve the support offered to women navigating both mental health challenges and gynaecological illness. Expert insights from individuals with lived experience are interwoven throughout, offering an authentic patient voice that underscores the psychological burden these conditions can impose. The goal is to deepen understanding and promote compassionate, integrated care in clinical practice.

With many women in perimenopause experiencing a subjective sense of change in cognitive function, understanding normal cognitive function in perimenopause is important for clinicians in day-to-day practice. This chapter aims to equip mental health professionals with the knowledge and confidence to appropriately explore cognitive concerns arising during the perimenopause. The chapter outlines normal cognitive function in perimenopause, exploring symptoms and how they may present, as well as aiming to identify who may be at greater risk from cognitive change. It then offers suggestions on how to support women to reduce symptoms of cognitive dysfunction as far as is practicable. The chapter later explores the role of hormone replacement therapy (HRT) on both cognition in perimenopause and beyond into postmenopause, as well as considering the impact HRT has on the brain and risk of dementia in later life. With up to 45% of dementia now felt to be preventable, the chapter discusses the role of the healthcare professional in identifying risks presenting around the time of perimenopause, allowing clinicians to then offer intervention and promote good brain health in mid-life leading into later-life.

Perimenopause is a period of heightened risk of onset and relapse of mental illnesses including depressive disorders, schizophrenia spectrum disorders and bipolar affective disorder, as well as a time of increased risk of psychological symptoms including low mood, cognitive problems and anxiety. Perimenopausal depression can be seen as a distinct diagnostic entity with specific clinical features and treatment pathways. The risk of suicide in the perimenopause is widely reported and we look at the nuances of this association and other possible confounding factors. Perimenopause may be a particularly challenging time for women with pre-existing severe mental illness; women with severe mental illness are at risk of substandard menopause education and care, and there maybe diagnostic overshadowing, with menopausal symptoms not being identified, exacerbation of psychiatric symptoms due to perimenopausal symptoms, and an impact of ovarian hormones on psychopharmacology. We explore the evidence base behind psychological, pharmacological and hormonal treatment strategies (including hormone replacement therapy and selective oestrogen receptor modulators) proposed for treatment of perimenopausal mental illnesses.

Trans and non-binary people face many barriers to accessing healthcare. There is also a lack of research and guidance focusing on the health of transgender and non-binary people. Many clinicians also do not feel confident in their knowledge of specialist care for trans and non-binary people. As part of gender-affirming care, trans and non-binary people may start gender-affirming hormone therapy to provide masculinising or feminising changes that are more congruent with their gender identity. This has shown to a positive impact on the mental health and quality of life of trans and non-binary people. Over the life course, trans and non-binary people may also access other hormonal medications such as contraceptives and hormone replacement therapy for menopause. There are unique considerations for prescribing these medications for trans and non-binary people, especially if they are on gender-affirming hormones. In this chapter, we summarise evidence around the care for trans and non-binary people with specific considerations for the intersection between gender-affirming hormones, mental health, and sexual and reproductive healthcare.

In this chapter, we examine the experiences of neurodivergent autistic people and attention deficit hyperactivity disorder (ADHD) individuals around menstruation and the life transition of menopause. The chapter is informed by personal insights from neurodivergent individuals with first-hand encounters of menstrual and menopausal challenges, our ‘experts by experience’. In doing so, we aim to inform and empower clinicians to appropriately support these patients with their menstrual and menopausal health. We begin by discussing what autism and ADHD are, the features of these conditions, and why they are particularly relevant and important in regard to health needs and for healthcare, and the shared interpersonal-environmental and intrapersonal factors of autistic people and ADHD individuals (ADHDers). We then individually consider autistic and ADHD experiences of menstruation and menopause with narrative from our experts by experience. Based on this information, we provide point-by-point advice for health professionals supporting neurodivergent people with menstruation and menopause health.

Sexual and reproductive health needs are often overlooked in psychiatric care; people with severe mental illness are at risk of unintended pregnancy and may struggle to access sexual health services. The link between psychological symptoms and contraceptive use is complex and the impact of hormonal contraceptives on mental health is poorly understood. There can be interactions between hormonal contraceptives and psychotropic medication, and where psychotropics with potential teratogenic effects are considered, good contraceptive counselling is imperative. The chapter explores mechanisms, risks and benefits of different types of contraceptives and explores their use beyond pregnancy prevention, including alternative therapeutic indications. Contraception choices are considered in specific groups including perimenopause, trans and non-binary people, and other marginalised groups. We aim to empower mental health professionals to engage collaboratively with their patients in discussing contraception as part of assessment and formulation. Where relevant, we encourage consideration of how contraceptive choices may interact with mental health conditions and influence management plans

The fluctuations of ovarian hormones in the menstrual cycle (oestradiol, progesterone) are stimulated by luteinising hormone and follicle-stimulating hormone released from the anterior pituitary gland on stimulation from gonadotrophin-releasing hormone from the hypothalamus: this is the hypothalamopituitary gonadal axis. The role of these hormones is widespread and changes through puberty, pregnancy, the postnatal period, breastfeeding and perimenopause. The effect of these hormones on the brain and from external influences (e.g. trauma) on the hormonal circuitry identifies possible mechanisms behind hormonally related psychological symptoms and mental disorder. The relevance of the hypothalamopituitary gonadal axis for mental health professionals is explored, including pathological psychological responses to normal hormonal states, mental health symptoms related to hormonal disorders, and the impact of some psychiatric disorders and treatments on hormones.

Premenstrual dysphoric disorder (PMDD) is a psychiatric condition marked by severe symptoms in the premenstrual phase, including affective, cognitive and physical changes. It is triggered by fluctuations in allopregnanolone, a metabolite of progesterone that acts as a GABA-A receptor modulator. Diagnosis relies on prospective symptom tracking across menstrual cycles. Although suicidality is not part of the diagnostic criteria, an association with PMDD has been observed. The evidence base for managing premenstrual disorders includes lifestyle changes, certain supplements, cognitive behavioural therapy, selective serotonin reuptake inhibitors, combined hormonal contraception and gonadotrophin-releasing hormone analogues. Surgical removal of the ovaries may benefit individuals with severe, treatment-resistant PMDD. Evidence around premenstrual exacerbation or cyclical changes in other mental disorders remains sparse. However, encouraging individuals to track their cycles and identify symptom patterns can support personalised care planning. Menstruation per se can be a challenge to certain populations and disentangling this from psychological response to hormonal changes is key.