Menstruation and menopause are everyday biological realities for half the world’s population. Given the ubiquity, one might expect that menstruation and menopause would be well-chartered medical and scientific territory, but in reality, they remain overlooked and shrouded in stigma and misinformation. Perhaps this is because they are natural ‘non-events’, falling outside the scope of medicalisation. And for many women, menstruation and menopause are unremarkable. However, just as pregnancy is a natural process, few would dispute that it is the role of healthcare professionals to understand the spectrum of what is considered ‘normal’, and know when and how to offer medical intervention to minimise harm and suffering. Menopause and menstruation share this ‘natural’ yet ‘significant’ role in human biology, but, perhaps unlike pregnancy, both are burdened by stigma and taboo, making it a challenge for them to be discussed and addressed routinely, even in clinical consultations.

Disentangling the differential effects of sex and gender on health conditions is a complex and evolving area. Throughout this book, the terms ‘female’ and ‘woman’ are used for brevity, though it is important to acknowledge that the hormonal changes associated with menopause and menstruation can affect a range of individuals, including cisgender women, transgender men, and non-binary people assigned female at birth. These experiences may be even more nuanced and varied in gender-diverse populations (see Chapter 12), underscoring the need for inclusive and person-centred approaches to health.

Women’s health has long been neglected in all aspects of medicine, and gender bias in research and healthcare systems perpetuates medical misogyny. The ‘male-default’ in medical science means that female presentations are considered ‘atypical’, leading to misdiagnosis and mismanagement [Reference Criado-Perez1]. The complexity of fluctuating physiology with the menstrual cycle and the concerns about risks in pregnancy has contributed to the under-representation of women in scientific research. Sex-differences are ubiquitous through medical conditions, yet diagnostic and therapeutic guidelines remain gender-neutral, ultimately failing to meet the specific needs of women.

Although we may have come some way from widespread diagnosis of ‘hysteria’ and the forced institutionalisation of women for ‘moral insanity’, we are now in a new era of medical misogyny. Women’s accounts of symptoms are often trivialised or dismissed as ‘psychosomatic’, and women ‘have never been respected as reliable narrators of what has happened, or is happening, to our bodies’ [Reference Cleghorn2] countered perhaps by an overmedicalisation of distress [Reference Bacigalupe and Martin3]. The rise of the term ‘medical gaslighting’, particularly as a hashtag on social media, has drawn attention to the phenomenon of patients (often women) feeling that their symptoms are dismissed or downplayed [Reference Wise4]. However, this experience is not limited to women; individuals from other marginalised groups such as Black and Minority Ethnic communities, LGBTQI people, neurodivergent individuals and those living with mental illness are also disproportionately affected. The interplay between these identities/characteristics and biological sex often intensifies the impact, highlighting the need for nuanced and inclusive approaches to healthcare.

Our experiences and understanding of what is a ‘health problem’ are very much framed and influenced by our cultural context; this is especially true for women’s hormonally related mental health problems. A paper entitled ‘Menopause and psychosis’ from 1931 [Reference Farrar and Franks5] remarks on ‘the age old tradition which unduly exaggerates the morbific potential of the climacteric’ (p. 1043), implying that fear of illness within the menopause (climacteric) may become a self-fulfilling prophecy. It goes on to say ‘This state of the feminine mind in general is unfortunately encouraged all too often by the medical profession and the opinion is too readily expressed that difficulties of all sorts occurring during the rather wide span of the transition years are to be attributed to the menopause’ (p. 1043). This debate remains to this day, with some feeling that the biological impact of menopause is overstated and health problems in midlife are more likely a product of psychosocial factors, including, perhaps the individual’s psychological response to the menopause. On the other hand, there are plenty of clinicians who view menopause as a ‘hormone deficiency’ and advocate for widespread prescription of hormone replacement therapy (HRT) [Reference Clark6]. Few medical interventions have been as controversial as HRT, with prescribing and uptake trends often more influenced by the socio-cultural backdrop rather than clinical evidence base.

Social media has become a key platform in this discourse, with many women turning to it as a primary source for information on menopause, contraception and menstrual health, as well as for peer support and shared experiences. This is both a brilliant way of disseminating information and for women to connect with those around them but also a dangerous tool. Complex medical information distilled into short videos can be misleading, and the commercialisation of menopause and menstrual health can put content from qualified professionals on a par with influencers touting a product. There is a trend towards assuming medical professionals will be ignorant or dismissive (i.e. the medical gaslighting hashtag), thus women are being urged to do their own research and arm themselves ready for medical appointments, particularly when discussing menstrual- or menopause-related symptoms. The confirmation bias on social media only leads to amplification of experiences of medical gaslighting and the transformative experience of various treatments (e.g. HRT/testosterone for menopausal symptoms): experiences of a positive or unremarkable interaction with a healthcare professional or a limited response to a treatment do not make compelling content. Clinicians may find themselves unwittingly set up for a battle and may have to spend some time dismantling false information rather than a preferred consultation model of hearing the patient’s experiences, sharing ideas and information, and collaborating on a management plan.

The lack of comprehensive training in menopause and menstrual health has long been a gap in medical education: Improving menopause-related education for practicing healthcare professionals has been identified as a particular priority [Reference Currie, Abernethy and Hamoda7]. In this context, the social media-driven trend to ‘do your own research’ can serve as a source of empowerment for women, especially when clinical expertise and support are lacking or inconsistent. However, I would argue that we can do better, and as healthcare professionals, it is our job to seek education in response to discovering gaps in our knowledge base. As clinicians, we also need to look out for the proportion of women who will not have had access to social media or other sources of education around menopause, menstruation and contraception and where there will be a role for the professional to educate the person about these aspects of health, and proactively ask about any related symptoms.

This book serves as a guide for health professionals to understand the relationship between menstruation, menopause, contraception and mental health. This is an area with very little evidence base to inform clinical practice, thus I have interwoven quotes from interviews conducted with experts by experience in the field, mainly women with lived experience, but some from carers and health professionals, to illustrate the points in the text (see quotes above and through subsequent chapters). I am incredibly grateful for the generosity of these women in sharing their experiences and moved by their determination to advocate for better care and understanding for future generations of women whose mental health may be affected by menopause or menstruation.

I have hope for women and clinicians of the future. Campaigns such as Make Menopause Matter [8] are improving public understanding, healthcare professional training and political response to the menopause. Initiatives such as the Women’s Health Strategy [9] seek to address inequalities in healthcare and improve outcomes for women, including in mental health care around menstruation and menopause. As public awareness around menopause and menstruation continues to grow, clinicians are increasingly motivated to enhance their knowledge so they can engage confidently and effectively in conversations with their patients.

As mental health professionals, we are experts in being able to hold in mind all the co-existing and intertwining biological, psychological and social factors that underpin menstruation and menopause for each individual woman. Demonstrating curiosity and exploring these aspects of health with a woman adds depth to formulation, diagnosis and a holistic treatment plan [Reference Marwick, Reilly, Allan and Golightly10]. It is also an area where we may need to collaborate with colleagues in primary care, gynaecology, endocrinology and sexual health, and this is key in order to avoid patients getting lost in the artificial physical versus mental health divide.

Menstruation and menopause are not niche concerns, they are central to the health and well-being of millions. As clinicians, we have a responsibility to move beyond outdated assumptions and gaps in training, and instead embrace a more informed, inclusive and compassionate approach. By listening to lived experiences, challenging stigma and integrating hormonal health into mental healthcare, we can ensure that every woman, and every person affected by these processes, receives the understanding and support they deserve.