- Related to the reproductive stages of life from the premenstrual and perinatal periods to perimenopause and menopause
- Several psychiatric disorders reflect a complex interplay of biological vulnerability
- Gender-related patterns of help-seeking and diagnosis
Beyond mental health conditions related to the reproductive stages of life from the premenstrual and perinatal periods to perimenopause and menopause, several psychiatric disorders demonstrate a consistent female predominance across the lifespan. These sex-based differences reflect a complex interplay of biological vulnerability, psychosocial influences, and gender-related patterns of help-seeking and diagnosis.
These findings were described in a journals-based article on "Mental health challenges in women: A clinical perspective" which was authored by D.L.U. Amarakoon (Senior Lecturer attached to the Sri Jayewardenepura University's Medical Sciences Faculty's Psychiatry Department), and R. Fernando (Senior Lecturer attached to the Kelaniya University's Medical Faculty's Psychiatry Department), and published in the Sri Lanka Journal of Psychiatry's 16th Volume's Second Issue.
Mental health is a core component of overall well-being; yet, its presentation and determinants often differ significantly across genders. In women, biological factors interact with psychological and social factors to shape distinct patterns of vulnerabilities and experiences. Certain mental health conditions, such as those related to the perinatal period and menopause, are unique to women and require specific clinical recognition and management. In addition, women are disproportionately affected by common mental disorders, including depression and anxiety, with significant implications for functioning and the quality of life.
PMS and PMDD
Premenstrual Syndrome (PMS) and Premenstrual Dysphoric Disorder (PMDD) refer to a range of physical, affective, and cognitive symptoms that arise during the late luteal phase of the menstrual cycle (days 14-28 of the menstrual cycle but will vary per individual and per cycle) and improve after the onset of menstruation, with resolution typically occurring within one week following the onset of menses.
PMS is not included in the current classifications of psychiatric disorders, but, PMDD is recognised in both the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition (DSM-5) and the World Health Organisation's International Classification of Diseases: 11th Revision (ICD-11). Both classification systems require that the symptoms are confined to the luteal phase and include at least one core emotional symptom: depressed mood, irritability or anger, affective lability (the tendency to shift rapidly between states of emotion), or anxiety. In addition, a range of supporting cognitive and physical symptoms may be present, including poor concentration, lethargy, overeating or specific food cravings, hypersomnia (excessive time spent sleeping or excessive sleepiness) or insomnia, breast tenderness, swelling, and joint pain. The DSM-5 further includes decreased interest in usual activities and a sense of being overwhelmed, while the ICD-11 describes an additional cognitive symptom of forgetfulness. Both the DSM-5 and the ICD-11 require that symptoms are associated with clinically significant distress or functional impairment and are not better explained by substance use, medical conditions, or an exacerbation of another mental disorder. The DSM-5 additionally specifies that the diagnosis requires the presence of five or more symptoms. A confirmed diagnosis in both systems requires prospective symptom monitoring over at least two menstrual cycles; otherwise, the diagnosis remains provisional.
The prevalence of PMS among women of reproductive age is estimated to be between 30 per cent and 40%, while PMDD affects approximately 2% to 6% of women.
The neuroactive metabolites of progesterone, particularly allopregnanolone, which rise sharply during the late luteal phase, have been strongly implicated in the pathophysiology of PMS and PMDD.
Selective serotonin reuptake inhibitors (SSRIs) are effective in the treatment of PMDD. However, the optimal dosing regimen (continuous; luteal-phase only; symptom-onset) remains to be determined. In addition to SSRIs, combined oral contraceptives, gonadotropin/gonadotrophin-releasing hormone agonists, and surgical interventions such as ovarian resection have shown benefit in refractory cases.
Perinatal mental health
The perinatal period extends from pregnancy to 12 months postpartum and represents a phase of heightened vulnerability to mental health disorders in women. During this time, complex biological, psychological and social factors interact to increase the risk of psychiatric morbidity, particularly depressive and anxiety disorders.
During pregnancy, psychiatric disorders are most commonly observed in the first and third trimesters. Psychiatric morbidity in the first trimester may be higher due to psychological stress related to unplanned or unwanted pregnancies, miscarriage, ectopic pregnancy (a pregnancy in which the foetus develops outside the uterus, typically in a fallopian tube), hyperemesis gravidarum (severe or prolonged vomiting), and assisted reproductive treatments, including in vitro fertilisation. In contrast, concerns related to childbirth, foetal well-being, congenital abnormalities, and stillbirth become more prominent in the third trimester and may contribute to increased psychiatric morbidity. Psychiatric morbidity during pregnancy is more likely in women with pre-existing medical or psychiatric conditions, while new-onset psychotic disorders during pregnancy remain relatively uncommon.
During the postnatal period, maternal blues are a common and self-limiting condition, affecting approximately 50-70% of women. Symptoms typically emerge within the first few days following delivery, peak around the fourth postpartum day, and resolve spontaneously within two weeks. Affected mothers often present with tearfulness, tension, irritability, and rapid fluctuations in mood, ranging from transient euphoria to misery, without a sustained depressed mood. This condition is thought to result from postpartum hormonal readjustment and is more commonly observed in primiparous (producing a child for the first time, or having produced only one child) women, those who experienced anxiety or depressive symptoms during pregnancy, and women with limited social support.
Postnatal psychosis is a rare but severe psychiatric condition, affecting approximately 0.1-0.25% of women. This term is used as an umbrella to describe psychiatric conditions occurring in the postnatal period in which psychotic symptoms are present, including severe depressive episodes with psychotic features, manic episodes with psychosis, schizophrenia, delirium, and other psychotic disorders. Clinical symptoms typically emerge within the first one to two weeks following delivery and may vary according to the underlying diagnosis. Identified risk factors include primiparity, a personal or family history of psychiatric illness, and single motherhood, while obstetric factors do not appear to have a consistent association. With prompt and appropriate treatment, most women recover; however, the prognosis is poorer in women diagnosed with schizophrenia. Recurrence rates in subsequent pregnancies are estimated to be approximately 20% for depressive disorders and 50-90% for bipolar affective disorder. Depression is the most common psychiatric disorder during the perinatal period. Global prevalence estimates range from 10-20%, while Sri Lankan data indicate rates of eight-23% during pregnancy and seven-32% in the postpartum period. Suicidal ideation and self-harm attempts among affected women have been reported at 5.8% and 0.8%, respectively. In Sri Lanka, maternal suicide remains a significant contributor to maternal mortality; available data indicate that 29 maternal deaths occurred in 2020, with underlying depression likely present in 36.8% of the cases. Psychological autopsy studies are routinely conducted to better understand maternal suicides and to inform preventive strategies.
Risk factors for perinatal depression include a personal or family history of depressive illness, unplanned pregnancy, high neuroticism based personality traits, social adversity such as poor family support or domestic violence, and coexisting medical conditions. Perinatal depression is associated with adverse obstetric outcomes, including premature delivery, as well as longer-term consequences for the child, such as emotional and behavioural difficulties, disorganised attachment patterns, depressive symptoms, and impaired intellectual development. Many postnatal depressive episodes have their onset during pregnancy and may present with prominent fatigue, irritability, or anxiety rather than a persistent depressed mood. Intrusive thoughts, phobias, and obsessions related to harm to the infant may also occur. In Sri Lanka, postpartum maternal mental health is routinely screened using the Edinburgh Postnatal Depression Scale during Medical Officer of Health clinic visits.
In addition to depressive disorders, women, during the perinatal period, may experience anxiety disorders, such as panic disorder, as well as other psychiatric conditions, including obsessive-compulsive disorder (OCD) and eating disorders. Pseudocyesis is a rare condition in which a woman holds a fixed belief that she is pregnant despite the absence of pregnancy.
The management of perinatal mental health conditions should begin with early recognition and timely intervention, as delays in treatment can increase morbidity and adversely affect both the mother and the infant. Careful and ongoing risk assessment is essential, with attention not only to maternal safety but also to the well-being of the infant and the quality of the mother-infant relationship. Mental health during perimenopause and menopause
Perimenopause refers to the transitional period preceding the cessation of menstrual cycles, during which ovarian hormone production becomes increasingly irregular, resulting in fluctuations in the oestrogen and progesterone levels. This phase may begin several years before the final menstrual period. Menopause is defined as the point at which a woman has experienced 12 consecutive months without menstruation, signalling the end of ovarian reproductive functions, and is therefore identified retrospectively. Following menopause, circulating oestrogen levels decline markedly. Perimenopause typically begins in the fourth decade of life, while menopause most commonly occurs in the early 50s. The duration and experience of the perimenopausal period vary considerably between individuals, but, it generally lasts for approximately five years.
Many biopsychosocial changes occur during the perimenopausal period, contributing to increased vulnerability to mood and other psychological symptoms. Fluctuations in oestrogen and progesterone are considered key biological factors underlying these changes. Although oestrogen does not exert a direct effect on mood, it plays an important modulatory role on central neurotransmitter systems, particularly serotonin and noradrenaline. Oestrogen enhances serotonergic activity. Additionally, it increases noradrenergic activity in the brain by reducing neurotransmitter reuptake and degradation.
Within this biological and psychosocial context, many of the core symptoms experienced during the perimenopausal period have important mental health implications. These include vasomotor symptoms such as hot flushes and night sweats, genitourinary symptoms, including vaginal dryness, mood-related symptoms such as low mood and anxiety, musculoskeletal complaints, including joint and muscle pain, and sexual difficulties, most commonly reduced sexual desire.
Among the psychiatric conditions associated with this period, depressive disorders are estimated to affect approximately 34% of women. It is more frequently observed during the perimenopausal period, when ovarian hormone levels fluctuate, rather than after menopause, when hormonal levels are relatively low and stable. The strongest predictors of depressive disorders during this period include a personal history of depression and previous premenstrual or postpartum mood disorders.
There is substantial overlap between depressive symptoms and symptoms associated with perimenopause. Features such as low mood, irritability, anxiety, reduced interest, low energy, impaired concentration, sleep disturbance, reduced libido, and subjective memory difficulties may be present in both conditions. Insomnia is a common and often debilitating symptom during the perimenopausal period. It may occur as a primary symptom related to declining or fluctuating oestrogen levels, or secondarily as a consequence of vasomotor symptoms such as hot flushes and night sweats. Insomnia may also occur as part of a depressive disorder or, conversely, contribute to the development or exacerbation of depression, anxiety, irritability, and psychological distress.
In addition to mood and sleep disturbances, a range of anxiety and severe mental disorders may emerge or worsen during the perimenopausal period. Anxiety-related presentations are particularly prominent, with some women experiencing a new onset of panic disorder or an exacerbation of previously diagnosed panic symptoms. These symptoms appear to be more commonly observed during perimenopause than in the postmenopausal period and are often characterised by prominent somatic features. Similarly, OCD may newly emerge or worsen during this phase, and there are changes in the pattern or severity of symptoms in pre-existing OCD. The exacerbation of bipolar affective disorder may occur during perimenopause, with depressive episodes reported more frequently than manic episodes. In addition, it has been suggested that the higher prevalence of late-onset schizophrenia in women compared with men may, in some cases, be temporally associated with the menopausal transition.
Memory impairment is also a common complaint among women during the menopausal transition. Cognitive difficulties may occur as an intrinsic feature of menopause or be secondary to co-occurring conditions such as depression or mild cognitive impairment. Oestrogen has been recognised for its neuroprotective and neuromodulatory effects, promoting neurogenesis, enhancing synaptic plasticity, and facilitating neurotransmission in brain areas crucial for memory and executive functioning, including the prefrontal cortex and hippocampus. Declining estrogen levels during menopause are associated with reduced serotonergic, cholinergic, and dopaminergic activity, all of which play essential roles in cognitive processing and attention. In addition, oestrogen contributes to cerebral perfusion and glucose metabolism; therefore, reduced oestrogen levels may impair neuronal energy utilisation and synaptic efficiency, resulting in both subjective and objective memory difficulties during menopause.
Mental health conditions with female predominance
Depressive and anxiety disorders are consistently more prevalent in women than in men across the lifespan. Although reproductive transitions influence risk and presentation, these sex differences persist beyond such stages. Standard psychiatric epidemiology indicates that rates of major depression are approximately twice as high in women as in men across different cultures, and women also experience a greater non-fatal disease burden, reflected in higher years lived with disability. Anxiety disorders likewise show female predominance, although the magnitude varies by diagnosis, with generalised anxiety disorder, panic disorder, and agoraphobia occurring more frequently in women, while social anxiety disorder shows smaller sex differences between community and clinical samples. Overall, the higher prevalence of depressive and anxiety disorders in women is thought to reflect a multifactorial interplay of biological sensitivity to stress, internalising psychological coping styles, disproportionate exposure to interpersonal and gender-related stressors, and differences in help-seeking behaviour and diagnostic practices.
Eating disorders show one of the most pronounced sex differences in psychiatry, with a clear predominance among women. Anorexia nervosa is particularly more common in females, with female-to-male ratios often reported in the region of 10: one, while bulimia nervosa also shows female predominance, although with a less marked sex difference. The female predominance in eating disorders is thought to reflect a complex interaction of biological vulnerability, psychological traits such as perfectionism and harm avoidance, and sociocultural influences related to body image and weight-related ideals. From a biological perspective, vulnerability to eating disorders may be influenced by sex differences in how appetite, stress, and reward are regulated, as well as by the effects of gonadal hormones on neural circuits involved in eating behaviour and emotional regulation.
Certain personality disorders are diagnosed more frequently in women, with borderline personality disorder being the most prominent example in the clinical practice. Women are over-represented in clinical samples of borderline personality disorder, while population-based studies suggest that sex differences in prevalence are less pronounced than those observed in treatment settings. This discrepancy highlights the influence of help-seeking behaviour and diagnostic practices, rather than clear differences in underlying vulnerability. Differences in symptom expression may further shape recognition pathways, with women more likely to present with affective instability and self-harm, while men may more often exhibit externalising features such as impulsivity and anger. Higher rates of interpersonal trauma, particularly sexual trauma, alongside gendered patterns of emotional socialisation, are also thought to contribute to observed sex differences in clinical presentation and diagnosis. Histrionic and dependent personality disorders have also been diagnosed more commonly in women in clinical settings, although observed sex differences appear modest and are likely to be strongly influenced by sociocultural expectations and diagnostic practices.