Enone McKenzie, consultant psychiatrist at The Soke, a private clinic integrating mental healthcare, wellbeing and performance coaching, explains why we should bridge the hormonal gap in mental healthcare.
Despite decades of progress in mental health awareness, one critical aspect remains chronically under-recognised: the powerful role of hormones in shaping women’s psychological well-being. Women are twice as likely as men to experience depression and anxiety, yet the profound impact of hormonal fluctuations on mental health remains one of the most overlooked aspects of clinical practice.
Hormones are not just reproductive messengers – they are central players in the regulation of mood, motivation, memory, and behaviour. By interacting with neurotransmitters like serotonin and dopamine, their cyclical patterns create unique vulnerabilities that demand specialised attention.
The statistics are sobering. Premenstrual dysphoric disorder (PMDD) affects 1.6% of women, while up to 8% experience premenstrual exacerbation (PME) of existing mood disorders. During perimenopause, the risk of depression increases by 40% compared to those not experiencing menopausal symptoms, coinciding with the age bracket that sees the highest rate of completed suicide among women. Postpartum depression impacts nearly one in five mothers within the first year of childbirth – but half go undiagnosed or unsupported.
These conditions share a common thread: abnormal reactions to normal hormonal changes. When these responses go unrecognised, they can lead to misdiagnoses, delayed treatments, and unnecessary suffering.
It’s time to reframe the conversation around women’s mental health – with hormone literacy at its core. So how do we do that?
Integrate hormonal assessment into every mental health evaluation
From puberty to post-menopause, women’s mental health cannot be accurately understood without considering the hormonal landscape in which it unfolds.
PMDD, for example, takes over a decade on average to be properly diagnosed and PME is rarely recognised or diagnosed, leading to missed opportunities for optimal treatment. The onset of postnatal depression (PND) can be gradual and persist for months before diagnosis. The symptoms of perimenopausal depression are often mislabelled as generalised anxiety or stress attributed to being in the sandwich generation, with too many demands placed on women, rather than the root cause being considered. This can all lead to unnecessary or suboptimal treatment with psychotropic medications.
There are however a number of simple yet transformative interventions that can be utilised. These include: incorporating menstrual, pregnancy, and menopausal history into all mental health assessments for women of reproductive age; focusing on cycle patterns; tracking the timings of symptom onset; and exploring the links to hormonal transitions.
Consider hormonal therapies as first-line interventions for hormonally driven mental health symptoms
There is growing recognition in UK clinical guidance that hormone therapies should be considered as first-line treatment for hormonally driven mental health symptoms, particularly when symptoms coincide with reproductive transitions such as perimenopause or present with clear cyclical patterns.
The National Institute for Health and Care Excellence (NICE) recommends hormone replacement therapy (HRT) as a primary intervention for the mental health effects of menopause, advising against the use of antidepressants unless a depressive disorder is clearly present.
Similarly, expert consensus supports the use of hormonal treatments – ranging from combined oral contraceptives to transdermal oestradiol with progestogen, and even GnRH analogues with add-back HRT – for managing severe premenstrual disorders like PMDD and PME. These therapies can offer mood stability, symptom relief, and an alternative to unnecessary psychotropic medication.
Recognising the hormonal root of a condition doesn’t mean dismissing psychological distress – it means treating it effectively, at the source.
Educate, collaborate, and advocate for integrated care
The evidence is clear: hormonal fluctuations can be identified within a significant percentage of mental health presentations in women, yet this connection remains systematically overlooked.
When treating women with hormonal mental health difficulties, it is crucial to recognise and address all aspects of each individual’s needs, as hormonal fluctuations can affect mental, emotional, and physical well-being in unique ways, requiring a personalised approach. A holistic perspective is essential. Comprehensive education about hormonal impact on mental health, as well as how to manage existing conditions exacerbated by hormonal fluctuations, is central to caring for women.
A multidisciplinary approach, involving collaboration between psychology, psychiatry and psychotherapy, is especially important – considering the needs of the individual as well as the families. Further interventions like nutrition, stress management, and mind-body practices can complement medical and psychological therapies and support overall hormonal balance. Furthermore, bringing together expertise from mental health, primary care, gynaecology and other specialities ensures comprehensive care, coordinated treatment, and shared decision-making.
As clinicians, we have a responsibility to bridge this hormonal gap in mental healthcare. By acknowledging the central role of hormones in women’s psychological well-being, we can shift from reactive treatment to proactive, personalised care, transforming outcomes for millions of women whose suffering has been dismissed as stress or inadequately treated with standard approaches.
We hope that our colleagues in the industry also adopt this approach, believing that women’s hormonal mental health needs to be a clinical priority and is fundamental to providing equitable, effective healthcare for half our population.
