We hear a lot about the male loneliness epidemic, but loneliness is just as common in women. One survey¹ across 142 countries found that one in four women feel very or fairly lonely, the same proportion as men, and in more than half of those countries women reported higher loneliness than men did. Our circles are shrinking too. In the US, the share of women with six or more close friends fell from 41 percent in 1990 to 24 percent in 2021².

Yet female loneliness rarely makes the headlines, despite what we know about the impact of social connection on health. It can also carry a particular kind of shame. Women are expected to be naturally good at friendship, and social media is full of close-knit girl gangs. When that is not your experience, it is easy to assume the problem is you.

In this episode I talk to psychotherapist Yvonne Richter about why adult friendships can feel so hard, how big life transitions test old friendships, and why they make new ones harder to find. We also cover how attachment style shapes the way we read a silence, why envy deserves a place in the conversation, and what you can do this week if you feel lonely.

Guest Bio

Yvonne Richter is a psychotherapist who leads Revive Mental Health, a Singapore-based practice supporting international women, in person and online. She holds a Postgraduate and Professional Diploma in Psychotherapy and Counselling, has additional training in perinatal mental health, and is a provisional clinical member of the Singapore Association for Counselling. Her work focuses on the challenges women face after moving abroad, including identity, self-worth, loneliness, fertility, pregnancy loss and perimenopause.

What We Cover

00:02:16 The loneliness nobody talks about

• Why female loneliness stays hidden, and the shame of not having a “girl gang”

• How you can be surrounded by people and still feel unseen

00:05:05 Expectations, attachment and the friends we choose

• Do women ask more of their friendships than men do?

• What an unanswered message reveals about your attachment style

00:08:08 Is there a magic number of friends?

• Why the social media version of friendship sets an impossible bar

• Treating loneliness as a signal, much like hunger

00:11:02 Why making friends gets harder as an adult

• What school and university gave us that adult life takes away

• The number of hours it takes to turn an acquaintance into a close friend

00:15:09 Champagne friends and life away from home

• What I saw as a doctor in Hong Kong during COVID

• Losing the “mirrors” that reflect back who we are

00:18:50 Old friends, new goodbyes

• Practical ways to stay close to friends in another time zone

• The cost of protecting yourself from people who might leave

00:25:02 The upside of starting again

• Why expat communities can be fertile ground for friendship

• Finding yourself again in a second language

00:29:23 Who am I here?

• Identity, authenticity and belonging after a move

• Why your partner cannot be your only source of connection

00:34:54 How to make new friends

• Starting with what gave you joy when you were younger

• The step that turns a classmate or gym buddy into a friend

00:38:28 Envy, motherhood and friendships that change

• Why envy reflects your own pain rather than your character

• Making and keeping friends through new motherhood

Key Takeaways

• Adult friendships take time. Take the conversation beyond the place you met, even if it is just a coffee after class.

• Let people see a little more of you, be vulnerable, and be the one who makes the next invitation.

• A friendship can matter even if it does not last. Don’t be afraid to open up anyway.

^{1- Gallup, Meta. The Global State of Social Connections. Washington, DC: Gallup; 2023.}

^{2- Cox DA. The State of American Friendship: Change, Challenges, and Loss. Washington, DC: Survey Center on American Life, American Enterprise Institute; 2021.}

Further Resources and Support

Loneliness and social connection

• WHO Commission on Social Connection Global evidence, reports and resources on loneliness and social connection.

• Global Initiative on Loneliness and Connection An international network of organisations working to reduce loneliness.

• Foundation for Social Connection US-based organisation with research and practical tools on building connection.

• Campaign to End Loneliness UK campaign with research and guidance on loneliness across adult life.

• Ending Loneliness Together Australian network offering resources and a directory of local connection services.

• Marmalade Trust Charity behind Loneliness Awareness Week, with resources for anyone feeling lonely.

Meeting people and building friendships

• Meetup Find local groups and events built around shared interests, in cities worldwide.

• Bumble For Friends An app designed for meeting people who are also looking for new friends.

• InterNations An international community for people living abroad, with local events and groups.

Motherhood and new parents

• Peanut An app for connecting with other women through fertility, pregnancy, motherhood and menopause.

• Postpartum Support International Support, online groups and help finding perinatal mental health care around the world.

Disclaimer

The content of this podcast and these show notes is for educational purposes only. It is not intended to replace the doctor-patient relationship, nor does it constitute personalised medical advice. If you are affected by any of the topics discussed, please speak to your doctor or a qualified healthcare professional. If you are in crisis or worried about your safety, contact your local emergency services or a crisis helpline straight away.

Of all the topics in health, what you ‘should’ be eating, has got to be the one crowded with the most conflicting views and just so much misinformation.

One week the advice is to count calories, the next calories are insignificant and it’s all about macros. Except not carbohydrates. Never carbohydrates, unless you are fibremaxxing, in which case, pile on the carbs, they’re good for you. You should be fasting, we all eat too much and too frequently, but not if you’re a woman. Then fasting is bad for you. Saturated fat is the devil. No, sugar is the ultimate fiend. The continuous flip-flopping of conflicting, yet seductive advice is exhausting. And much of it is of course targeted at and absorbed by women. It’s so common that I hear from frustrated women; I simply do not know what to eat anymore.

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So with these women in mind, I sat down with academic dietitian, , to put the biggest diet claims to the test. We look at what the research actually shows on calories, keto, fasting, glucose spikes with continuous glucose monitors (CGMs), ultra-processed foods and menopause, and finish with her simple, practical and evidence based way to build your meals.

For those of you that have been on a diet treadmill your entire lives, I hope you come away with more clarity, and less fear around food.

Guest Bio

Dr Nicola Guess is an academic dietitian and nutrition scientist at the University of Oxford, registered as a dietitian in both the UK and the US. Her research focuses on how diet can prevent and manage type 2 diabetes, with particular expertise in glucose regulation, insulin resistance, fatty liver and cardiometabolic health. She holds a PhD from Imperial College London and a Master of Public Health from Florida International University. Alongside her research, she runs a clinical practice supporting people with cardiometabolic disease and glucose dysfunction, and writes about which nutrition claims hold up to scrutiny on her Substack, Dr Guess’s Blog.

What We Cover

02:47 Does a calorie deficit still work?

• The viral claim that your body simply burns 500 fewer calories, and what it gets right and wrong

• What actually helps you keep weight off once it has gone

06:03 Keto, insulin and the “fat-burning” theory

• The tightly controlled study that put the insulin hypothesis to the test

• Where ketones may genuinely help, from type 2 diabetes to Nicola’s own trial in treatment-resistant depression

19:15 Should you be afraid of carbohydrates?

• Why sweet potatoes and bananas deserve a place on your plate

• When a low-carb approach can still be the right fit for someone

23:13 Glucose monitors and the fear of spikes

• Why a reading of 7.8 on a CGM does not mean prediabetes

• How last night’s dinner or a spin class can change today’s numbers

32:31 Can a CGM help you lose weight?

• What the evidence says, and the problem with “dressing your carbs”

• One encouraging finding for people with type 2 diabetes

34:29 Ultra-processed foods and the snack aisle

• What the landmark ultra-processed food trial may really be telling us

• Does the texture of your crisps matter? Separating fact from fiction

42:40 Fibre maxxing

• Water, volume and why some foods fill you up for fewer calories

• How a high-fibre diet may change the calories your body absorbs

44:45 Fasting and meal timing

• A surprising finding about meal frequency and insulin

• Early eating windows, fasting days and longer fasts: who they suit

52:35 Menopause, metabolism and body shape

• Does your metabolism really slow down at menopause?

• The type of fibre that may help protect body composition

55:56 Nicola’s plate, and the myth she most wants to bust

• A simple template for lunch and dinner

• Why fear of additives may be getting in the way of healthy eating

Key Takeaways

• Keto, fasting and meal timing are all ways of eating less. The best approach is the one you can sustain.

• If you don’t have diabetes, there is no need to fear the glucose rise after fruit, sweet potato or oats on CGMs.

• A calorie deficit works for weight loss, but keeping the weight off depends on building muscle and choosing foods that keep you full.

Further Resources and Support

Evidence-based nutrition

• World Health Organization: Healthy diet: Global guidance on the foundations of a healthy diet.

• The Nutrition Source: Healthy Eating Plate: Harvard T.H. Chan School of Public Health’s visual guide to building balanced meals.

• British Dietetic Association: Food Fact Sheets: Free, dietitian-written fact sheets on fibre, protein, weight and more.

Finding a qualified dietitian

• International Confederation of Dietetic Associations: Links to national dietetic associations around the world.

• Academy of Nutrition and Dietetics: Find a Nutrition Expert: Directory of registered dietitians in the United States.

• Dietitians Australia: Find an Accredited Practising Dietitian: Directory of accredited dietitians in Australia.

Weight and obesity

• World Obesity Federation: Global organisation working to improve prevention and treatment of obesity.

• Obesity Action Coalition: Education, support and advocacy for people living with obesity.

Blood glucose and diabetes

• International Diabetes Federation: Global information on preventing and managing diabetes.

• Diabetes UK: Information on prediabetes, type 2 diabetes and blood glucose testing.

• American Diabetes Association: Resources on diabetes risk, diagnosis and healthy eating.

Menopause and midlife health

• International Menopause Society: Global, evidence-based information on menopause and midlife health.

• The Menopause Society: North American society offering patient resources and a practitioner directory.

• Australasian Menopause Society: Fact sheets and a directory of menopause practitioners in Australia and New Zealand.

• Women’s Health Concern: Patient arm of the British Menopause Society, with clear fact sheets.

Physical activity and strength

• World Health Organization: Physical activity: Global recommendations on activity, including muscle-strengthening exercise.

Support with food and eating

• National Alliance for Eating Disorders: Helpline, support groups and treatment referrals in the United States.

• Beat: UK eating disorder charity offering helplines and online support.

• Butterfly Foundation: Support for eating disorders and body image concerns in Australia.

Disclaimer: This episode and these show notes are for general information and education only and do not constitute medical advice. Always speak to your doctor, a registered dietitian or another qualified health professional before making changes to your diet, medication or exercise routine, particularly if you have diabetes, a heart condition, a history of disordered eating, or are pregnant or breastfeeding

We shouldn’t have to work this hard to be heard

Whenever I talk about helping women advocate for themselves, I’m met with understandable frustration: why should this be necessary at all? Why should someone who is already managing pain, illness and everything else in her life have to become an expert in her own condition before she has a chance of being believed?

I agree. Good care shouldn’t depend on how confidently you speak, how precisely you describe your symptoms or whether you know the right medical terminology. You should be able to arrive frightened, uncertain or struggling to explain yourself and still receive thoughtful care. But we also have to be realistic about the current state of the healthcare system and the fact that the women who need help now, don’t have time to wait for the system to become what it should be.

Why being heard can be difficult

As you’ve probably already heard repeated elsewhere, research in women’s health and our knowledge about female-specific and female-predominant disease, has important gaps. That’s not to say there is no research or that our physiology is completely different from men, but there are still too many women’s health conditions that we don’t understand enough about. And too often the attention (and funding) given to them has centred on fertility rather than their wider effects on a woman’s health.

Healthcare is also horribly fragmented. If you have a condition that fits neatly under the umbrella of one speciality it can be easier to navigate, but for many women’s health conditions, whose symptoms and complications span specialities, it can be more difficult to find someone to piece the puzzle together. A woman may see one doctor for pelvic pain, another for bowel symptoms and another for chest pain, and for conditions like endometriosis, PMOS and even perimenopause to name just a few, that can mean treating each symptom separately rather than someone looking after the whole woman.

Then there are the beliefs that we have all absorbed about women’s bodies and women’s pain. “Periods are painful. Childbirth is painful. It’s just our lot and we need to get on with it.” Sometimes that message is passed down through generations from mother to daughter. Sometimes from a clinician who’s been taught to believe this herself.

They’re assumptions carried by men, women, doctors and patients alike. We see them in female doctors that surreptitiously roll their eyes when confronted with the severe ‘period pain’ of a chronic endometriosis sufferer. We see them in the male gynaecologist who keeps trying to bring the conversation back to fertility despite that not being the main concern. We see them in women themselves who wait longer to call an ambulance for themselves when they have chest pain and are more likely to put it down to anxiety.

Whilst I won’t go into it any detail here, because it deserves an article of it’s own, there are also the downstream effects of what happens to ‘carers’ in a system that does not seem to care about them. There is a hardening, an armour formed, that impacts compassion, empathy, patience and a willingness to delve beyond what is common, familiar and easily ‘fixable’.

All of this leaves women struggling to have their concerns properly considered. And it’s compounded by the fact that when we’ve been dismissed often enough, it starts to change how we behave. We start to explain away our own symptoms, in direct conflict with our innate intuition about our bodies. We minimise, apologise and wait longer than we should to seek help the next time.

I know, because I did it myself.

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When the doctor becomes the patient

Before my thoracic endometriosis was diagnosed, I had experienced multiple episodes of severe chest pain. Whenever I saw a doctor, investigations failed to identify a cause. I was sure there was something serious underlying it all, but eventually, I resolved to just get on with it and stop making a fool of myself by continuing to turn up. After all, I was also a doctor in the community and didn’t want to lose credibility with my own colleagues, who I was worried were beginning to think I was a hypochondriac.

I turned my focus to motherhood, a new baby and work. But a few years later, the chest pain returned and was worse. After a few months of burying my head in the sand, I had a stern word with myself about the possible dangers of continuing to brush it under the carpet, steeled myself for what was to come and asked my GP for a referral to a respiratory physician.

I should have taken the first consult as a sign; when I told her about my medical history including multiple bowel obstructions and surgical injury, she laughed. I wish I’d asked to see someone else right then, but at the time, I told myself that if she was skilled enough to work out what was going on, that mattered more than her bedside manner.

I mentioned that I thought I was having recurrent small lung collapses, although at that point I had not put that together with my endometriosis. However, the CT she ordered at the time was normal and she let me know in no uncertain terms what she thought of my unresolved symptoms. “I don’t know what you expect me to do for you”, were her parting words.

Completely belittled, I decided to draw a line under it and vowed to never to mention my chest pain in a medical setting again.

A few months later the chest pain was back with a vengeance. I very nearly kept to the promise I had made to myself and got on the plane for a trip I was very much looking forward to the next day. But something told me to just try one more time (made possible only because by then I had found a lovely GP who I trusted).

I had a massive right sided lung collapse. Had I got on that plane, my outcome could have been life-threateningly different. I had come incredibly close to ignoring my symptoms because of my previous experiences. Something I fear is all too common.

Why I share this advice

What happened next was another ordeal to be believed that my lung collapse was because I had endometriosis growing in my chest like I said it was. Once I’d finally had the correct surgery, I couldn’t help thinking about how someone without my background and the confidence to advocate for herself, would have navigated the same situation. What might have helped her explain her concerns? What could she ask if the explanation didn’t fit? How would she know when to seek another opinion?

I know how much many of my colleagues care. But I also know that good intentions do not always translate into good care. We can miss things, have gaps in our knowledge, we can become too attached to an initial, familiar explanation. As a patient, you shouldn’t have to manage those shortcomings. But understanding how to describe your concerns, ask about your doctor’s reasoning and establish what happens next can help you get more from a consultation.

I acknowledge that some of these suggestions depend on having choices. Changing doctors, attending further appointments and seeking another opinion take time, energy and sometimes money and I appreciate that those options are not always equally available to everyone.

It’s also important to say that if you have been dismissed, as I was, the fault doesn’t lie with you. These suggestions are simply things I’ve found useful as a patient myself, and as a doctor, they’re the things I wish every woman knew before walking into any consultation.

My top things to help you be heard

It’s completely reasonable to research your symptoms and bring questions to your doctor.

You’re allowed to be informed and curious about your health. A patient who wants to take an active part in her care is, in many ways, a gift to us. There may be good reasons why your doctor doesn’t think something applies to you, but they should be able to discuss what you’ve read respectfully and explain their thinking.

If you’re worried about a particular condition because of your family history or a previous experience, say so. “I’m concerned about endometriosis because the pain follows my cycle. Does that fit?” This gives them the chance to reflect, decide whether it needs exploring, and if not, tell you why.

Keep a record of your symptoms, including their timing, frequency and any patterns you notice.

In short, pressured appointments, it can be hard to find the right words: when the symptoms started, what makes them better or worse, which medications you’ve tried. A symptom diary helps. It gives you insight into what’s happening, and it gives your doctor information they can work with. If your symptoms seem to change with your menstrual cycle, sleep or activity, record that too.

If you have a long medical history, write it down and bring it to each new doctor. Yes, they should have read your notes. But notes are often incomplete, whether because entries lack detail or because different systems don’t talk to each other. If your history is complicated, a doctor who knows you well can help you condense it.

Describe what’s happening without minimising it.

Use your notes to explain your symptoms and their impact. “The pain wakes me three nights a week and I’ve stopped exercising” tells me far more than “I get some pain.”

And try to resist softening what you’ve said with “But it’s probably nothing” or “It’s not that bad really.” A doctor may take that reassurance at face value, particularly if you don’t match their idea of what an unwell person looks like. It’s better to just be direct.

Ask what the doctor thinks is happening, and what else they’re considering.

A useful question is: “What’s your working diagnosis?” That means the explanation they currently think is most likely, even if it hasn’t been confirmed. It makes us think. You can follow up with: “What else could explain this?” and “What makes you favour that explanation?” Understanding their reasoning helps you make sense of the plan, and tells you what might need reconsidering if things don’t improve.

A doctor admitting uncertainty is not necessarily a bad sign. What they do next matters.

“I don’t know yet” doesn’t mean you have a bad doctor. The question is what happens next. Will they investigate, seek advice, refer you or arrange to review how things develop? A doctor who recognises the limits of their knowledge and asks for help, rather than brushing you off with the wrong explanation, may be exactly the person you need.

Never feel too embarrassed to ask for a second opinion.

If a problem feels unresolved or is getting worse, if you don’t feel listened to, or if you’re facing a major treatment decision, I’d strongly encourage it. After my X-ray showed a the large lung collapse, I had to see three consultants at different hospitals before I found one willing to consider thoracic endometriosis as the underlying cause and treat it accordingly.

Ask your team directly whether a colleague with particular expertise could give a second opinion, or ask your GP for a referral elsewhere. Many specialists also offer online consultations for case reviews and advice.

Tell a new doctor if past experiences have made it hard to trust.

You don’t have to pretend those experiences haven’t affected you, and being open about it may help the new doctor have the context to understand what you need from them. You could say: “I’ve felt dismissed about this before, so I’m anxious about explaining it again.”

Here are some links to recent podcast episodes that touch on theme of how to advocate for yourself:

In the UK, maternal mortality is now around 20% higher than it was fifteen years ago and the reasons for that are complex. More women are entering pregnancy with long-term health conditions. Services are stretched, care before and after pregnancy is patchy, and too many women describe raising concerns that were not taken seriously.

The risk is also unequal. Black women are almost three times more likely to die in pregnancy or the year after birth than White women, and women in the most deprived areas face around double the risk. The UK is not alone in this. Similar inequalities are seen in other high-income countries, including the United States.

In this episode I speak with Dr Jacqueline Bamfo, consultant obstetrician and maternal fetal medicine specialist, about what is driving these figures and what you can do about them. We cover the conditions to know, the warning signs to act on, and practical ways to make sure your voice is heard before, during and after pregnancy.

Guest Bio

Dr Jacqueline Bamfo is a Consultant Obstetrician and subspecialist in Maternal Fetal Medicine at Luton and Dunstable University Hospital, where she leads the fetal medicine, antenatal screening and preterm birth services. With 25 years in obstetrics and a decade as a consultant, her clinical interests include high-risk pregnancy, preterm birth and fetal growth.

What We Cover

02:39 Why are maternal deaths rising?

• The factors that may sit behind the UK’s worsening figures

• Why comparing countries is more complicated than it looks

04:31 The appointment before the pregnancy

• Pre-pregnancy counselling, and who would benefit most from it

• Why Jacqueline calls the booking appointment the jewel of antenatal care

07:26 The gap after the six-week check

• Why postnatal support varies so much depending on where you live

• What to do if you’re struggling after birth and do not know where to turn

11:01 Why the risk is not equally shared

• The leading causes of maternal death, and how risks build on one another

• Where deprivation, ethnicity and bias fit into the picture

13:23 Inside a stretched system

• How the women arriving on the labour ward have changed over two decades

• Burnout, staffing and what it would take to keep midwives and doctors

18:28 The conditions every pregnant woman should know about

• Blood clots, high blood pressure and pre-eclampsia, explained

• The weathering hypothesis and how chronic stress may affect the body

23:37 How to be heard

• Why even Serena Williams struggled to be listened to

• The questions to ask, when to seek a second opinion, and why antenatal classes matter

28:08 Is the gap really narrowing?

• What the improving figures for Black women may and may not mean

• The role community campaigns have played in amplifying women’s voices

29:27 Continuity of care, doulas and free birthing

• How to get consistent care when you see a different person each time

• Jacqueline’s view on doulas, and what she would say to women considering free birth

36:54 Practical advice for every stage

• What to do before pregnancy, at your booking appointment and at your postnatal check

• Why the time between pregnancies matters more than many women realise

Key Takeaways

• Prepare before you are pregnant. If you have a long-term condition, a previous complicated pregnancy or a history of mental illness, ask your doctor to help you get as well as possible first.

• Know the warning signs. If something does not feel right at any stage, call your midwife or maternity unit and advocate for yourself.

• Ask questions and escalate when you need to. You are entitled to a second opinion, and bringing someone you trust to appointments can help.

• Pay attention to the year after birth. Tell someone how you are really feeling, and if a pregnancy condition needs monitoring, do not wait until the six-week check.

Further Resources and Support

Pregnancy information and warning signs

• Tommy’s: Evidence-based pregnancy information, including planning for pregnancy and symptoms not to ignore.

• Royal College of Obstetricians and Gynaecologists: Patient information leaflets on pregnancy conditions and birth.

• American College of Obstetricians and Gynecologists: Patient guides covering pregnancy, labour and postpartum care.

Pre-eclampsia and blood clots

• Action on Pre-eclampsia: Information and a helpline for women affected by pre-eclampsia.

• Preeclampsia Foundation: International patient education and support on hypertensive disorders of pregnancy.

• Thrombosis UK: Information on blood clots, including risk and symptoms in pregnancy.

Black maternal health and equity

• Five X More: Campaign and charity working to improve maternal outcomes for Black women.

• Black Mamas Matter Alliance: US-based alliance advocating for Black maternal health, rights and justice.

Perinatal mental health

• Postpartum Support International: Helpline, peer support and a directory of perinatal mental health support worldwide.

• Action on Postpartum Psychosis: Information and peer support for women and families affected by postpartum psychosis.

• PANDAS Foundation: Support for parents experiencing perinatal mental illness.

Birth rights, advocacy and support

• Birthrights: Information on your rights and choices in pregnancy and childbirth.

• Make Birth Better: Support and resources for anyone affected by birth trauma.

This episode and these show notes are for general information and education only and do not constitute medical advice. Every pregnancy is different. Please speak to your own doctor, midwife or healthcare provider about your individual circumstances. If you are worried about your health or your baby’s health, contact your maternity unit or seek urgent medical care.

Of course, hormones are a major cause. Vasomotor symptoms (hot flushes) from falling oestrogen frequently disrupt sleep, and this can happen even when a woman isn’t aware of having had night sweats. Falling progesterone also plays a role through the withdrawal of its sedative effect on the brain. So it’s unsurprising that menopause hormone therapy (MHT) improves sleep quality in many women at midlife. But it isn’t a sleep panacea for all women.

I’ve said this before but it’s important to remember that not every symptom at midlife can be blamed on the menopause, and in this case, not every sleep problem is hormonal. Midlife is a perfect storm of reproductive ageing, somatic ageing, career stress, caring responsibilities and everything else that comes with being an adult woman in today’s world, all colliding at once. It’s absolutely right that perimenopause and menopause are now considered much more often as a cause of symptoms; hormones are important to so much more than reproduction. But we should be wary of swapping one blind spot for another.

If you’re a woman at midlife whose sleep hasn’t improved on MHT, these are some of the causes that commonly get missed.

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Ageing

This isn’t one that you can do anything about but some of what happens to sleep in our forties and fifties would happen even without menopause. More frequent and longer nocturnal awakenings are common with age and happen to men too.

As we get older, sleep becomes lighter and more broken. We spend less time in deep sleep and we wake more often. When we’re younger, these wakings at the end of each sleep cycle are so short that we never remember them, but with age they get longer. Long enough for us to notice, perhaps that we have a half full bladder and to get anxious about the fact that we have woken up… again.

But these night awakenings have little to do with our hormones and everything to do with our ageing brains. Sometimes understanding that as normal physiology can help to reduce the anxiety that can come with night wakings, that is often the true culprit of chronic poor sleep.

Restless legs syndrome

This gives you an urge to move your legs and is thought to be due to a dopamine imbalance in the brain, that can be triggered by low brain iron in people who are genetically susceptible. Usually the urge is accompanied by an uncomfortable crawling, fizzing or aching sensation and tends to start at rest and is worse in the evening and at night. Many people also have small, repetitive leg jerks during sleep that cause sleep disruption, even though they may not be aware of them.

It’s around twice as common in women as in men and becomes much more common with age. It’s also closely linked with hot flushes and night sweats, which is one reason it gets lost among menopausal symptoms. One clue is that if you had restless legs in pregnancy, you’re more likely to develop them again later in life.

Low iron is one of the biggest fixable contributors and you don’t need to have co-existing anaemia for it to matter. New guidelines from the American Society of Haematology now define iron deficiency as a ferritin of 30 or below, or 50 or below if you have heavy periods, which are common in the perimenopause. For restless legs, sleep specialists usually aim higher still; typically a ferritin of 75 to 100.

MHT won’t impact restless legs directly; though it might improve things if it’s related to your hot flushes or heavy bleeding causing iron deficiency, but the evidence for it improving restless legs itself isn’t there.

Obstructive sleep apnoea

Obstructive sleep apnoea (OSA) is hugely under-recognised in women. One recent review estimated that up to three quarters of women with OSA are undiagnosed.

Much like heart disease, where the model for what is abnormal has been shaped by what is commonly abnormal for men, disease in women with OSA go undiagnosed because we don’t always present like men. Not only that, but even if you do present in the ‘classic’ way, you will score less than a man simply because you’re a woman (being a man gets you an automatic point)! And it uses a neck circumference cut off that few women will ever reach.

As such, we have developed a biased picture of what OSA actually looks like; a middle aged man, with overweight or obesity, with a bulky neck, that contributes to a narrowing of the relaxed airway with sleep causing loud snoring. The narrowing briefly lowers oxygen levels, briefly pulling the person out of deep sleep, before the sequence is repeated, often hundreds of times a night.

But what evidence is only just discovering, is that women are less likely to present like this and more likely to report insomnia, fatigue, morning headaches, low mood and poor concentration, and needing to get up at night to pass urine. Almost every one of those overlaps with menopausal symptoms, which is why if your doctor doesn’t think about OSA, it will probably be missed, and it won’t get better with MHT either.

Getting a diagnosis matters because untreated OSA is linked to high blood pressure, diabetes and heart disease, but it is very treatable once the diagnosis is made.

Genitourinary syndrome of the menopause

Now I know I’m supposed to be talking about causes that aren’t hormonal here, but I’ve added this one for a reason.

Genitourinary syndrome of the menopause (GSM) doesn’t just cause vaginal symptoms like burning, itching and pain with sex; it can also lead to bladder urgency, frequency, recurrent urine infections and the need to get up at night to pass urine. The latter can obviously have a significant impact on sleep.

But somewhere between one in ten and one in four women on MHT will continue to experience these symptoms unless they also receive topical vaginal oestrogen alongside. So even if you are on MHT, if you’re waking frequently to go to the loo at night, it may be a lack of vaginal oestrogen that is the cause.

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There are of course many other lifestyle related factors that can impact sleep, which I haven’t gone into here and need to be addressed if you're that woman whose sleep has fallen off a cliff at midlife. But the main takeaway is once lifestyle and hormonal change have been addressed, don’t stop there if your symptoms are still ongoing.

Listen to my recent episode of my podcast ‘How To Be A Woman’ with Dr Oliver Bernath:

I recently sat down with Dr Oliver Bernath, a consultant neurologist and sleep physician, to delve into all of this. We talk about what oestrogen and progesterone actually do to sleep, how much MHT can realistically be expected to help, and why waking in the night is a normal feature of ageing. We also cover the conditions that get missed in women, what to do with the numbers your ring or watch gives you every morning, which supplements are worth trying, and the advice he gives every woman who is struggling to sleep.

Guest Bio

Dr Oliver Bernath is a consultant neurologist and sleep physician based in London. He trained in neurology at the University of Chicago and in clinical neurophysiology and sleep medicine at the UCSF and Stanford sleep centres, and previously directed the Northern California Sleep Disorders Center at Kaiser Permanente in San Francisco. He is certified in sleep medicine by the American Academy of Sleep Medicine, the European Sleep Research Society and the German Sleep Society, and treats the full range of sleep disorders.

What We Cover

02:29 Why sleep falls apart at fifty, and how much of it is really hormonal

• Why blaming everything on hormones misses half the picture at this life stage.

• The changes that arrive at the same age as menopause and affect men just as much.

03:44 Oestrogen, progesterone and what hormone therapy can realistically do

• The menstrual cycle clue that explains why sleep changes in perimenopause.

• How many women see their sleep improve on HRT, and what it does not touch.

06:05 Waking in the night is normal, and how much sleep you actually need

• The evolutionary reason your brain wakes you every ninety minutes, and why you only started noticing it after forty.

• The one question Dr Bernath uses instead of counting hours.

15:18 How an ordinary night waking turns into chronic insomnia

• The three o’clock thought spiral, and the moment it becomes a learned pattern.

• The reframe Dr Bernath uses on himself.

18:31 Light, body clocks and the treatment that outperforms tablets

• Why morning daylight matters more than anything you do in the evening.

• Melatonin as a body clock signal rather than a sleeping pill, including timing and dose.

22:56 Supplements: which ones do something and for whom

• Magnesium, valerian, ashwagandha and black cohosh, matched to the type of sleep problem.

27:27 Your hormones are optimised and you still are not sleeping

• The medical conditions that mimic menopausal insomnia and are found on a simple blood test.

29:07 Sleep apnoea and restless legs: the diagnoses women are not getting

• The overnight symptoms that should send you for a sleep test, including the ones you can spot without a bed partner.

• Why the standard screening score is skewed against women, and the iron level that may get called normal.

34:50 What your wearable is actually measuring

• Why the sleep stage percentages are the least reliable number on the screen.

• The overnight oxygen readings that trigger panicked phone calls and rarely mean anything.

47:20 If you take three things from this episode

• Dr Bernath’s top recommendations for a woman whose sleep has deteriorated.

• How to weigh the risks of long-term sleep medication against the risks of not sleeping.

Key Takeaways

• Nocturnal awakenings lengthen with age in both sexes and are physiological, not pathological. Insomnia develops when anticipatory anxiety about those awakenings becomes conditioned.

• Hormone therapy improves sleep for a substantial proportion of women, largely through vasomotor symptom control and the sedative effect of progesterone. It does not address age-related sleep fragmentation or a primary sleep disorder.

• Snoring, witnessed apnoeas, morning headache, dry mouth, nocturnal reflux and daytime sleepiness warrant assessment for obstructive sleep apnoea. Current screening tools underestimate risk in women.

• If sleep does not improve on adequate hormone therapy, the differential includes thyroid disease, depression, obstructive sleep apnoea, restless legs with low ferritin, and chronic pain. Ask for the relevant investigations.

Further Resources and Support

Sleep and insomnia

• The Sleep Charity Evidence-based sleep information and a free national helpline staffed by trained sleep advisors.

• Sleep Health Foundation Free plain-language fact sheets on insomnia, melatonin, shift work and sleep in midlife.

• World Sleep Society Global sleep organisation with public education resources and World Sleep Day campaigns.

Obstructive sleep apnoea

• Sleep Apnoea Trust Patient-run charity covering diagnosis, sleep testing, CPAP, driving and travel, with an email helpline.

Restless legs and iron

• Restless Legs Syndrome Foundation Patient information on diagnosis, iron studies and treatment, plus peer support groups.

Menopause and hormone therapy

• International Menopause Society Global menopause body with evidence-based resources and a directory of national menopause societies.

• The Menopause Society Independent evidence-based information on the menopause transition, including a specialist finder.

• Australasian Menopause Society Free information sheets on menopause symptoms, hormone therapy and alternatives.

• Women’s Health Concern Patient service of the British Menopause Society, with factsheets on menopause and sleep.

Mood, anxiety and mental wellbeing

• Mind Information and support for anxiety, low mood and depression, including their effect on sleep.

• Beyond Blue Free mental health support and 24-hour counselling line.

References

1. Baker FC, de Zambotti M, Colrain IM, Bei B. Sleep problems during the menopausal transition: prevalence, impact, and management challenges. Nat Sci Sleep. 2018;10:73-95. doi:10.2147/NSS.S125807

2. Sleep disruption in the menopausal transition and postmenopause: a narrative review. 2026. PMCID: PMC13543820

3. Kravitz HM, et al. Sleep disturbance during the menopausal transition in a multi-ethnic community sample of women. Sleep. 2008;31(7):979. PMCID: PMC2491500

4. Cintron D, Lipford M, Larrea-Mantilla L, et al. Efficacy of menopausal hormone therapy on sleep quality: systematic review and meta-analysis. Endocrine. 2017;55(3):702-711. doi:10.1007/s12020-016-1072-9

This article and episode are intended for general information and education. They are not a substitute for individual medical advice, diagnosis or treatment. Please speak to your own doctor or a qualified healthcare professional about your symptoms, your medication and any decision about hormone therapy or sleep treatment. If your sleep is significantly affecting your health, mood or safety, seek medical help.

But I wonder how many of you would have instinctively pictured a woman?

Cardiovascular disease is our biggest killer and yet many of us still think of it as a male disease.

This TIME magazine cover came out over 20 years ago and still many women believe they are more likely to die of breast cancer than they are of cardiovascular disease. In fact, awareness of cardiovascular disease in women has fallen rather than improved over the last decade, especially amongst younger women. The 2021 Lancet Commission on women and cardiovascular disease described stagnating progress in terms of reducing the burden of disease in women. Five years later, the problem is far from solved.

And it isn’t hard to see why.

Women wait on average 30 minutes longer than men to seek help when they’re having symptoms of a heart attack, maybe in part because they’re less likely to believe they are actually having one. We are nearly twice as likely than men to attribute symptoms to anxiety. And when women become unwell outside of the home, bystanders are less likely to call an ambulance for us than they would for a man.

Sadly the differences do not end when we get to hospital. Studies show that women presenting with possible cardiac symptoms are less likely to be triaged as an emergency, less likely to have an electrocardiogram (ECG) and less likely to be admitted, even after accounting for differences in presentation.

Then there is the problem of what a heart attack is supposed to look like.

To be clear, chest pain remains the most common symptom of acute coronary syndrome in both women and men. But, women are more likely to experience additional symptoms, distracting from the classic presentation most of us were trained to recognise. We tend to have more breathlessness, nausea, fatigue and pain in the neck, jaw, shoulder or back. We are also somewhat more likely than men to have a heart attack without chest pain at all.

It isn’t that women have an entirely different set of “female heart attack symptoms”. It’s that the way we present can be more complex and less likely to fit the pattern that we; patients, bystanders and clinicians, have traditionally been taught to recognise. One study identified more than 400 different symptom combinations among women with myocardial infarction, roughly twice the number seen in men.

We also carry cardiovascular risk factors the standard calculators don’t always account for. Pregnancy complications such as pre-eclampsia and gestational diabetes are associated with higher cardiovascular risk later in life. So are conditions that disproportionately affect women, including several autoimmune diseases. Yet much of this information isn’t captured by the methods doctors commonly use to estimate cardiovascular risk.

Diagnosis can introduce yet another layer of inequality.

The level of a blood test we rely on to help diagnose heart attacks; Troponin (a protein released by damaged heart muscle), is set at a threshold that works well for men but poorly for us. Many diagnostic pathways have used this single threshold for both women and men, despite the fact that women generally have lower troponin concentrations. Research has shown that this contributes to myocardial infarction being underdiagnosed in women.

And our coronary arteries don’t behave the way we were taught they would. Women are more likely to have myocardial infarction or ischaemic symptoms without the large obstructive coronary lesions we typically associate with coronary disease. Instead they may have spontaneous coronary artery dissection (a tear in the vessel wall), coronary spasm or dysfunction of the tiny vessels that regulate blood flow through the heart.

Whilst conventional angiogram is very good at showing us the anatomy of the major coronary arteries, it less equipped to tell us about how small vessels are functioning. An artery can look free of blockage but still not function normally.

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It Isn’t All Bad…

This doesn’t make for a very reassuring read and nor should it. I realise these four words come up again and again when discussing women’s health, but when it comes to female-specific cardiovascular disease, it is without doubt understudied, under-recognised, underdiagnosed and undertreated.

But there is reason to be hopeful! Things are changing…

Just last week, four cardiovascular bodies; the European Society of Cardiology, the American College of Cardiology, the American Heart Association and the World Heart Federation, agreed a new universal definition of a heart attack. Mechanisms of heart disease that disproportionately affect women, like a tear in the artery wall or vessel spasm, are now included in the primary category and sex-specific troponin thresholds were explicitly recommended.

There is also now a clear, guideline driven pathway for people who have suspected heart disease but a clear angiogram; ANOCA and INOCA (angina or ischaemia with no or non-obstructive coronary arteries). The European Society of Cardiology changed its guidance in 2024 to recommend that invasive coronary functional testing takes place to assess coronary artery function, rather than just what they look like, for anyone whose symptoms persist despite medical treatment.

Cardiac MRI is also changing the diagnostic landscape. Rather than just assessing the vessels like in an angiogram, MRI looks at the heart muscle itself so it can find patterns of injury and disease that an angiogram can’t. In a study of more than 300 people who had a myocardial infarction with unobstructed arteries, an MRI changed either the diagnosis or the treatment plan in around two thirds of them.

Heart failure management has improved too. Heart failure with preserved ejection fraction (HFpEF) is the type that predominantly affects women. In this type, the amount of blood the heart can pump with each heartbeat can appear relatively normal, but the ventricle is often stiff and doesn’t fill with blood normally.

Despite not having any targeted treatment for this type of heart failure for decades, it now has two drug classes available! SGLT2 inhibitors, originally used in diabetes management, such as dapagliflozin and empagliflozin reduce worsening heart-failure events in people with HFpEF. More recently, finerenone, a non-steroidal mineralocorticoid receptor antagonist, has been shown to improve morbidity and mortality in heart failure with mildly reduced or preserved ejection fraction.

Of course, none of this means the cardiovascular gender gap has closed. But as understanding of women’s hearts on their own terms has progressed, it feels we are finally moving in the right direction.

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I recently sat down with Dr Sara Moscatelli, cardiologist and researcher, to talk all things female specific cardiovascular disease. Have a watch or a listen if you want to understand how heart disease differs in women, what screening is worth having, her views on statins, and what you can do to look after your heart.

References:

1. Cushman M, Shay CM, Howard VJ, et al. Ten-Year Differences in Women’s Awareness Related to Coronary Heart Disease: Results of the 2019 American Heart Association National Survey. Circulation. 2021;143(7):e239-e248.

2. Vogel B, Acevedo M, Appelman Y, et al. The Lancet women and cardiovascular disease Commission: reducing the global burden by 2030. Lancet. 2021;397(10292):2385-2438.

3. Bugiardini R, Ricci B, Cenko E, et al. Delayed Care and Mortality Among Women and Men With Myocardial Infarction. J Am Heart Assoc. 2017;6(8):e005968.

4. Lichtman JH, Leifheit EC, Safdar B, et al. Sex Differences in the Presentation and Perception of Symptoms Among Young Patients With Myocardial Infarction: Evidence from the VIRGO Study. Circulation. 2018;137(8):781-790.

5. Banco D, Chang J, Talmor N, et al. Sex and Race Differences in the Evaluation and Treatment of Young Adults Presenting to the Emergency Department With Chest Pain. J Am Heart Assoc. 2022;11(10):e024199.

6. Van Oosterhout REM, de Boer AR, Maas AHEM, et al. Sex Differences in Symptom Presentation in Acute Coronary Syndromes: A Systematic Review and Meta-analysis. J Am Heart Assoc. 2020;9(9):e014733.

7. Brush JE, Krumholz HM, Greene EJ, Dreyer RP. Sex Differences in Symptom Phenotypes Among Patients With Acute Myocardial Infarction. Circ Cardiovasc Qual Outcomes. 2020;13(2):e005948.

8. Grandi SM, Filion KB, Yoon S, et al. Cardiovascular Disease-Related Morbidity and Mortality in Women With a History of Pregnancy Complications: Systematic Review and Meta-Analysis. Circulation. 2019;139(8):1069-1079.

9. Shah ASV, Griffiths M, Lee KK, et al. High sensitivity cardiac troponin and the under-diagnosis of myocardial infarction in women: prospective cohort study. BMJ. 2015;350:g7873.

10. Safdar B, Spatz ES, Dreyer RP, et al. Presentation, Clinical Profile, and Prognosis of Young Patients With Myocardial Infarction With Nonobstructive Coronary Arteries (MINOCA): Results From the VIRGO Study. J Am Heart Assoc. 2018;7(13):e009174.

11. Vrints C, Andreotti F, Koskinas KC, et al. 2024 ESC Guidelines for the management of chronic coronary syndromes. Eur Heart J. 2024;45(36):3415-3537.

12. Rajwani A, Giudicatti L, Telyuk P, Maredia N, Ihdayhid A, Chieng D, Pasupathy S, Beltrame J, McQuillan B, Spiro J, Schultz C, Hillis GS, Austin D, Dwivedi G. Clinical impact of cardiac magnetic resonance imaging in myocardial infarction with non-obstructive coronary arteries: a prospective multicentre cohort study. Heart. 2025 Dec 24;112(2):95-102.

Cardiovascular disease is the leading cause of death in women worldwide, and yet for decades it has been studied and treated as though women are simply smaller men. The symptoms we are most likely to experience are still labelled atypical, despite the fact that women are half of the population. We tend to get disease within the smallest vessels of the heart, where a standard angiogram shows nothing at all. And the risk calculators used to decide who gets treated do not account for female specific or predominant disease like preeclampsia, gestational diabetes, preterm birth, autoimmune disease or menopause.

In this episode I sit down with cardiologist Dr Sara Moscatelli to separate what is really important to know how about to look after your heart. We cover how heart disease actually presents in women, which tests find it and which miss it, what statins do and do not do, where hormone therapy currently sits, and how much exercise your heart really needs. Most importantly, we talk about what you can start doing straight away because for too many women, the biggest risk factor is that we put ourselves last.

Guest Bio

Dr Sara Moscatelli is a cardiologist with specialist expertise in paediatric cardiology, women’s health and cardiovascular imaging. Originally from Italy, she moved to London to train in cardiovascular magnetic resonance at the Royal Brompton Hospital. She is now undertaking a PhD at University College London and Great Ormond Street Hospital, investigating arrhythmogenic cardiomyopathies in children. Alongside her clinical and translational research, she writes and speaks internationally on sex differences in cardiovascular medicine, including diagnostic bias in cardiovascular imaging in women.

What We Cover

[00:02:50] The awareness gap, and what it costs women

• Why so few women know that cardiovascular disease is their leading cause of death

• The measurable consequences: longer delays, fewer cardiology referrals, worse outcomes

[00:05:30] The risk factors standard calculators leave out

• Pregnancy complications, autoimmune disease and menopause as cardiovascular risk factors

• Why the risk scores your doctor uses still cannot account for any of them

[00:07:32] What a heart attack actually feels like in a woman

• Breathlessness, profound fatigue and upper abdominal pain, and why calling these symptoms atypical is part of the problem

• The case from a colleague that changed how Sara listens

[00:10:32] Small vessels, invisible disease, and the tests that find it

• Why men’s disease sits in the large arteries and ours in vessels too small to stent

• What a clear angiogram really means, and how cardiac MRI has changed the picture

[00:19:34] Statins: the evidence versus the algorithm

• A viral social media clip on statins, taken apart claim by claim

• Whether the dementia claim survives scrutiny, and what actually drives cognitive risk

[00:25:14] Blood pressure, the silent killer

• When to start measuring, how often, and what to do with a high reading

• Where home monitors and wearables genuinely help, and where they do not

[00:27:43] How much exercise your heart actually needs

• Walking, running, HIIT, VO2 max and lifting: what to prioritise and in what order

• Why the three month mark matters more than finding the perfect programme

[00:32:20] Heart attacks in younger women

• Coronary artery dissection, and why chest pain in your thirties should never be dismissed

• The other cause of heart attacks in young people that rarely gets discussed

[00:34:56] Menopause, hormone therapy and the heart

• Why losing oestrogen changes cardiovascular risk, and what HRT may or may not do about it

• Where the evidence currently sits, and what Sara is waiting for

[00:38:08] Why heart failure looks different in women

• Diastolic dysfunction, and how a heart that pumps normally can still be failing

• What decades of sex bias in clinical trials has meant for the way women are treated

What You Will Learn

• What are the symptoms of a heart attack in women?

• Why are women’s heart attack symptoms described as atypical?

• What is coronary microvascular disease?

• Why is my angiogram normal when I still have chest pain?

• What are MINOCA and INOCA?

• Does preeclampsia increase your risk of heart disease later in life?

• Do cardiovascular risk calculators work for women?

• Do statins cause dementia or memory loss?

• Do statins work as well in women as they do in men?

• At what age should women start checking their blood pressure?

• How much exercise do I need for heart health?

• Is walking enough exercise for your heart?

• Do I need to know my VO2 max?

• Does HRT protect the heart?

• Can you have a heart attack in your thirties?

• What is spontaneous coronary artery dissection (SCAD)?

• What is heart failure with preserved ejection fraction?

Key Takeaways

• Your symptoms may not look like the ones in the textbook. Unusual exhaustion, breathlessness and pain around your stomach can all be cardiac.

• A clear angiogram does not always mean a healthy heart. If you have ongoing symptoms and no explanation, ask whether microvascular disease has been considered.

• Your obstetric history is cardiac history. Preeclampsia, gestational diabetes and preterm birth belong on the list every time your risk is assessed. Mention these risk factors yourself if you have not been asked directly.

• Start small and start now. Walking counts. Three months of a habit you actually keep will do more for your heart than a programme you abandon in a fortnight.

Further Resources and Support

Heart health information and support

• World Heart Federation. Global alliance of heart foundations, with campaigns and links to national member organisations

• Go Red for Women. The American Heart Association’s women’s heart health initiative, including symptom guidance and survivor stories

• British Heart Foundation. Patient information, risk checkers and a cardiac nurse helpline

Microvascular disease, SCAD and less common presentations

• Beat SCAD. Support, information and community for people affected by spontaneous coronary artery dissection

• SCAD Alliance. International patient-centred organisation advancing SCAD research and awareness

• Cardiomyopathy UK. Support line and information for people living with inherited heart muscle conditions

Heart failure

• Pumping Marvellous Foundation. Patient-led heart failure charity offering peer support and practical day to day information

• Global Heart Hub. International alliance of heart patient organisations, including heart failure advocacy

Cholesterol and blood pressure

• HEART UK. Cholesterol charity with a helpline and clear information on statins and inherited high cholesterol

• Blood Pressure UK. Practical guidance on measuring your blood pressure accurately at home

• World Hypertension League. International blood pressure awareness resources and links to national societies

Pregnancy-related cardiovascular risk

• Preeclampsia Foundation. Information on preeclampsia and the long-term cardiovascular follow-up that should follow it

• Action on Pre-eclampsia. Support and information for women who have had a hypertensive pregnancy

Physical activity

• World Health Organization physical activity guidance. Global recommendations on how much activity is needed at each stage of life

Disclaimer

The content of this episode and these show notes is provided for general information and education. It does not constitute medical advice and is not a substitute for an individual assessment by your own doctor or healthcare professional. If you are experiencing chest pain, breathlessness, or any symptom that concerns you, seek urgent medical attention. Always discuss changes to medication, hormone therapy, diet or exercise with a qualified clinician who knows your medical history.

Whilst I didn’t know her; she was not a patient of the practice despite living very close, the news filled me with sadness. She would now pay the harshest of consequences having slipped through the net meant to protect her; the medical profession, the community around her and a society that still understands remarkably little about maternal mental health.

How could someone become so unwell without receiving the help she clearly needed? Why could nobody see how unwell she was? Why had she been left alone?

Questions that come up again and again every time I read another case of perinatal mental illness that has ended in tragedy.

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During my obstetrics training, I had developed a habit for reading MBRRACE reports. For those that are not familiar with it, MBRRACE-UK conducts confidential enquiries into the deaths of women during pregnancy and up to a year afterwards. They examine the circumstances surrounding each death, identify where care may have fallen short and make recommendations to prevent similar deaths in the future.

In one triennium, the leading cause of death might be thromboembolism, so departments all over the country would become consumed with compression stockings, thrombosis risk scores and the liberal use of blood thinning injections. In the next triennium thrombosis deaths would be down and cardiac ones would be leading, and we would have a new departmental focus for the next 3 years.

As a junior doctor, I learned an enormous amount from the short case histories contained in those reports. But the cases involving mental illness were the ones that stayed with me.

They showed, repeatedly, how easily serious symptoms of perinatal mental illness can be mistaken for the normal challenges of new motherhood. Not sleeping? Of course not, you have a newborn. Feeling worried? That’s natural, you’re a new mother. Exhausted to your core? Nobody sleeps with a new baby. Finding everything overwhelmingly difficult? Of course; it gets easier. The intention being to reassure, but the result can be dismissal of women actually trying to express a deeper distress.

Part of the problem is that our collective understanding of perinatal mental illness remains extraordinarily narrow. We often use the term interchangeably with postnatal depression, the term conjuring up an image of a person obviously sad and unable to get out of bed. Yet, the reality of mental illness in the perinatal period and how it presents is so much more complex than that.

We live in a society in which motherhood has become heavily idealised. We tell new mothers to enjoy every moment, praise maternal instinct and talk about an immediate rush of love as though these things are universal or even realistic. Many women are so frightened to say anything that might suggest they’re not coping or worse, not blissfully content all the time. When you’ve been led to believe that every other mother is effortlessly embracing her new role, admitting to fear, detachment, anger, regret or distress, can feel like offering yourself up to a public stoning for ‘bad’ mothers.

We hurry women out of hospital before their feet touch the ground and then offer one six week appointment, often shared with a newborn check; the emphasis on feeding, sleeping and contents of nappies rather than the contents of her mind. We expect her to not only recognise she is unwell, but then find the language to explain it and express her most vulnerable thoughts to someone she may have only met that very day.

It’s not surprising that women continue to fall through the gaps. The latest MBRRACE data show that suicide remains the leading cause of maternal death between six weeks and one year after pregnancy. Psychiatric causes account for around a third of deaths during this period. This has been the case for 25 years. And for every maternal death, many more women will have experienced profound suffering.

We have to do better than this.

Here are some things I think everyone who comes into contact with pregnant women and new mothers should understand about perinatal mental illness:

1. Not all perinatal mental illness is postnatal depression

When we talk about perinatal mental illness, you may reflexly think about postnatal depression. But the real spectrum of conditions women suffer with in pregnancy and postpartum is much more varied.

For a start, anxiety disorders are at least as common as depression and women can suffer with several other conditions in both pregnancy and the postpartum:

• Perinatal obsessive compulsive disorder involves unwanted, distressing intrusive thoughts, which lead to behaviours intended to reduce the resulting anxiety, like repeatedly checking the baby in the night or avoiding particular activities, like giving a bath, because it causes overwhelming anxiety.

• Post-traumatic stress disorder can develop following a frightening or traumatic pregnancy, birth or postnatal experience. Symptoms can include re-experiencing the event, nightmares, persistent hypervigilance, irritability and sleep disturbance that continues even when the baby is sleeping. PTSD and depression frequently occur together, but PTSD needs to be identified because they require different treatment.

• Eating disorders can also recur or worsen around pregnancy. Some women experience an improvement during pregnancy, only for symptoms to return after delivery. Others symptoms, like binge eating disorder, can develop for the first time in pregnancy. Shame and fear of judgement mean that these difficulties may not be disclosed unless someone actually asks.

• Postpartum psychosis affects one to two women in every thousand births. It usually begins rapidly within the first two weeks after delivery, but often within days. It is a medical emergency requiring urgent, same-day, specialist assessment and treatment. Most women will make a complete recovery.

Despite this wide spectrum of illness, routine perinatal mental health screening we rely on in busy clinics to detect these women early, still focus predominantly on depression.

2. Postpartum depression may not look the way you are expecting it to

Even when a woman is suffering with postnatal depression, it may not look the way we think it will. We tend to picture depression as visible sadness, withdrawal and an inability to function, and whilst some women with postnatal depression will present this way, many will not.

When you compare women with depression after birth to women with depression at any other time, the picture is different. Sadness is less prominent, and restlessness, agitation, difficulty concentrating and difficulty making decisions are more obvious. Anxiety and guilt are also more pronounced. Women will often still complain of low energy but the agitation and restlessness may mean that she is simultaneously exhausted and unable to sit still at the same time. In fact, she will probably look like she is coping very well.

3. Psychosis may be more subtle than you expect

This is the one people think they would spot immediately. But Hollywood depictions of ‘the psychotic woman’ rarely resemble the reality of early postpartum psychosis.

Women who have experienced it commonly describe initial changes such as feeling unusually excited or elated, becoming much more active or talkative, or needing far less sleep than usual. Anxiety, irritability, low mood, confusion and changes in thinking may follow. The illness can also fluctuate rapidly so that a woman can appear lucid and well one moment, then completely different later.

It may just strike you as a mother who seems a bit ‘off’ that you can’t quite put your finger on, rather than the florid and intense ‘madness’ you may be expecting.

4. Intrusive thoughts are not the same as psychosis

This is so important for mothers to know because the fear of being judged, or of having her baby taken away, can prevent women from being honest about what they are experiencing.

Unwanted intrusive thoughts about harm coming to your baby are almost universal among new mothers. They can occur without any mental illness, although they may become more frequent or distressing in anxiety, depression or obsessive compulsive disorder.

They’re different from the fixed false beliefs or significant loss of contact with reality that can occur in psychosis and evidence suggests that experiencing them does not mean that a mother will act on them.

Women need to be able to disclose intrusive thoughts without automatically being treated as dangerous. And clinicians need the time and training to explore the nature of those thoughts properly and sensitively.

5. Insomnia is a red flag for severe perinatal mental illness

Often women with severe perinatal mental illness will report not being able to sleep. Sleep disruption is of course expected after a baby, which can make this really easy to miss. But there is a difference between being repeatedly woken by a newborn and being unable to sleep even when the baby is settled or another person is looking after them.

A woman who remains unable to sleep despite having the opportunity, particularly if this is accompanied by unusual energy, agitation, rapidly changing mood or altered behaviour, needs prompt medical assessment.

6. The greatest danger mothers pose is to themselves, not their children

Public discussion of severe perinatal mental illness frequently centres on rare cases in which her children have been harmed. These cases are shocking and emotionally evocative and so of course I understand why they capture so much attention, as that case caught mine all those years ago. But the intense media coverage of these rare cases can distort our understanding of the condition.

A figure suggesting that 4% of women experiencing untreated postpartum psychosis will kill their baby is widely repeated, including in professional literature. But this seems to reflect older estimates of untreated illness and shouldn’t be presented as the risk faced by women receiving modern standards of care.

Recent research has highlighted how limited the evidence is, but examining population-level figures makes clear that such events are extremely rare.

This matters because exaggerated perceptions of danger increase stigma. A woman experiencing frightening symptoms may remain silent because she fears what other people will think or what might happen if she tells a professional. It is this very stigma that discourages disclosure; disclosure which may actually help expedite her diagnosis and treatment.

We must be able to recognise risk without portraying women with perinatal mental illness as inherently dangerous. The much larger and more persistent public-health risk is to the woman herself though suicide.

7. Isolation increases the risk of perinatal mental illness

Low social support is consistently associated with depression and anxiety during pregnancy and after birth, whilst there is also evidence to show the reverse is true. High levels of support can be strongly protective.

Isolation goes deeper than just the absence of people around you. Women may have partners, relatives, friends and healthcare professionals around them while still feeling unable to tell anyone how they really feel. In qualitative studies, women describe fearing that honesty would lead others to see them as inadequate mothers, which creates a vicious cycle. The pressure to perform ‘perfect motherhood’ results in silence, which deepens isolation and worsens the illness.

Yes, we need maternity and primary care services that ask better questions and provide continuity. And we need sufficient specialist perinatal mental health services and more mother and baby units. But we also need a culture in which women can describe motherhood honestly.

We need to dismantle the culture of silence and the image of the ‘perfect mother’. She doesn’t exist, and expecting women to imitate her is stopping them getting the help they need.

Perinatal mental health needs a movement

The increased attention that menopause has received over recent years shows what can happen when a previously neglected aspect of women’s health becomes part of the public conversation. Women at midlife now have more information, more language with which to describe their experiences and, in many places, better access to clinicians with relevant training.

Perinatal mental health needs an equally determined movement.

We should all be outraged that maternal suicide has remained a leading cause of death for so long. We should be talking more about the limited research, fragmented pathways, inadequate provision of specialist services and shortage of mother and baby units. I believe this is one of the most pressing and neglected women's health issues, and one that needs urgent attention.

But awareness must involve more than telling women to ask for help. Partners, families, friends, antenatal educators, health visitors, midwives, GPs, obstetricians, paediatricians, playgroup leaders and anyone else who regularly comes into contact with new mothers need to form part of the safety net.

In the same way that all parents now know how to differentiate a meningitis rash from any other because of successful public health campaigns, we should be aiming for the same shared understanding of perinatal mental illness: what it can look like, which changes require urgent attention and how to help someone reach appropriate care.

These conditions are treatable.

We need to take better care of mothers.

The Woman’s Handbook podcast episodes on perinatal mental health

How To Survive Postpartum:

In this podcast episode with Dr Kamini Rajaratnam, perinatal psychiatrist, we go through some of the case vignettes I talked about earlier from the MBRRACE report and highlight the ways in which these women fell through the net. We talk about the symptoms of the different ways perinatal mental illness can reveal itself, so that we all might be able to better recognise it in the women we love and care for. And we talk about treatment, and the positive outlook for women who get the help they need early.

How To Cope After Baby:

In this podcast with Dr Silvia Wetherall, perinatal psychotherapist, we talk about the normal adjustment to motherhood, why matrescence can be so hard, and why we need to speak more openly about this aspect of motherhood. As Dr Wetherall says, ‘we’re women, we can take it’.

If you’re struggling, please speak to your GP, midwife or health visitor or the Samaritans who are available free, day or night.

If you’re worried that you or someone you know may be at immediate risk, contact your doctor or emergency services without delay.

• PANDAS Foundation UK provides free support for parents and families affected by perinatal mental illness.

• Action on Postpartum Psychosis offers specialist information and peer support for women and families affected by postpartum psychosis.

• Maternal Mental Health Alliance provides information and resources about mental health during pregnancy and after birth.

• Association for Post Natal Illness provides information and support for women experiencing postnatal depression.

• The Birth Trauma Association offers peer support for people affected by traumatic birth and postnatal PTSD.

References

1. MBRRACE-UK. Saving Lives, Improving Mothers’ Care 2025: Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2021–23. National Perinatal Epidemiology Unit, University of Oxford.

2. MBRRACE-UK. Maternal Mortality 2022–2024 Data Brief. National Perinatal Epidemiology Unit, University of Oxford.

3. Parliamentary Office of Science and Technology. Mental Health During and After Pregnancy. POSTnote 765, April 2026.

4. Alford AY, et al. A systematic review of postpartum psychosis resulting in infanticide. Archives of Women’s Mental Health. 2024.

5. Bergink V, Rasgon N, Wisner KL. Postpartum psychosis: madness, mania, and melancholia in motherhood. American Journal of Psychiatry. 2016;173(12):1179–1188.

6. Challacombe FL, Wroe AL. A hidden problem: consequences of the misdiagnosis of perinatal obsessive-compulsive disorder. British Journal of General Practice. 2013;63(610):275–276.

7. Morgan JF, Lacey JH, Sedgwick PM. Impact of pregnancy on bulimia nervosa. British Journal of Psychiatry. 1999;174:135–140.

8. Fairbrother N, et al. Screening for perinatal anxiety disorders: room to grow. Journal of Affective Disorders. 2019.

9. Bernstein IH, et al. Symptom features of postpartum depression: are they distinct? Depression and Anxiety. 2008;25(1):20–26.

10. Fox MM, et al. A longitudinal study of women’s depression symptom profiles during and after the postpartum phase. Depression and Anxiety. 2018;35(4):292–304.

11. Heron J, et al. Early postpartum symptoms in puerperal psychosis. BJOG. 2008;115(3):348–353.

12. Kamperman AM, et al. Phenotypical characteristics of postpartum psychosis: a clinical cohort study. Bipolar Disorders. 2017;19(6):450–457.

13. Perry A, et al. Perinatal sleep disruption and postpartum psychosis in bipolar disorder: findings from the UK BDRN Pregnancy Study. Journal of Affective Disorders. 2023.

14. Bedaso A, et al. The relationship between social support and mental health problems during pregnancy: a systematic review and meta-analysis. Reproductive Health. 2021;18:162.

15. Lever Taylor B, et al. Mums alone: exploring the role of isolation and loneliness in the narratives of women diagnosed with perinatal depression. Journal of Clinical Medicine. 2021;10(11):2271.

16. Collardeau F, et al. Prevalence and course of unwanted, intrusive thoughts of infant-related harm. Journal of Clinical Psychiatry. 2024;85(3):23m15145.

17. Fairbrother N, et al. Postpartum thoughts of infant-related harm and obsessive-compulsive disorder: relation to maternal physical aggression toward the infant. Journal of Clinical Psychiatry. 2022;83(2):21m14006.

Then there’s the way the symptoms can end up sending you off on a merry-go-round of different specialists; ENT for tinnitus, cardiology for palpitations, dermatology for incessant itching and dry skin, making it even harder to pull the pieces together. And underneath it all, the fact that we’ve all been conditioned from a young age, our first period usually, to accept that discomfort is something to endure, adapt to and carry on in spite of. So when faced with these symptoms, that’s often exactly what we do; carry on anyway.

I can’t tell you the number of times I’ve heard women say, ‘I had no idea that was perimenopause’, and ‘I wish I’d known that was a symptom. I might have joined up the dots ages ago’. Years of struggling on when she could have been supported.

It doesn’t help that there’s no single test that can diagnose the perimenopause, (more on this later). Instead, it’s generally a clinical diagnosis; meaning we consider your symptoms in the context of your age, and make sure there’s nothing else going on that could explain them (thyroid issues, iron deficiency, B12 deficiency; there are many mimics).

The problem is, beyond hot flushes and missed periods, many of us aren’t familiar with what those symptoms are. And there are many symptoms. In an ideal world, all of us (including doctors, across specialties) would be able to rattle them off as easily as our ABCs or with at least as much familiarity as we can recount the signs of puberty.

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The Transition We All Know So Well

Perimenopause is often thought of conceptually as puberty in reverse; 2 sides of the same coin. One reproductive transition taking you from a dormant reproductive system to one that is hormonally active; puberty. And the other, which does the exact opposite; the perimenopause.

There’s no one test for puberty either, and if I suggested we needed one you would probably laugh. Yet puberty is also a major hormonal life transition accompanied by a wide range of physical and psychological changes. The difference is that its signs and symptoms are common knowledge (although admittedly the very physical nature of many of them gives puberty some advantage here).

We know to expect changes in body shape, hair growth, shifts in height and shoe size, mood swings, skin changes. We know it’s likely to start within a broad window of age, that timing is highly variable between individuals, and that each person will follow their own path in terms of speed and ease of transition. Take out the changes in height and shoe size and I could be talking about the perimenopause.

We also know that puberty usually starts with breast development (or pubic hair in some) and the beginning of a growth spurt. So then what is the herald sign of the menopause transition? The breast bud or sudden shoe size increase equivalent that tells us that the rollercoaster is about to set off?

For many women, it will be the menstrual cycle.

The Perimenopause Map: STRAW+10

This would be a good time to introduce you to the STRAW staging system, which stands for the Stages of Reproductive Ageing Workshop. You can think of it like the Tanner staging system for puberty shown above. Except instead of breasts, pubic hair and testicle size to tell us which stage of puberty our teens are in, we have the menstrual cycle.

STRAW was first developed in 2001 to map out the menopause transition, and was updated in 2011, which is why it’s now called STRAW+10. It laid out the stages of reproductive ageing, confirming that women do not go from their reproductive years to menopausal overnight. The process takes years. And during those years, the menstrual cycle can provide valuable clues as to which stage we are in. You just need to a) be paying attention and b) know what you’re looking for.

What might be the most surprising thing on this staging system is that the earliest changes we might notice in our cycle arrive before the transition has formally begun at all (see arrow). STRAW calls this the late reproductive stage. At this stage your egg supply has dwindled to a point that is not low enough to make you skip cycles, but is low enough to begin to change the hormonal conversation between the brain and the ovary. You still menstruate every month but there will be subtle changes in the flow (usually heavier) or cycle length to reflect that change.

I’ve written before about why it is so important for women to track their cycles and this is another example of why it matters. The most common first sign of the hormonal changes that underly the transition is your cycles becoming shorter. As the number of eggs in your ovaries start to decrease towards a critical point, your brain doesn’t just give up on its mission to keep the human race alive through you. Instead it turns up the hormonal volume to ensure the ovaries maintain their monthly egg output and that leads to a cascade of effects. One being that follicle development starts much earlier in the cycle, ovulation happens earlier, meaning your period comes earlier. You end up getting your period on day 25 instead of 28 for example but without tracking, it’s something that might be missed. As women then progress through the stages, the cycle length variability increases and becomes persistent before cycles start being skipped (intervals of amenorrhoea).

A Great Start, But Not The Whole Picture

In that sense, the STRAW framework is really helpful. It can help you to find where you are in the transition using trackable data. But it doesn’t provide the full picture, so use it, but with some caution. Here’s why:

1. It’s built almost entirely around the menstrual cycle, with only vasomotor symptoms and genitourinary syndrome of the menopause mapped as symptoms later in the transition. You may conclude that these are the only relevant symptoms aside from menstrual changes and that they only appear in the late transition. But this is incorrect. We know from studies like this that women in the late reproductive stage can experience symptoms, and that these symptoms are diverse: sleep disruption, mood changes, palpitations and more.

2. It risks being applied far too rigidly. I have come across many women who have menstrual changes but not yet a difference of exactly seven days or more between cycles, who have been told that they cannot possibly be in the perimenopause. I think this is a far too rigid an interpretation of the staging system. Yes, this is the definition of the early transition according to STRAW, but we have to remember that cut offs such as this exist because researchers needed a consistent way to mark the transition across different studies. It isn’t there to dismiss a woman with new free floating anxiety, poor sleep and a shortened cycle, who is clearly showing the signs of hormonal change.

3. It does not work for everyone. There are many women who don’t have a cycle to read, whether that’s because they have PMOS, an IUD in place, have had an endometrial ablation or a hysterectomy. So because STRAW focuses primarily on menstrual changes, it isn’t a helpful guide for all women.

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Your Playbook For Diagnosing Perimenopause Early

1. Know The Symptoms

Back to front and inside out. Hot flushes can be really debilitating and they deserve to be as well known as they are, especially as they respond so well to hormone therapy, but if women are wait until these appear before they feel they have a good enough reason to see their doctor, they may have been struggling with other symptoms for years.

The largest analysis of menopausal symptom prevalence to date found that the most common symptoms in the perimenopause aside from menstrual changes, in order were:

1. Joint and muscular discomfort

2. Physical and mental exhaustion

3. Memory problems and brain fog

4. Irritability

5. Hot flushes

6. Sleep problems

7. Anxiety

8. Mood swings

9. Difficulty concentrating

10. Vaginal dryness

Knowing these most common symptoms should be standard knowledge for all. Perhaps someone should make a catchy song of them that is taught to everyone at 30. It might be a pretty long one though if we included all the potential symptoms^*.

^*_{Other symptoms associated with the perimenopause: Night sweats, temperature intolerance, palpitations, worse PMS, pain during or after sex, vulval skin splitting, discomfort with tampons or tight clothing, recurrent thrush or BV symptoms, urinary frequency, urgency, nocturia (needing to pee in the night), stinging, recurrent UTIs, reduced arousal & orgasm, low mood, tearfulness, loss of enjoyment, anxiety, panic, irritability, rage, mood swings, brain fog: word-finding, forgetfulness, poor concentration, slowed thinking, difficulty juggling tasks, difficulty falling or staying asleep, early waking, apnoeas, restless legs, joint pain and morning stiffness, muscle aches, tendon pain, frozen shoulder, dry, itchy skin, crawling sensation on the skin, acne, facial flushing, new facial hair; hair thinning, shedding, texture change, brittle nails, burning mouth, dry mouth, altered taste, gum and dental problems; new or changed headaches and migraines, dizziness, vertigo, tinnitus, dry or gritty eyes, blurred vision, electric shock sensations; weight gain, central redistribution, reduced alcohol and caffeine tolerance; breast pain and tenderness, hives, flushing, change in body odour, voice deepening or tiring.}

2. Track Your Cycle and Symptoms (If You Can)

Hopefully you’ve been doing this for a while so you already know your cycle pretty well and can spot changes early, but if not, it’s a good time to start. Use an app or just a good old pen and a calendar and whilst you’re noting down your period dates, take note of your symptoms too and any patterns. A symptom tracker alone is a good idea even if you don’t have a cycle.

3. What Bloods Can And Can’t Do

As the STRAW table shows, FSH (Follicle Stimulating Hormone) one of the hormones the brain uses to communicate with the ovary, is variable in the early transition. This makes it unreliable as a snap-shot diagnostic test unless you are under 40, in which case testing is not optional. [Premature ovarian insufficiency is a different diagnosis with significant long-term consequences and it shouldn’t be missed.]

AMH, or anti-Müllerian hormone, is different. It reflects your ovarian reserve, and unlike FSH it holds reasonably steady across the cycle, and usually begins to fall by the late reproductive stage. What it can offer, alongside your age, is an estimate of how far you are from your final period. A result that is still comfortably detectable suggests your final period is unlikely to be within the next three years.

What it’s less good at is telling you though, is which part of the transition you are in. Access may also be an issue; in the UK for example, it would need to be ordered privately and may not be reimbursed by your insurance.

4. Not Everything That Sounds Like Galloping Hooves Is A Horse

Sometimes it will be a zebra.

It’s worth remembering that at this stage of life; already crowded with stress at work and at home, caring for the young and the old, where hormones and ageing collide, not everything will be perimenopause. Make sure you’re up to date with your general health check-up and that your screening bloods are up to date. Many things can mimic perimenopause symptoms: thyroid disease, anaemia, coeliac disease, diabetes, sleep apnoea, vitamin D and B12 deficiency, and whilst menstrual cycle changes are expected, not all changes are transition related ones. Bleeding between periods, after sex, bleeding that is much heavier than usual and any bleeding at all after twelve months without a period needs a doctor’s visit.

Learning The Language

So, how do you know if you’re in it? It can be hard and there is a lot more research to be done to improve our understanding of it, but it’s not impossible.

The transition has a language; the menstrual changes, the symptoms, and we can learn it just like we have the language of puberty. We teach children extensively about this transition, prepare girls for their menarche proactively. We now need to teach the perimenopause in the same way.

Once women know what to expect, what to look for and how to interpret those signs (with caution); those days of suffering on in silence will be numbered.

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References:

Soules MR, Sherman S, Parrott E, Rebar R, Santoro N, Utian W, Woods N. Stages of Reproductive Aging Workshop (STRAW). J Womens Health Gend Based Med. 2001;10(9):843-848.

Harlow SD, Gass M, Hall JE, Lobo R, Maki P, Rebar RW, Sherman S, Sluss PM, de Villiers TJ; STRAW+10 Collaborative Group. Executive summary of the Stages of Reproductive Aging Workshop +10: addressing the unfinished agenda of staging reproductive aging. Menopause. 2012;19(4):387-395.

Coslov, N., Richardson, M. K., & Woods, N. F. (2021). Symptom experience during the late reproductive stage and the menopausal transition: observations from the Women Living Better survey. Menopause, 28(9), 1012–1025.

Fang Y, Liu F, Zhang X, Chen L, Liu Y, Yang L, Zheng X, Liu J, Li K, Li Z. Mapping global prevalence of menopausal symptoms among middle-aged women: a systematic review and meta-analysis. BMC Public Health. 2024;24:1767.

Finkelstein JS, Lee H, Karlamangla A, Neer RM, Sluss PM, Burnett-Bowie SM, Darakananda K, Donahoe PK, Harlow SD, Prizand SH, Joffe H, Kumar A, Martin DE, McConnell D, Merrilat S, Morrison A, Pastore LM, Randolph JF, Greendale GA, Santoro N. Antimullerian Hormone and Impending Menopause in Late Reproductive Age: The Study of Women's Health Across the Nation. J Clin Endocrinol Metab. 2020 Apr 1;105(4):e1862–71.

The crime of this restless uterus was conveniently the absence of marriage, sex and childbearing. Marriage and pregnancy were the standard prescriptions, applied to an enormous range of physical and emotional symptoms from anxiety, palpitations, fainting, paralysis and mutism, to intellectualism and rebelliousness, in an attempt to calm this mischievous organ. By the 19th century, hysteria had become the dominant diagnosis applied to any woman, for any reason, with an expanded toolkit to include rest cures, pelvic and genital massage, vaginal fumigation, water therapy and, when those failed, surgical removal of the uterus itself.

By the late twentieth century, hysterectomy was the second most common major operation in women, after caesarean section. At the US peak in the mid-1980s, close to half of American women were having their uterus removed by the end of their reproductive years, overwhelmingly for benign conditions. The uterus was treated as a disposable organ. Once childbearing was over, it was assumed to have completed its purpose and was surplus to requirements.

I think it’s time we reframe this narrative; the uterus is actually a remarkable organ.

“Champ” by Zoe Buckman, 2016.

A model of eternal youth and regeneration?

The uterus does something almost no other adult organ in the human body can do. Every month, its lining sheds itself completely and regenerates from scratch, without scarring, up to 400 times in a lifetime.

Most parts of the body, when injured, heal by forming scar tissue. The lining of the uterus doesn’t. Every menstrual cycle, the top layer sheds, and within days a fresh 8mm of lining has grown back completely, with no scarring at all. The only other adult tissues that heal scar-free are some mucosal surfaces.

It is so unusual in fact, that the uterine lining is now being studied as a model for tissue repair to help us learn how to heal hearts, skin and spinal cords without scarring.

More than waste

The reason the uterine lining can regenerate like this is that it has its own built-in supply of stem cells. Once the top layer has shed, these cells, held safely in the deeper layer that stays put, rebuild it from scratch. Menstrual blood is now a recognised source of stem cells, and the cells from just one donor’s blood could theoretically be grown into enough doses to treat thousands of patients.

Menstrual blood is also emerging as a valuable sample for medical testing. It contains over 350 unique proteins that don’t appear in peripheral blood (taken from a vein) or in vaginal fluid, alongside cells, hormones and markers of inflammation, all shed directly from the uterine lining. This has the potential to make it a uniquely informative window into reproductive health.

For endometriosis, where diagnosis still routinely takes years, this could be groundbreaking. Studies have shown that women with endometriosis have distinctive patterns of certain proteins in their menstrual blood, meaning these signals could be used to develop a diagnostic test that doesn’t depend on surgery or scans.

Menstrual blood may also find a use as a tool for cervical cancer screening. A 2026 study compared HPV testing on pad-collected menstrual blood against samples taken by a doctor during a smear test, with both checked against tissue samples. The menstrual blood method performed similarly to the doctor-taken samples in detecting the strains of HPV that lead to cervical cancer. This could be incredibly useful for women who cannot tolerate or access standard smear tests.

A muscle like no other

The uterus is also one of the most extraordinary muscles in the human body.

During pregnancy it grows from roughly the size of a small pear to an organ capable of carrying a full-term baby, placenta and litres of amniotic fluid. Its weight increases around fifteen-fold, while its internal capacity expands from about 5-10ml to up to a thousand times more.

To support this transformation, its blood vessels enlarge dramatically and, by the end of pregnancy, the uterus receives around one in every eight litres of blood pumped by the mother’s heart.

Then comes labour. For hours, sometimes days, the muscular wall of the uterus contracts over and over again with remarkable force. Each contraction produces roughly enough force to lift the average ten-year-old child off the ground.

And then, perhaps most astonishingly of all, within six weeks of giving birth, the uterus shrinks back to almost exactly its original size.

No other organ in the human body undergoes this scale of expansion, mechanical work and recovery over such a short period of time.

The uterus, ovarian ageing and menopause

For decades, we assumed that if your ovaries were left behind during a hysterectomy, they would simply carry on as before and your menopause would arrive at the same time it otherwise would.

But that doesn’t appear to be the case.

Across multiple studies, women who have a hysterectomy while keeping both ovaries tend to reach menopause around two to four years earlier than women whose uterus remains intact.

The most well evidenced explanation is a disruption to the blood supply. The uterus and ovaries share an intricate network of blood vessels, and surgery inevitably interrupts some of that circulation leading to accelerated ageing.

But in some studies, blood flow to the ovaries appears to recover after surgery as new blood vessels develop. Yet accelerated ovarian ageing continues, suggesting that something more than temporary disruption of the circulation may be happening.

Could the uterus itself be helping to maintain ovarian function?

Perhaps. We know that the uterus and ovaries are connected not only by blood vessels but also by nerves and local chemical signalling. We also know that in animals such as cows and sheep, the uterus sends chemical messages that directly control ovarian function. We don’t yet know though whether similar signalling plays an important role in humans. But nonetheless, it is becoming harder to think of the uterus as simply a passive incubator for pregnancy.

It may actually be part of an integrated system that helps regulate ovarian health throughout a woman’s reproductive life.

Time to give her her flowers

For two thousand years the uterus was held responsible for women’s suffering and now we know that it’s actually one of the most dynamic, adaptive and biomechanically sophisticated organs in human physiology.

Its lining regenerates without scarring. It may teach us how to repair damaged organs. It grows a thousand-fold and then quickly returns to its original size. It generates the force needed to bring a new human into the world. And we’re only just beginning to understand whether it may even help support the ovaries long after childbearing is complete.

Perhaps the most remarkable thing about the uterus isn’t what we’ve discovered. It’s how long we assumed there was nothing left to discover.

It’s definitely time for the uterus to get the respect she deserves.

N.B. This post is not a call to keep your uterus come what may. Yes, it was given a bad rap for far too long and yes, it is a remarkable organ, but even so, it can sometimes genuinely go wrong and you may find your life much improved without it should it come to that.

Further Reading

• Tasca C, Rapetti M, Carta MG, Fadda B. Women and hysteria in the history of mental health. Clin Pract Epidemiol Ment Health. 2012;8:110–119.

• Salamonsen LA, Hutchison JC, Gargett CE. Cyclical endometrial repair and regeneration. Development. 2021;148(17):dev199577.

• Cousins FL, Filby CE, Gargett CE. Endometrial stem/progenitor cells: their role in endometrial repair and regeneration. Front Reprod Health. 2022;3:811537.

• Yang H, Zhou B, Prinz M, Siegel D. Proteomic analysis of menstrual blood. Mol Cell Proteomics. 2012;11(10):1024–1035.

• Wang H, Gan Z, Wang Y, Hu D, Zhang L, Ye F, Duan P. A noninvasive menstrual blood-based diagnostic platform for endometriosis using digital droplet enzyme-linked immunosorbent assay and single-cell RNA sequencing. Research. 2025;8:0652.

• Tian X, Cao C, Wang L, et al. Testing menstrual blood for human papillomavirus during cervical cancer screening in China: cross sectional population based study. BMJ. 2026;392:e084831.

• Thaler I, Manor D, Itskovitz J, Rottem S, Levit N, Timor-Tritsch I, Brandes JM. Changes in uterine blood flow during human pregnancy. Am J Obstet Gynecol. 1990;162(1):121–125.

• Moorman PG, Myers ER, Schildkraut JM, Iversen ES, Wang F, Warren N. Effect of hysterectomy with ovarian preservation on ovarian function. Obstet Gynecol. 2011;118(6):1271-1279.

• Trabuco EC, Moorman PG, Algeciras-Schimnich A, Weaver AL, Cliby WA. Association of ovary-sparing hysterectomy with ovarian reserve. Obstet Gynecol. 2016;127(5):819-827.

• Huang Y, Wu M, Wu C, Zhu Q, Wu T, Zhu X, et al. Effect of hysterectomy on ovarian function: a systematic review and meta-analysis. J Ovarian Res. 2023;16(1):35.

• 12. McCracken JA, Custer EE, Lamsa JC. Luteolysis: a neuroendocrine-mediated event. Physiol Rev. 1999;79(2):263-323

The average woman uses menstrual products for the equivalent of five years of her life, with an estimated 11,000 menstrual products used across her lifetime, more if she suffers with heavy menstrual bleeding. And yet despite the fact that menstrual products are in contact with the highly absorbent tissue that is the vagina and some areas of the vulva, these products receive the same regulation as a dishcloth.

In the UK and across Europe, menstrual products are regulated as consumer products. In the United States they’re classified as medical devices, which sounds more reassuring until you discover that unlike most medical devices, which require pre-market safety evidence, the classification doesn’t require manufacturers to test for chemical leaching or vaginal absorption.

Nearly two dozen studies have measured environmental contaminants in period products. All of them have found chemicals that we know are associated with health risks. But the evidence as to whether they play a role in poor health outcomes in women has received very little research attention.

How worried should we be? Are our period products making us sick? And will switching to organic period products or reusable methods help?

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A hard question to answer

Despite the biological plausibility, the question of whether our period products are making us sick is hard to answer from the evidence available to us at the moment.

The safety limits we have are based on oral exposure or exposure through normal skin. The vaginal surface however is no way near as thick, and dare I say, leathery as skin. We know the vagina is a highly vascular mucosal surface and substances absorbed through it also bypass the first pass metabolism of the liver, which is what makes it a good drug delivery route; direct and efficient. But this property could also mean that women are exposed to more chemicals from menstrual products than the manufacturers intend.

The evidence we have does not help to answer this. Whilst we have lots of evidence showing that menstrual products contain chemicals, finding a chemical in a tampon or pad doesn’t tell you how much of it actually leaches from the product during use. Leaching under real life conditions hasn’t ever been measured. And as mentioned above, even if a chemical does leach, we don’t have vaginal-route-specific safety thresholds to be able to interpret the level of possible harm.

We also need to account for the fact that women are already exposed to many of these same chemicals cumulatively from food, water, packaging, cosmetics and cleaning products. Designing a study that would be able to isolate the contribution of menstrual products to total body burden against that background noise, would be challenging.

But here’s what we do know.

What period products are made from, and what’s been found in them

Conventional tampons and pads are typically made from cotton, rayon or viscose, or a blend of these, sometimes bleached during manufacturing and often incorporating adhesives, fragrances and plastic components. Chemicals are introduced at multiple points in the processing across farming, manufacturing and packaging.

A 2023 systematic review by Marroquin and colleagues, identified 15 studies published over the preceding decade examining chemicals in menstrual products. Across product types, researchers detected: phthalates, volatile organic compounds (VOCs), parabens, environmental phenols including bisphenol A (BPA), dioxins and fragrance chemicals. Heavy metals including lead, arsenic and cadmium have also been detected in tampon materials across multiple brands and countries, as well as PFAS, the so-called forever chemicals.

Concentrations vary considerably between studies and product types, and results aren’t always consistent. Pads tend to show higher phthalate levels than tampons. Tampons tend to show higher VOC concentrations than pads.

Are these chemicals harmful?

The chemicals detected in period products are not new areas of concern: most have bodies of research linking them to health effects, though for the majority that evidence is associative rather than conclusively causal.

Here’s a brief overview of the main classes and what we know about them.

Phthalates

Phthalates are plasticisers, chemicals added to plastics to make them flexible. They’re one of the most widely studied groups of endocrine-disrupting chemicals (EDCs): substances that interfere with the body’s hormone system. Phthalate exposure has been linked to reproductive harm in both men and women, including reduced fertility, disrupted hormone levels and adverse pregnancy outcomes. Some phthalates have also been associated with metabolic effects and developmental problems in children exposed in utero.

Bisphenols (including BPA)

BPA and related compounds are found in plastics and resins. They mimic oestrogen in the body and have been associated with hormonal disruption, reproductive disorders, cardiovascular disease and an increased risk of certain cancers. BPA has been restricted or banned in some applications, including food contact materials, in multiple countries, though replacement bisphenols are increasingly being found to carry similar risks.

Volatile organic compounds (VOCs)

VOCs are a broad category of carbon-based chemicals that evaporate at room temperature. They’re found in fragrances, adhesives, solvents and manufacturing processes. Some VOCs are classified as known or probable carcinogens. Others are respiratory irritants. The health effects depend heavily on the specific compound and the level of exposure, but chronic low-level exposure to certain VOCs has been linked to respiratory problems, headaches and, in some cases, cancer risk.

Dioxins

Dioxins are byproducts of industrial processes, including the chlorine bleaching historically used in tampon production. They’re persistent organic pollutants, meaning they accumulate in the body over time rather than being cleared quickly. Dioxin exposure has been linked to immune system disruption, hormonal effects, developmental problems and cancer. Modern manufacturing has significantly reduced dioxin levels in period products, but trace amounts are still detected.

PFAS

PFAS, or per- and polyfluoroalkyl substances, are a large group of synthetic chemicals used to make products resistant to water, heat and stains. They’re called ‘forever chemicals’ because they don’t break down in the environment or the human body. PFAS exposure has been associated with immune suppression, thyroid disruption, liver damage, certain cancers and adverse reproductive outcomes. In 2023, the WHO classified two of the most widely used PFAS compounds as carcinogenic or possibly carcinogenic to humans.

Heavy metals

Lead, arsenic, cadmium and mercury are among the heavy metals detected in menstrual product materials. They enter cotton and other plant-based materials through soil and water during farming. All are toxic at sufficient exposure levels. Lead affects the nervous system and is particularly harmful in early development. Arsenic is a known carcinogen. Cadmium accumulates in the kidneys and has endocrine-disrupting properties.

Fragrance chemicals

Fragranced menstrual products contain a mixture of synthetic compounds, many of which fall into EDC categories already covered above. Some fragrance chemicals are also known skin sensitisers and allergens. Relatively little research has focused specifically on fragrance chemicals in period products, but the category is well-established as a source of endocrine disruption and local tissue irritation.

What the evidence actually shows beyond presence of chemicals in menstrual products

The central problem with this body of research is that it’s very established that chemicals have been detected in these products, but very poor at telling us whether those chemicals reach the bloodstream in amounts that matter.

A viral study looking at heavy metals illustrates this gap perfectly. When researchers tested tampon materials and found lead, arsenic and cadmium in every product sampled, they were explicit in the paper that they did not measure leaching or blood levels. The American College of Medical Toxicology reviewed the findings and concluded there’s no evidence that metals are absorbed through vaginal mucosa in quantities that would cause clinical effects. While the vaginal route is a direct route to the bloodstream by bypassing the liver, absorption still depends on whether a substance actually leaches from the product material and on its specific chemical properties. Heavy metals bound within cotton fibres behave very differently from drugs formulated for vaginal delivery. The ACMT also noted that exposure is further limited by the intermittent nature of menstruation.

The 2023 systematic BJOG review previously mentioned, covered 15 studies over a decade and gives us the best link between exposure and biological effect. Three of the 15 studies examined human biomarkers of chemical exposure from menstrual product use, measuring things like urinary phthalate metabolites and markers of oxidative stress. All three found that women who used menstrual products tended to have higher levels of certain chemicals in their bodies than those who didn’t.

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Are organic products safer?

Whilst the organic label isn’t meaningless, it’s sadly not a safety guarantee either. Organic certification means grown without synthetic pesticides, not genetically modified, using approved natural farming inputs. It doesn’t mean that it’s chemical-free, metal-free or independently tested for leaching.

The 2023 systematic review found only one study that directly compared organic and non-organic menstrual products, and it found no VOC advantage for organic tampons. Research into heavy metals in tampon materials found that organic products contained more arsenic, while non-organic contained more lead and cadmium. No category had consistently lower concentrations across all metals. This is because metals enter cotton from soil and water regardless of farming method, and organic fertilisers introduce their own soil chemistry.

There are no studies comparing health outcomes in women who use organic versus conventional period products over time.

What about reusable menstrual products then?

Reusable products are often presented as the safer and more sustainable alternative. The sustainability argument is absolutely valid but the safety argument is more complicated.

A 2025 study detected PFAS in nearly 30% of reusable menstrual products tested, including period underwear, reusable pads and menstrual cups, at concentrations suggesting they had been deliberately applied, most likely to create the moisture-resistant and leak-proof properties these products are marketed on. Period underwear and reusable pads showed the highest rates.

Of the reusable options, menstrual cups made from medical-grade silicone have the strongest clinical safety record. A Lancet Public Health meta-analysis found no adverse effects on vaginal flora and serious adverse events were rare. Silicone is also a more chemically stable material than the treated fabrics used in period underwear and reusable pads, making it less likely to leach chemicals during use, though PFAS and plasticisers have been detected in cups too.

If the goal is a reusable option with the best-evidenced safety data, cups are the strongest candidate, but no reusable product is entirely without chemical concerns.

What should worried women do?

The honest position is that there isn’t enough evidence to tell you that your current period products are definitely harming you. However, we also don’t have enough evidence to tell you that they’re not.

What we can say is that the concern is biologically plausible; absorption from vaginal and vulval tissues is not the same as through normal skin and these chemicals are associated with poor health outcomes. It is also obvious that the regulatory framework is inadequate, that organic isn’t reliably safer and that reusable products aren’t always automatically superior either.

Menstrual cups from established brands seem to have the best safety profile over the alternatives. But if cups aren’t for you, the next best options are less clear cut because no product category is without concerns. Some practical pointers that are evidence-informed:

· Choose unfragranced, unbleached products where available, as chlorine bleaching is the source of dioxins and fragrances are know EDCs.

· If using period underwear, look for brands that explicitly certify PFAS-free and have third-party testing to back that claim.

· Organic cotton products reduce pesticide residue exposure at least, even if they don’t eliminate all chemical concerns and this may be important for at least some women (younger women, those with risk factors for reproductive conditions, those trying to get pregnant).

We need structural change

The biggest change needed is structural. Right now, manufacturers aren’t required to tell you what’s in their products, test whether those chemicals leach during use, or demonstrate safety via the vaginal route rather than the oral one and this needs to change. There are signs of political pressure building on both sides of the Atlantic: in California, a new state bill passed in 2025 which requires mandatory ingredient labelling, and for manufacturers to maintain data on lead, arsenic, cadmium and zinc concentrations and disclose it to the state regulator by 2026. In the UK, an Early Day Motion calling for mandatory ingredient disclosure and independent testing gathered 45 parliamentary signatures in 2025, although no legislation has followed.

If you want to push for change, the Women’s Environmental Network is leading the campaign for regulation in the UK and their Toxic Tipping Point petition has already gathered nearly 80,000 signatures. In the US, Women’s Voices for the Earth campaigns for the Robin Danielson Act (which would require the NIH to research health risks from chemicals in menstrual products) and publishes ongoing research on chemicals in menstrual and intimate care products.

It’s time this was taken seriously to give us the answers we need to be able to make evidence based decisions for our health. The science is now asking the right questions but it’s time the regulation caught up.

References

1. Marroquin J et al. Chemicals in menstrual products: A systematic review. BJOG. 2024;131(5):655-664.

2. Upson K et al. Menstrual products as a source of environmental chemical exposure: a review from the epidemiologic perspective. Current Environmental Health Reports. 2022;9:452-461.

3. Nicole W. A question for women’s health: chemicals in feminine hygiene products and personal lubricants. Environmental Health Perspectives. 2014;122(3):A70-A75.

4. Pollard CM. Menstrual tampons and vaginal pessaries: regulation of intravaginal medical devices by the US FDA. Frontiers in Reproductive Health. 2023;5:1224421.

5. Shearston JA et al. Tampons as a source of exposure to metal(loid)s. Environment International. 2024;190:108849.

6. American College of Medical Toxicology. Position Statement: No Evidence that Tampons Cause Metal Poisoning. October 2024.

7. Singh J et al. Tampon use, environmental chemicals and oxidative stress in the BioCycle study. Environmental Health. 2019;18(1):11.

8. Vercellini P et al. Chemicals in menstrual products: biological plausibility should be combined with epidemiological evidence to define the magnitude of exposure. BJOG. 2024.

9. Hassan S et al. Endocrine disruptors: unravelling the link between chemical exposure and women’s reproductive health. Environmental Research. 2024;241:117385.

10. Ding N et al. Perfluoroalkyl and polyfluoroalkyl substances (PFAS) and their effects on the ovary. Human Reproduction Update. 2020;26(5):724-752.

11. Zhou Y et al. Per- and polyfluoroalkyl substances (PFAS) in personal hygiene products: the implications for human exposure and emission to the environment. Environmental Science & Technology. 2023;57(12):4989-4999.

12. Wicks A, Brady S, Whitehead HD et al. Per- and polyfluoroalkyl substances in reusable feminine hygiene products. Environmental Science & Technology Letters. 2025;12:924-929.

13. Smith-Spangler C et al. Are organic foods safer or healthier than conventional alternatives? Annals of Internal Medicine. 2012;157(5):348-366.

14. Cioni L et al. Plastic additives in single-use and reusable menstrual products: potential implications for human health and the environment. Environmental Science & Technology. 2025.

15. van Eijk AM et al. Menstrual cup use, leakage, acceptability, safety, and availability: a systematic review and meta-analysis. Lancet Public Health. 2019;4(8):e376-e393.

Vital sign? Well yes, although not exactly…

The menstrual cycle is our 5th vital sign, or so the saying goes. It’s a sentiment I believe in, but the pedant in me wouldn’t necessarily have chosen that word had I been clever enough to coin the phrase first. Important, valuable, significant, all yes, but vital? Not in the sense that if you don’t have it, you’re life is in immediate danger ‘vital’. Maintaining your airway: vital. Breathing: vital. A heart rate, a blood pressure, a blood sugar above a certain threshold: all vital. In fact, one of the reasons that makes it a great parameter to track in the first place is the fact that it isn’t vital in the truest sense of the word. The body will shut it down to direct energy to processes it deems more important the moment it senses the need and this is a valuable sign.

I also worry about the word ‘vital’ because I think it creates a fear that women who don’t menstruate are somehow damaging themselves irreversibly. Of course, there are many situations where women do not menstruate and can be perfectly healthy; when they knowingly take a form of contraception that stops menstruation for example, when they are pregnant or postmenopause.

I believe one of the reasons this fear exists is because it feeds into the misinformed narrative that a period is a detox for the body and that not having one is somehow allowing toxins to build up and make us sick. This is not true; the absence of a period can be a sign of suboptimal health that deserves attention, but not because of a buildup of toxins.

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The menstrual cycle is a coordinated dance, not just a uterine event

To explain why the menstrual cycle can tell us so much, we need a quick physiology recap. The process of menstruation is not just about what’s happening in the uterus; it’s actually a beautifully coordinated dance between multiple areas of our body upstream of the uterus.

The brain: Specifically, the hypothalamus and pituitary gland. If menstruation was a company, let’s call it Menstruation Inc., the hypothalamus and pituitary would be the CEO and the managing director, controlling the rest of the reproductive system and communicating with them via the hormones they release.

How efficiently the hypothalamus and pituitary release these hormones can be affected by anything from stress to malnourishment, to overexercising, excessive or rapid weight loss or a structural problem affecting the hypothalamus or pituitary. The commonest reason for the latter would be a benign pituitary tumour that presses on the healthy cells and stops them producing the necessary hormones to communicate with the ovaries. These are almost always (99.9%) benign.

The ovaries: The brain bosses communicate with the workers of the company, the follicles within the ovaries, with different hormones depending on what they want the follicle to do. FSH- grow the egg and produce oestrogen. LH- release the egg and transform the follicle sac into a progesterone producing corpus luteum. So, anything wrong with your ovaries or the quality or quantity of the follicles within them can affect your menstrual cycle; premature menopause, perimenopause, inflammation or scarring of your ovaries or conditions that affect both the brain and the ovary like PMOS.

The uterus & vagina: The hormones produced by the workers (the follicles) are used to manipulate the lining of the womb. Of course, they do a lot more than that in the body more generally but we’re talking menstrual cycles here so I’m keeping it simple. The lining either grows under oestrogen, stabilises under progesterone or sheds when both are removed. Anything that impacts on the production of these hormones e.g. perimenopause, PMOS, endometriosis, or impacts the surface area of the lining e.g. fibroids or polyps, or contractility of the uterus e.g. adenomyosis for example, will change the heaviness and length of your period.

So a change in the regularity, length, and flow of your period can be a symptom of many underlying pathologies, which is why it’s so important to know what your normal is and be able to tell when your cycle has diverged from that.

There seems to be a lot made of the colour of your period blood and what it can tell you. I’ve been in women’s health for a long time and I’ve been at women’s health conferences where the evidence for the menstrual cycle as a window into health has been discussed extensively. The colour of menstrual blood has never once been discussed. This part of menstrual tracking I think probably came from a clever influencer and has since been regurgitated as gospel over and over again as seems to happen on social media (to be fair it’s a topic that makes for a very visually engaging post).

The colour, unless there is an infection and pus present, will tell you only whether the blood has left the uterus quickly: bright red, or slowly: darker and browner as it has had more time to oxidise. Obviously, a heavy bleed that leaves the uterus quickly will be redder than the drips at the beginning or end, but there’s not much more you can infer from the colour than that.

The case for tracking

So why do I believe girls and women should track their cycle? It’s not because I think you can diagnose exactly what may be wrong by a change in regularity, flow or length of your cycle. Whilst I’ve tried to simplify it here, many of the causes are overlapping and may require more than just your menstrual history to make complete sense of. But, what I can be sure of is that if I’m a woman with a normal cycle length, that comes within a few days of when it is expected most of the time, that is not painful or heavy in a way that interferes with my life at all and that lasts for 7 days or less, all members of Menstruation Inc. are present, correct, and working well. On the contrary, if this changes or has never been the case, I know that the opposite is true.

It’s a signal, like your sleep, or your mood, or your energy levels. Something gently nudging you to notice that something has changed in your body. No doubt women carried this innate knowledge for centuries prior to modern medicine, and we need to teach this skill again.

A guide to tracking: what’s normal

• Cycle length between 24–38 days

• Length of period 3–7 days

• Pain or flow should not interfere with your daily life in any way. If you can get through the day only by taking back-to-back ibuprofen and paracetamol (advil and Tylenol for US readers) or by wearing a super absorbency tampon and pad at the same time and changing them every hour; you are coping but it is not normal.

• Consistent change away from your normal is what is most significant here. A month or 2 that is off may need more monitoring to see where the pattern is heading.

An important caveat is adolescent girls.

We do not expect them to have a regular cycle for at least a year after menarche (day of first period). In fact it can take up to 2-3 years in some girls and some new evidence suggests it might take up to 8 years for the brain-ovary-uterus hormonal connection to fully mature. Of course this makes sense. We know adolescent brains can take a decade to fully mature, so why would this process be any different. In any new start up it takes time for all employees to learn the ropes.

Too many teenage girls in the past were started on hormonal contraception to treat their adolescent ‘physiology’ when they had no actual pathology and this was wrong. It is normal for the cycle of a teen girl to be irregular for some time and girls will differ in this: some girls mature quickly, some take a little more time. This can make the diagnosis of PMOS in this age group trickier but I will talk about this in a separate article.

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Why the article lost me at cycle tracking on hormonal contraception

All hormonal contraception delivers supraphysiologic doses of synthetic hormones: usually a synthetic oestrogen paired with a progestin (the collective name for synthetic progesterone), or a progestin alone. The job is to trick the powers that be at Menstruation Inc. that they have been so efficient in their running of the company that they can take a break. The high levels of oestrogen and progesterone trick the brain into thinking that they have an abundance of produce, that the ovaries have surpassed themselves, the hormone shelves are stuffed full and everyone can go off early on their summer break.

Trying to track your cycle in this situation is like trying to take a roll call when everyone has already gone home. It won’t tell you anything, because the bleed is determined by withdrawal from these hormones, not the carefully coordinated hormonal dance that is the brain-ovary-uterus connection.

Now, does this mean that hormonal contraception is inherently bad? No. Read my last post for more discussion on that. Does it mean that they cause long-term fertility issues? No. The members of Menstruation Inc. are temporarily on holiday and will return as soon as they sense that hormone levels are back to normal and their work is needed. They may take some time to get into the swing of things when they get back; (holiday blues, you know how it is), but there is no evidence that hormonal contraception permanently damages this hormonal connection.

(Of course, if they were bad at their job before the holiday, the holiday will have done nothing to improve their competency and this is why hormonal contraception is often blamed for causing conditions like PMOS that were inadequately assessed and diagnosed before hormonal contraception was started. Irregular periods were not properly assessed → hormonal contraception was started → withdrawal bleeds gave the impression of a regulated cycle → contraception stopped → irregular cycles re-appear.).

All of this does mean however, that trying to track your cycles over and above monitoring for side effects, when you’re on hormones doesn’t make sense.

So, if you have a natural cycle, do track it, understand your normal, be vigilant to changes that may be trying to tell you something. And I’d urge your teen girls to do so too. Having recorded evidence of how her brain is maturing is pretty cool to say the least. But it also gives her a chance to understand her normal once it’s established; an invaluable if not truly vital piece of information that all women should have.

References

1. American Brain Tumor Association. Pituitary Tumors. https://www.abta.org/tumor_types/pituitary-tumors/

Pregnancy is one of the most extreme physiological events a human body can undergo. Cardiac output rises by 30%, the kidneys filter up to 50% more blood per minute, and metabolic rate reaches levels comparable to elite endurance sport. As well as having a significant impact in the perinatal period itself, complications such as pre-eclampsia, gestational diabetes, preterm birth, and perinatal mood disorders are markers. Women with gestational diabetes are up to 70% more likely to be diagnosed with type 2 diabetes within ten years. Women who have had pre-eclampsia have a 2 to 4 times increased lifetime risk of heart disease. And women who deliver preterm carry a 1.5 times increased lifetime risk of cardiovascular and cerebrovascular disease. This points to subclinical endothelial dysfunction and metabolic susceptibility that existed before the pregnancy began, and that may endure long after the baby arrives.

This information isn’t new. The issue is whether a care structure exists that allows that knowledge to be held by someone able to offer continuity across a woman’s life course. A woman who’s just had a baby is, of course, focused on surviving those early days: feeding, sleeping, healing, and keeping a new human alive. The last thing she’ll be thinking about at six weeks postpartum is her lifetime cardiovascular risk. But that moment passes and if the healthcare system hasn’t built in a mechanism to follow her over the long term, those signals go unread.

This episode is about changing that. I’m joined by Dr Christina Aye, consultant obstetrician and clinician scientist specialising in maternal-fetal medicine, to talk about what pregnancy can reveal about a woman’s long-term health across cardiovascular, metabolic, and mental health domains, and what a life course approach to women’s healthcare would actually look like if we took that information seriously.

Guest Bio

Dr Christina Aye is a Consultant in Obstetrics and FetalMedicine and Honorary Senior Clinical Lecturer at the Nuffield Department of Women’s and Reproductive Health, University of Oxford. She completed a DPhil in Cardiovascular Medicine at Oxford and her research focuses on the long-term cardiovascular consequences of pregnancy complications, including hypertensive disorders and preterm birth, in both mother and child.

What We Cover

[00:02:18] Pregnancy as a Physiological Stress Test

• Why pregnancy puts the body under demands comparable to running an ultramarathon, and how complications that arise in that context are often early signs of vulnerabilities that were already there.

[00:09:42] Pre-eclampsia: What It Is and Why It Matters Long-Term

• What pre-eclampsia actually is, how it is diagnosed, and why having it in pregnancy raises your lifetime risk of heart disease and stroke, even after your blood pressure returns to normal.

[00:17:51] The Placenta, Blood Vessels, and What Goes Wrong

• How a healthy placenta remodels the blood vessels that supply it, why that process fails in pre-eclampsia, and new research showing that the effects on the kidneys can still be measured months after birth.

[00:23:25] What Should Happen After a Hypertensive Pregnancy

• Why monitoring your blood pressure at home in the weeks after birth can have lasting benefits, and why so many women currently leave hospital without the follow-up plan they need.

[00:27:49] Preterm Birth and Long-Term Health

• Why giving birth early, for any reason, is an independent risk factor for heart and circulatory disease later in life, and why women who have delivered preterm are rarely told about this.

[00:30:05] Gestational Diabetes: A Metabolic Warning Sign

• Why gestational diabetes does not simply disappear after pregnancy, what the statistics on type 2 diabetes risk actually look like, and what checks you should be having in the years that follow.

[00:39:21] Perinatal Mood Disorders and Future Mental Health

• How postnatal depression can be a signal of longer-term mental health vulnerability, including at perimenopause, and the striking data linking it to cardiovascular risk decades later.

[00:45:11] What Pregnancy Can Tell Us About Our Children’s Health

• What the science of epigenetics and fetal programming actually means in practice, why the messaging around it needs to be handled carefully, and how to think about your child’s health without adding to the pressure of pregnancy.

[00:52:57] What Better Postnatal Care Would Look Like

• What a joined-up system of care after a complicated pregnancy would actually look like, including the case for using your obstetric history as part of every future cardiovascular health check.

What You Will Learn

• Why is pregnancy described as a stress test for the body?

• What is pre-eclampsia and does it increase the risk of heart disease later in life?

• Does preterm birth affect a mother’s long-term health?

• What is gestational diabetes and does it go away after pregnancy?

• How soon after gestational diabetes should you be checked for type 2 diabetes?

• Does postnatal depression increase the risk of cardiovascular disease?

• What is epigenetics and how does pregnancy affect a baby’s long-term health?

• What follow-up should women expect after a pregnancy complicated by high blood pressure or gestational diabetes?

Key Takeaways

• Complications like pre-eclampsia, gestational diabetes, and preterm birth are early signals of underlying vulnerabilities that require long-term monitoring. You may need annual checks.

• If you had postnatal depression, perinatal anxiety, or struggled with your mental health around pregnancy, that history may be relevant to your future mental health and, emerging evidence suggests, your cardiovascular health too. It’s worth telling your doctor.

• Your obstetric history is part of your health history. Whether you are navigating midlife health decisions or speaking with a new clinician, what happened in your pregnancies matters.

Further Resources and Support

Cardiovascular Health After Pregnancy

British Heart Foundation — Information on heart disease risk, prevention, and support for women.

American Heart Association — Resources on cardiovascular risk in women, including pregnancy-related risk factors.

World Heart Federation — Global resources on cardiovascular disease prevention across the lifespan.

Hypertensive Disorders of Pregnancy

Action on Pre-Eclampsia (APEC) — Education, support, and resources for women affected by pre-eclampsia.

Preeclampsia Foundation — International support organisation with resources on diagnosis, management, and long-term health.

Gestational Diabetes

Gestational Diabetes UK — Peer support, dietary guidance, and information on postnatal follow-up after gestational diabetes.

American Diabetes Association — Information on type 2 diabetes risk, prevention, and management following gestational diabetes.

Perinatal Mental Health

PANDAS Foundation — Support for women and families affected by perinatal mental illness, including postnatal depression and anxiety.

Postpartum Support International — Global network offering support, resources, and provider referrals for perinatal mood disorders.

Maternal Mental Health Alliance — Advocacy and resources focused on improving access to perinatal mental health care.

Preterm Birth

Tommy’s — Research and support for pregnancy complications including preterm birth, miscarriage, and stillbirth.

March of Dimes — International organisation working to improve outcomes for mothers and babies, with resources on premature birth.

Women’s Health Research and Longevity

Royal College of Obstetricians and Gynaecologists (RCOG) — Clinical guidelines and patient information on pregnancy complications and women’s health across the lifespan.

Society for Women’s Health Research — Advocacy and resources promoting sex-specific research and women’s health across the lifespan.

Disclaimer

The content of this podcast is intended for informational purposes only and does not constitute medical advice. Always consult a qualified healthcare professional regarding any health concerns or before making changes to your care or treatment. The views expressed are those of the individuals speaking and do not represent the position of any institution or organisation.

It is the leading cause of death for women in the UK and Australia, and a significant proportion of those cases are preventable.

In this short extract from our recent episode on women’s brain health, Dr Natalie Hutchins asks Professor Cassandra Szoeke, neurologist and principal investigator of the Women’s Healthy Ageing Project, one direct question: what are the top three things women can do right now to reduce their dementia risk?

The answers are specific, evidence-based, and in some cases, not what you might expect.

She also weighs in on creatine, vitamin D, the ketogenic diet, and what the data from over 20,000 Australian women actually shows about diet and brain health.

For the complete conversation — including what happens to women’s brains at menopause, why brain fog is not the same as dementia, and what 30 years of longitudinal data tells us — watch the full episode here:

This post is for educational purposes only and does not constitute individual medical advice. Please speak to your doctor for advice tailored to you.

She carefully unfolds the information insert from her pill packet in a poorly lit room, a tiny square turns into an impressive A1 sheet, covered in illegible small print: the side effects. The camera zooms in as a haunting audio of a girl screaming plays over and over.

10 seconds. No words, context or story. Millions of views. And just like that, the space women had been unknowingly waiting for had been created. Women who had been dismissed about the experiences they had had on the pill over the years, whom we had bashed down with our population based evidence like a game of complaint whack-a-mole, had validation. ‘The pill may have liberated us but it’s far from perfect and some of us feel awful on it’, was the message.

To be clear, I’m not ‘anti-pill’. Far from it; it stops me from having recurrent lung collapses and bleeding into my chest cavity from my thoracic endometriosis. It has enabled me to live a pretty ‘normal’ life, for the outsider looking in, despite having a pelvis that looks like it’s gone to war with a cheese grater and a litre of concrete. But, I’ve been on some preparations of the pill that make the thought of weeks of solitary confinement under a duvet seem desperately appealing. I can empathise with these women.

And whilst I really don’t like the way the ‘anti-pill’ rhetoric has progressed since then, dangerously so, it has made me reflect on how we, as a profession, have contributed to getting here.

When women told us they were struggling, we reached for the population data and used it to close the conversation down rather than stay curious to associations yet undiscovered. We prescribed the pill like it was the same drug for every woman. We prescribed whatever the formulary allowed, which was to be fair the safest from a clotting risk point of view, without explaining that the progestin in one pill is not the same as a progestin in another, that the oestrogen dose matters, and that the variation in chemical structure between formulations translates into meaningfully different effects in different bodies. We treated a class of drug as a single entity, when it was not.

But the evidence is now beginning to tell us that whilst this approach may be fine for many women, there are significant subsets of women who may struggle more than others and that this is further impacted by the type of pill that is given. Certain biological characteristics appear to modify how individual women respond to the pill, and we are getting better at identifying what those are.

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‘The’ pill is not one drug

What we haven’t explained enough is that the pill, is not ‘the’ pill at all. There are 100s of formulations that differ by oestrogen type, oestrogen dose, type of progestin and whether the dosing changes across the month or not (monophasic or multiphasic).

And each one of these differences can change the side effect profile or be utilised to provide a benefit. For example if a woman is on a low dose oestrogen pill and experiencing breakthrough bleeding or low libido, you might up the oestrogen dose. Conversely, if she is getting lots of oestrogenic side effects on the higher oestrogen pill; nausea, breast tenderness, you might drop her to a lower dose one. A pill that has the body identical oestrogen oestradiol in it, might be more suitable for a woman in perimenopause who wants contraception and better symptom management in one pill, over the synthetic oestrogen containing pills.

Progestin type also matters. An anti-androgenic progestin may not be suitable for a woman with low libido, but might be great for a woman with acne brought on by an androgenic progestin.

And progestin type also matters for mood.

Progestin type and mood

Progestins are synthetic, lab made, versions of our own natural progesterone hormone. They are very similar to progesterone, enough to attach to its receptors and create progesterone like effects, but they’re not exactly the same and can also attach to other receptors.

First and second-generation progestins (the earlier versions), including levonorgestrel and norethisterone, have some androgenic activity and that can worsen acne, cause weight gain and affect mood in some women.

Third and fourth-generation progestins either have a neutral effect on androgen receptors or are actually anti-androgenic, like drosperinone, making them useful for women with acne, hirsutism, or fluid retention. Drosperinone is also the progestin in the only combined pill formulation licensed specifically for PMDD. However, the trade-off here is they tend to have higher clotting risk profiles so usually aren’t given as first line.

Unfortunately, personalised prescribing of the pill has not always been routine practice. In the UK for example, the most commonly prescribed combined pills contain androgenic 1^st or 2^nd generation progestins (e.g. Microgynon, Rigevidon, Ovranette, Brevinor). They carry the lowest clotting risk and are the cheapest making them the perfect first line option. However, these androgenic containing progestins are also known to negatively affect mood in some women.

The reason progestin type influences mood is thought to be partly due to the effect of their metabolites on the brain. Progesterone is metabolised in the brain into neuroactive steroids, the most important of which is allopregnanolone: a natural calming agent that acts on the same receptors targeted by sedatives. Fluctuations in its levels are now understood to be central to mood disorders including PMDD (premenstrual dysphoric disorder, a severe form of PMS) and, potentially, to the mood sensitivity some women experience on hormonal contraception.

Natural progesterone is readily converted to allopregnanolone. Synthetic progestins, however, vary considerably in how readily this conversion occurs, meaning different progestins produce different levels in the brain. Progestins also appear to differ in their effects on other mood-regulating neurotransmitter systems, including serotonin, though the exact mechanisms aren’t fully understood. But what we do know is that androgenic and anti-androgenic progestins seem to differ in their neurological effects, with the former seeming to have more negative impacts.

Having said that, we also know that there are some women who are simply intolerant to all progestogens (synthetic or natural), which is referred to as progesterone intolerance.

Who reacts differently, and why

Mood disturbance is one of the commonest reasons for a woman to discontinue hormonal contraception and yet, not all women will experience mood problems. We now know there are some risk factors that make it more likely.

Adolescents

Emerging evidence suggests that adolescents may be particularly vulnerable to mood effects from hormonal contraception. Large population studies have found significant associations between hormonal contraception and depression or psychotropic drug use in adolescent girls, while finding little or no significant association in adult women. The type of progestin also appears to be relevant.

The increase in absolute risk is small though; 1 in 100 risk of being prescribed an antidepressant for a 12-14 year old not on the pill, versus 4 in 100 on the pill. So not an insignificant increase but nor is it deterministic. And of course this risk needs to be considered in context; her medical history, risks of not using reliable contraception, risk of unintended pregnancy with its own profound effects on mental and physical health.

Women with pre-existing PMS or mood disorders

A 2021 Swedish study found that women with a previous or ongoing mental health problem had nearly double the odds of experiencing mood side effects from hormonal contraception compared to women without any mental health history. This is supported by a placebo-controlled trial from 2018, which found that women with a history of mood, anxiety, or eating disorders who took a combined oral contraceptive had significantly worse mood scores than those given a placebo. Women without pre-existing mental health problems showed no mood difference between the pill and placebo at all. This suggests that the mood effects attributed to the pill at a population level may be largely driven by a subgroup of women who are biologically predisposed to them, rather than being a universal effect of the drug.

A 2026 UK study of 1,133 contraceptive users found that women with pre-existing PMS were 2.5 times more likely to stop the combined pill due to side effects, and 2.3 times more likely to stop the progestogen-only pill. Women with a history of anxiety or mood disorders were also more likely to discontinue the combined pill. Mood problems were the most commonly reported reason for stopping overall.

Notably, this pattern was not seen with the hormonal IUD, which works locally at much lower systemic hormone levels and avoids the daily hormonal peaks and troughs of oral methods. This may matter: it suggests that for women with pre-existing PMS or mood disorders, it is not necessarily progestogen itself that is the problem, but the way oral methods deliver it.

Women with ADHD

There is growing evidence that women with ADHD represent a specific subgroup with heightened sensitivity to oral hormonal contraception. A large Swedish national register study covering nearly 30,000 girls and young women with ADHD and over 760,000 without, found that women with ADHD already carry a threefold higher baseline risk of depression irrespective of contraceptive use. When taking a combined oral contraceptive, their risk of depression was substantially elevated further, with women with ADHD on the pill showing approximately five times the depression risk of non-ADHD women not using hormonal contraception. The progestogen-only pill produced a similarly elevated risk. Non-oral hormonal methods, including the implant and hormonal IUD, appeared to carry a lower excess risk in preliminary analysis, leading researchers to speculate that daily hormonal fluctuation from pill-taking may be a contributing factor, though this finding requires confirmation in larger studies.

Women with ADHD are also at substantially elevated risk of PMDD: a 2025 British Journal of Psychiatry study found that over 40% of women meeting an ADHD symptom threshold met criteria for provisional PMDD, compared to under 10% of controls. And as we see above, women with PMS symptoms have a higher risk of side effects with the pill.

A call for more personalised prescribing

A history of PMS, a mood disorder, ADHD, progesterone intolerance or being an adolescent is not necessarily a reason to not take hormonal contraception at all if there are other reasons that make taking it compelling, but it is a reason to prescribe it differently. The type, the dose and route of the contraception may need to be carefully considered, and these women will need more thorough counselling, earlier follow-up, and a lower threshold for switching formulation or method if symptoms occur.

The pill is such a useful medication for so many things. A cure? No. But an effective treatment? Absolutely! I hate to see 60 years of development and a solid evidence base for it’s contraceptive and therapeutic efficacy be completely trashed by what the the ‘anti-pill’ movement has become. The women being steered away from it entirely by social media without consideration for each woman’s own context, sometimes into fertility awareness apps with no clinical validation or unintended pregnancy, are not being better served.

But we also have to be honest about where we went wrong. The women whose side effects were dismissed with population statistics were not being well served either. What the evidence is now giving us is something more valuable than a blanket verdict: the tools to identify which women are likely to do well on which formulation, to have a different conversation with an adolescent than with a 30-year-old, to recognise ADHD or a history of progesterone sensitivity as signals for a different approach.

We should have been saying this for years. The pill is not ‘the’ pill. And its prescription needs a personalised approach.

References

· Douxfils J et al. Are natural estrogens used in contraception at lower risk of venous thromboembolism than synthetic ones? A systematic literature review and meta-analysis. Frontiers in Endocrinology. 2024.

· Didembourg M et al. Lower reporting of venous thromboembolism events with natural estrogen-based COCs compared to ethinylestradiol containing pills: A disproportionality analysis of the Eudravigilance database. Contraception. 2024.

· Stegeman BH et al. Different combined oral contraceptives and the risk of venous thrombosis: systematic review and network meta-analysis. BMJ. 2013.

· Zettermark S et al. Hormonal contraception increases the risk of psychotropic drug use in adolescent girls but not in adults: A pharmacoepidemiological study on 800,000 Swedish women. PLOS ONE. 2018.

· Kraft MZ et al. Symptoms of mental disorders and oral contraception use: A systematic review and meta-analysis. Frontiers in Neuroendocrinology. 2023.

· Pletzer B et al. Progesterone and contraceptive progestin actions on the brain: A systematic review of animal studies and comparison to human neuroimaging studies. Frontiers in Neuroendocrinology. 2023.

· Bengtsdotter H et al. Ongoing or previous mental disorders predispose to adverse mood reporting during combined oral contraceptive use. European Journal of Contraception and Reproductive Health Care. 2018.

· Lundin C et al. Towards individualised contraceptive counselling: clinical and reproductive factors associated with self-reported hormonal contraceptive-induced adverse mood symptoms. BMJ Sexual and Reproductive Health. 2021.

· Lundin C et al. Hormonal Contraceptive Use and Risk of Depression Among Young Women With Attention-Deficit/Hyperactivity Disorder. Journal of the American Academy of Child and Adolescent Psychiatry. 2022.

· Broughton T et al. Increased risk of provisional premenstrual dysphoric disorder (PMDD) among females with attention-deficit hyperactivity disorder (ADHD): cross-sectional survey study. The British Journal of Psychiatry. 2025.

· Wynchank D et al. Menstrual Cycle-Related Hormonal Fluctuations in ADHD: Effect on Cognitive Functioning: A Narrative Review. Journal of Clinical Medicine. 2025.

· Stevens R et al. Patterns of contraceptive side-effect variation: assessing medical and lifestyle factors associated with side-effects among those using hormonal contraception in the United Kingdom. European Journal of Obstetrics and Gynaecology and Reproductive Biology. 2026.

The problem is that the IVF industry does not make it easy to choose wisely. Success rates are presented in formats that are virtually incomparable between clinics. Regulation varies dramatically from country to country, and even within regulated systems, quality of care, laboratory standards, and treatment add-ons fall largely outside the scope of oversight. A clinic can display a headline live birth rate that looks impressive and entirely fail to mention that it only accepts patients with excellent prognosis.

Then there is the question of cost, access, and geography. In many countries, publicly funded fertility treatment is limited, inconsistent, or unavailable. Waiting times can stretch to a year or more, and the eligibility criteria can be opaque until you are already deep in the process. The result is that the people most in need of support are often the least equipped to navigate a market that is, frankly, not well designed with them in mind.

In this episode, I am joined by Emma Whitney, an embryologist and chair of the fertility charity Fertility Action, and Professor Bassel Wattar, a gynaecologist and clinician researcher specialising in reproductive medicine. Together we cover everything from how to read a success rate, to what actually goes on in an IVF laboratory, to which treatment add-ons have genuine evidence behind them and which do not. If you’re thinking about IVF, already in the middle of it, or just trying to understand your options, this episode gives you the tools to ask better questions and advocate more effectively for yourself.

Guest Bios

Emma Whitney is a clinical embryologist and the chair of Fertility Action, a charity dedicated to improving access to fertility treatment and supporting those navigating the fertility landscape. She has extensive experience in clinical embryology, including embryo selection, preimplantation genetic testing, and laboratory quality.

Professor Bassel Wattar is a gynaecologist and clinician researcher with a specialist interest in reproductive medicine. He co-leads a research unit dedicated to evidence synthesis in women’s health and the Clinical Trials Unit at Anglia Ruskin University with a focus on delivering high quality applied clinical research.

What We Cover

00:03:04 Access to IVF: public funding, waiting times, and the postcode lottery

– Why 60% of IVF cycles are now done privately, and how eligibility criteria for publicly funded treatment vary enormously depending on where you live.

00:10:48 The global picture: how other countries fund fertility treatment

– International comparisons showing that some countries offer unlimited IVF cycles as a matter of public health policy, in response to declining birth rates and demographic pressures.

– Why the economic and societal case for funding fertility treatment is largely absent from political debate in many places.

00:13:10 How to choose a clinic: what to look for beyond the website

– The role of specialist matching, multidisciplinary team culture, and continuity of care in predicting a good clinic experience, none of which are visible on league tables.

– How corporate ownership models and rented laboratory arrangements can fragment the care pathway in ways that matter to outcome.

00:16:55 Understanding IVF success rates and how they can mislead

– Why live birth rate per embryo transferred systematically excludes patients who never reached a transfer, and why cumulative and per-cycle-started metrics give a more honest picture.

– How patient selection, including excluding older women or those with low ovarian reserve, can significantly inflate a clinic’s published success rates.

00:26:55 The embryology laboratory: the part patients never see

– What makes a high-quality embryology lab, including time-lapse incubation, seven-day working, and embryologist involvement in clinical decision-making.

– How the embryologist consultation works in practice, and what questions patients can ask to understand the lab team’s role in their care.

00:38:55 IVF add-ons: what they are and how to evaluate the evidence

– How the add-on designation works, what it means in practice, and why the current regulatory framework for assessing add-ons has significant limitations.

– The distinction between add-ons offered to everyone versus those targeted at specific patient groups, and why that distinction matters for evaluating the evidence.

00:43:21 Preimplantation genetic testing (PGT-A): green, amber, or red?

– What PGT-A does and does not do, including the risk of discarding mosaic embryos that might have self-corrected, and why the evidence base is still contested.

– Why age is the key variable in deciding whether PGT-A is appropriate, and how to have an informed conversation with a clinician about whether it is right for you.

00:51:41 Endometrial scratching, embryo glue, and other add-ons reviewed

– An evidence-by-evidence review: endometrial scratching (limited and contested), embryo glue (minor benefit, no additional cost, now standard in many labs), time-lapse incubation (standard, not add-on).

– Why immune treatments for recurrent implantation failure, including intralipids, IVIGs, and steroids, currently lack robust randomised trial evidence despite being widely offered.

01:00:13 Going abroad for IVF: regulation, risk, and what to ask

– How regulatory standards for IVF clinics and laboratories differ significantly between countries, and why some popular destinations for fertility tourism have minimal oversight.

– Practical advice on accessing reliable information about overseas clinics, including the value of seeking referrals from clinicians who have direct knowledge of the labs they recommend.

What You Will Learn

• Why is publicly funded IVF so difficult to access, and does it depend on where I live?

• What happens if I am on the waiting list for IVF and I age out of eligibility before I am seen?

• How do I choose between IVF clinics when they all look similar online?

• What does an IVF success rate actually mean, and how can it be misleading?

• Why do different clinics show different types of success rate, and which is the most honest?

• Should I be asking to meet the embryologist, not just the consultant?

• What is a high-quality embryology laboratory and how would I know if a clinic has one?

• What is a treatment add-on in IVF and how do I know whether it has real evidence behind it?

• What is PGT-A (preimplantation genetic testing) and should I have it?

• What is the risk of discarding a viable embryo through genetic testing?

• Does endometrial scratching improve IVF success rates?

• What is embryo glue and is it worth having?

• Is there any evidence for immune treatments like intralipids or IVIGs in IVF?

• Is IVF abroad safe, and how do I know if a clinic in another country is properly regulated?

• What should I ask a fertility clinic before I commit to treatment?

• Where can I find free, reliable support and information about IVF?

Key Takeaways

• Success rates on clinic websites are not straightforward. Always look for live birth rate per cycle started, ask about age banding, and find out what patient groups the clinic accepts. A high headline number may reflect careful patient selection, not superior care.

• The embryology team matters as much as your consultant. Ask whether you can speak with an embryologist before treatment begins, and find out whether the lab operates seven days a week. These details are not on the regulatory website, but they are worth asking about.

• Most IVF add-ons are offered ahead of the evidence. Before agreeing to any additional treatment, ask what the current evidence shows, whether it is targeted at your specific situation, and what the additional cost is.

• Knowledge is your best protection. The IVF market, wherever you are, is not perfectly regulated. Educate yourself, seek peer support, consult more than one specialist if you can, and make use of the independent resources that exist.

Further Resources and Support

Regulatory Bodies and Official Information

• HFEA (Human Fertilisation and Embryology Authority) — UK regulator of IVF clinics; includes a clinic search tool with independently reported success rates and a guide to treatment add-ons.

• HFEA Clinic Finder — Search and compare licensed clinics in the UK, including reported success rates and available treatments.

• HFEA Treatment Add-Ons — Independent evidence ratings for common IVF add-ons, updated regularly.

Charities and Peer Support

• Fertility Action — UK fertility charity co-chaired by episode guest Emma Whitney; provides free peer-to-peer support groups monitored by qualified psychologists, plus advocacy for improved access to treatment.

• Fertility Network UK — The UK’s leading patient-facing fertility charity, offering information, emotional support, and community for people at all stages of the fertility journey.

• Resolve: The National Infertility Association (USA) — Advocacy, education, and support for people experiencing infertility in the United States.

• ESHRE (European Society of Human Reproduction and Embryology) — Professional body for reproductive medicine; publishes evidence-based patient guidance on a range of fertility topics.

Mental Health and Emotional Support

• British Infertility Counselling Association — Directory of counsellors specialising in fertility, pregnancy loss, and assisted conception, for patients in the UK and internationally.

• Mind (UK) — Mental health charity with resources on managing grief, anxiety, and the emotional impact of fertility treatment.

Miscarriage and Pregnancy Loss

• Tommy’s — Research and support charity for pregnancy complications including miscarriage, stillbirth, and premature birth; includes guidance for those experiencing recurrent pregnancy loss.

• Miscarriage Association — UK charity providing support and information for those affected by pregnancy loss at any stage.

• Sands.org.uk — Support and information for anyone affected by the death of a baby, including a helpline, online community, and local groups.

Disclaimer

The content of this podcast episode and these show notes is intended for general informational and educational purposes only. It does not constitute medical advice and should not be used as a substitute for professional medical guidance, diagnosis, or treatment. Always consult a qualified healthcare professional about your individual circumstances before making any decisions about your fertility care. The views expressed by guests are their own and do not represent the official position of any regulatory body or institution.

Do I need to test my hormones?

And it is one of the questions that generates some of the most misleading answers online.

In this focused extract from our menopause controversies episode, Dr Natalie Hutchins is joined by Mr Vikram Talaulikar, consultant gynaecologist, menopause specialist and researcher, to give an honest, evidence-based answer.

The short version: for most women over 45, a random hormone blood test tells you very little.

Because perimenopause is defined by hormonal chaos. Oestrogen levels rise and fall unpredictably. Where you happen to catch a woman on that journey determines the result, which may have no correlation whatsoever to how she actually feels.

One of the clearest messages from this conversation:

Symptoms are a far more reliable guide than any number on a lab report.

We also explore:

• Why the NICE guidelines moved away from routine hormone testing and what that means in practice

• The problem with testing hormone levels while already on HRT

• When blood tests genuinely are useful, and for whom

• Whether continuous hormone monitoring devices are worth the investment yet

• What actually tells you if your HRT is working

There is a growing market for hormone testing, both in clinics and direct to consumer. Some of it is useful. Much of it is not.

Knowing the difference could save you money, confusion and a great deal of unnecessary anxiety.

This is an extract from our full episode: HOW TO MENOPAUSE: An Honest Take on the HRT, Testosterone and Dementia Debate. Listen to the full conversation wherever you get your podcasts.

Women have been conditioned to think about their health in purely reproductive terms: have I had my smear test? Is my mammogram due? All essential for health but how often do women think about how to protect their brains?

Dementia is a disease of midlife in the sense that the pathological changes which eventually produce symptoms in late life, begin in middle age. Midlife is also the time that several risk factors start to converge, meaning women’s vulnerability begins to accumulate precisely at the point where reproductive health tends to dominate clinical attention.

Some of the answers around sex-specific Alzheimer’s risk remain unknown: the trials needed to test them take decades to run and are logistically and commercially difficult to fund. But there is already a great deal we know. And I think it is something women in midlife need to be thinking about more.

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Why are women at higher risk?

The standard explanation is straightforward: women live longer than men, and age is the greatest risk factor for Alzheimer’s, so of course there will be more women with it overall. But when you look more closely at the data, longevity doesn’t explain all of the difference.

Prevalence tells you how many people have a disease at any given time. Incidence tells you how fast new cases are developing. The longevity argument only addresses prevalence. When researchers have examined incidence, the picture is more complicated: women’s excess risk doesn’t disappear when you account for the fact that we live longer. The sex gap in incidence is smaller than the gap in prevalence, but it’s still present. That points to the fact that there is something specific about being a woman, either the effect of sex on our biology, or the impact of how we live their lives in the context of societal gender norms, that impact negatively on women’s brain health.

It’s unlikely that a single mechanism can explains the female excess in Alzheimer’s incidence. Instead what we have are several overlapping potential contributors that are likely to be playing a role:

Menopause and oestrogen

The strongest evidence for the sex difference points to oestrogen. Before menopause, women are protected against both cardiovascular disease and dementia. Oestrogen is anti-inflammatory, protects the microvasculature, and acts on receptors distributed throughout the brain. When it is withdrawn at menopause, that protection is removed. Women who experience early menopause, whether naturally or through surgical removal of the ovaries, develop both heart disease and dementia earlier than women who reach natural menopause at the typical age. This relationship has been replicated across multiple cohorts and is one of the most consistent findings in this space.

Genetics

Equally well established is the sex-differential effect of the APOE4 gene variant, the strongest known genetic risk factor for late-onset Alzheimer’s. Women who carry one copy of APOE4 carry approximately four times the risk of developing Alzheimer’s, compared with roughly twice the risk in men carrying the same allele, though the mechanisms behind this difference are not yet understood. There is also evidence that female carriers experience a faster rate of cognitive decline than male carriers and female non-carriers.

Neuroinflammation

Chronic low-grade immune activation in the brain is now understood to be a central feature of Alzheimer’s disease. Oestrogen acts as an anti-inflammatory, so its withdrawal at menopause may shift the brain toward a more pro-inflammatory state. Women also have more complex immune systems than men, reflected in their higher rates of virtually all inflammatory and autoimmune conditions. Whether this immune complexity directly drives excess dementia incidence is still an active area of research, but the mechanistic plausibility is there.

Depression

Women have roughly twice the lifetime prevalence of depression compared with men. Depression is an independent risk factor for dementia and is associated with hippocampal atrophy, elevated cortisol, and neuroinflammation, all directly relevant to Alzheimer’s pathology. The relationship also runs the other way: early dementia can present as depression, meaning the underlying disease is missed and treated as a mood disorder instead.

Sleep

Women are more likely to experience disrupted sleep across the lifespan, especially around menopause. Sleep is when the brain clears amyloid via the glymphatic system. Chronic sleep disruption impairs that clearance and is now considered a significant modifiable risk factor for Alzheimer’s. The menopause transition, which removes oestrogen’s anti-inflammatory protection, also reliably degrades the sleep quality needed to clear the protein aggregates that oestrogen was helping to suppress.

The role of gender

Beyond biology, cultural and social gender roles and expectations also affect women’s specific risk.

Women in current older cohorts received significantly less formal education than men of the same generation. Lower educational attainment is associated with reduced cognitive reserve: the brain’s ability to keep functioning well even as disease-related changes accumulate. Women with less education have less of this buffer, and consistently higher rates of Alzheimer’s.

Women provide the majority of informal care across the lifespan: for children, for ageing parents, for partners, and disproportionately for those living with dementia. In OECD countries around 60% of informal caregivers are women, and women aged 50 to 65 are more likely than men to be simultaneously caring for parents while managing other caring responsibilities. Almost a third of female carers provide care for more than one person at a time.

The biological consequences of chronic caregiving stress are well-documented: elevated cortisol, disrupted sleep, physical inactivity, social isolation, and depression, and every one of these is an independent risk factor for dementia. Studies on informal dementia caregiving found that elevated cortisol and poorer cognitive performance were consistent findings in caregivers compared with non-caregivers. Women who provide intensive care carry an elevated risk of developing dementia themselves.

Physical inactivity is another place where biology and social circumstance intersect. Exercise is one of the most consistently evidenced modifiable risk factors for dementia, yet women are significantly less active than men across the lifespan, and the gap is widest in midlife. The reasons are partly structural: time spent in caregiving, domestic labour, and employment leaves less space for exercise, and safety concerns limit where and when many women feel able to be active. This matters particularly for brain health because the evidence suggests the protective effect of physical activity may be even greater in women than in men. Data from the Women’s Healthy Ageing Project identified cumulative physical activity from midlife as the strongest single predictor of verbal memory performance in later life, stronger than any other modifiable factor measured.

What does the evidence say about hormones protecting the brain?

If oestrogen protects the brain, the logical question is whether replacing it at menopause reduces dementia risk. What we know is that women who undergo premature menopause have a higher risk of dementia, and that this risk is reduced if they take menopausal hormone therapy (MHT) until around the average age of natural menopause.

Beyond that, the evidence becomes more complicated. Some observational studies suggest that women who initiate MHT around the time of the menopausal transition may have a lower risk of dementia, but the observational findings are inconsistent, and the randomised controlled trial evidence has not resolved the question.

The most influential trial in this space was the Women’s Health Initiative, stopped in 2002 after finding elevated rates of breast cancer and blood clots in participants on combined oestrogen-progestin therapy. But the dementia sub-study enrolled women with a mean age of 75, on average two decades past their final menstrual period. Asking whether oestrogen protects a brain that has been without it for twenty years is a different question entirely from asking whether it protects a brain during the transition. This is the basis of the timing hypothesis: that oestrogen may only be neuroprotective if initiated within a critical window around menopause. That hypothesis is biologically plausible and supported by intermediate data on vascular health and brain structure in women who initiated hormones early, even though a direct effect on dementia incidence remains unproven.

The type of progestogen used and whether oestrogen is taken orally or transdermally are also likely to matter. The Women's Health Initiative used conjugated equine oestrogen, derived from pregnant mares, combined with medroxyprogesterone acetate, a synthetic progestogen. Neither is the formulation commonly prescribed today. Transdermal oestradiol, which delivers bioidentical oestrogen directly through the skin, bypasses the liver and carries a lower clotting risk than oral preparations. Micronised progesterone, the body-identical progestogen now widely used alongside it, has a different safety and metabolic profile to the synthetic progestogens used in the WHI. Whether these differences in formulation translate into different outcomes for brain health specifically is not yet established, but the cardiovascular evidence suggests formulation matters considerably, and there is no strong reason to assume the brain would be an exception

What is missing is the long-term randomised trial that would settle all of these questions definitively. But given dementia takes decades to develop, a randomised controlled trial that would be able to follow women for that long seems most unlikely.

However, what the list of potential contributors to the sex differences in Alzheimer’s makes clear, is that whilst oestrogen withdrawal is central to the story, it is far from the whole story. The excess risk women carry is shaped by biology, genetics, immune function, life circumstances, and structural inequality, often acting together over decades. It would be surprising, then, if replacing one hormone, however important, were sufficient to undo that cumulative burden. MHT may well be part of the answer, but the evidence suggests it is unlikely to be all of it.

In my latest podcast episode, I discuss all of this with Professor Cassandra Szoeke, neurologist and principal investigator of the Women’s Healthy Ageing Project. We get into what is known and unknown about MHT for dementia risk and why we may never get the trial evidence needed to answer the question definitively. We also discuss her top evidence-based strategies for protecting brain health that have nothing to do with hormones and everything to do with how we live going into midlife and beyond.

Watch here

And in case you missed it, check out this episode on menopause management controversies where Dr Vikram Talaulikar and I discuss HRT for brain health, as well as cardiovascular disease, longevity, testosterone and how to navigate the grey areas in evidence.

References

1. Alzheimer’s Association. 2024 Alzheimer’s Disease Facts and Figures. Alzheimers Dement. 2024;20(5):3708-3821.

2. Rocca WA, Grossardt BR, Shuster LT. Oophorectomy, menopause, estrogen, and cognitive aging: the timing hypothesis. Neurodegener Dis. 2010;7(1-3):163-166.

3. Altmann A, Tian L, Henderson VW, Greicius MD; Alzheimer’s Disease Neuroimaging Initiative Investigators. Sex modifies the APOE-related risk of developing Alzheimer disease. Ann Neurol. 2014;75(4):563-573.

4. Villa A, Vegeto E, Poletti A, Maggi A. Estrogens, neuroinflammation, and neurodegeneration. Endocr Rev. 2016;37(4):372-402.

5. Shumaker SA, Legault C, Rapp SR, et al. Estrogen plus progestin and the incidence of dementia and mild cognitive impairment in postmenopausal women: the Women’s Health Initiative Memory Study. JAMA. 2003;289(20):2651-2662.

6. Stern Y. Cognitive reserve in ageing and Alzheimer’s disease. Lancet Neurol. 2012;11(11):1006-1012.

7. Byers AL, Yaffe K. Depression and risk of developing dementia. Nat Rev Neurol. 2011;7(6):323-331.

8. Ju YE, Lucey BP, Holtzman DM. Sleep and Alzheimer disease pathology: a bidirectional relationship. Nat Rev Neurol. 2014;10(2):115-119.

9. Vitaliano PP, Murphy M, Young HM, Echeverria D, Borson S. Does caring for a spouse with dementia promote cognitive decline? J Am Geriatr Soc. 2011;59(5):900-908.

10. Szoeke C, Lehert P, Henderson VW, Dennerstein L, Desmond P, Campbell S. Predictive factors for verbal memory performance over decades of aging: data from the Women's Healthy Ageing Project. Am J Geriatr Psychiatry. 2016;24(10):857-867.

Dementia is a women’s health issue, but it is rarely framed in that way. Two-thirds of people living with Alzheimer’s disease are women, and yet it’s not something we tend to talk about in those terms. Women’s health has long been synonymous with reproductive health, and of course reproductive conditions can affect women profoundly, but they are not what most of us will die of. In many countries, dementia is the leading cause of death in women. But when was the last time you thought consciously about what you can do for your brain health?

We know that the changes associated with dementia begin two to three decades before any symptoms appear, and that a significant proportion of the risk is modifiable through lifestyle. It is something every woman at midlife needs to be thinking about. But it is also a confusing space to navigate. There are mixed messages about brain changes at menopause, conflicting views on whether hormone therapy is protective, and no shortage of supplements claiming to do things the evidence does not support.

In this episode, I speak with Professor Cassandra Szoeke, a neurologist, author, and principal investigator on the Women’s Healthy Ageing Project, one of the longest-running longitudinal studies of women’s brain health in the world. We get into what is actually happening to our brains at midlife, the difference between cognitive symptoms at menopause and dementia, what we do and do not yet know about the relationship between menopause and brain health, and what you should be doing right now to protect your brain for the long term.

Guest Bio

Professor Cassandra Szoeke is a neurologist, clinician-scientist, author and is currently the Director of the Women’s Healthy Ageing Program and Lead of the seXXspecific education for the Academy in HealthCare at Monash Centre for Health Research & Translation. She was the principal investigator of the Women’s Healthy Ageing Project (WHAP), a landmark longitudinal study tracking women’s brain and cardiovascular health from midlife onwards, which has generated important sex-specific findings in dementia research.

What We Cover

00:03: Why Alzheimer’s is a women’s health issue

04:16: Alzheimer’s, vascular dementia, and mixed pathology

08:31: Why women’s brains are more vulnerable

12:56: Does dementia presents differently in women?

16:05: What menopause actually does to the brain

21:40: Brain fog at menopause: dementia or not?

27:38: Hormone therapy and the brain: what the evidence shows

34:40: Professor Szoeke’s top three prevention priorities for women

40:25: Supplements, diet, and what the data actually supports

45:25: Social connection, brain stimulation, and the research frontier

Key Takeaways

• Dementia is not a gender-neutral condition and more women need to be aware of protecting their brain health.

• Brain fog at menopause is real, but it is almost always driven by the physical disruptions of the transition, not by neurodegeneration. Treating the symptoms often clears the fog.

• Your most important levers for brain protection are daily physical activity, blood pressure control, and staying socially and intellectually active.

Further Resources and Support

Research and Education

Women’s Healthy Ageing Project (WHAP) -- Professor Szoeke’s longitudinal study of women’s brain and cardiovascular health from midlife, University of Melbourne.

Lancet Commission on Dementia Prevention, Intervention, and Care -- The most comprehensive global review of modifiable dementia risk factors, updated in 2024.

Alzheimer’s Disease International -- International federation of Alzheimer associations, with resources and research spanning over 100 countries.

Support Organisations

Alzheimer’s Association (US) -- Support, information, and research funding for people affected by Alzheimer’s and other dementias.

Alzheimer’s Society (UK) -- Information, helplines, and local support services for people living with dementia and their carers.

Dementia Australia -- Australia’s peak dementia body, with resources, helplines, and advocacy.

Alzheimer’s Disease Association (Singapore) -- Support and services for people living with dementia and their families across Singapore.

Menopause and Hormone Therapy Information

The Menopause Society (formerly NAMS) -- Evidence-based information on menopause management and hormone therapy from a leading professional body.

British Menopause Society -- Clinical guidelines and patient resources on menopause, including HRT and long-term health risk.

Jean Hailes for Women’s Health (Australia) -- Accessible, evidence-based women’s health resources covering menopause and cognitive health.

The content of this podcast is for educational purposes only. It is not intended to replace the doctor-patient relationship, nor does it constitute personalised medical advice. If you are affected by any of the topics discussed, please speak to your doctor or a qualified healthcare professional.

In this In Focus episode, Dr Natalie Hutchins sits down with consultant dermatologist Dr Justine Hextall to talk through what is happening to skin in midlife, and why.

They cover the science of collagen loss around menopause, the role oestrogen plays in skin hydration, elasticity and even antioxidant protection, and why the gut microbiome may matter more to your complexion than your 10-step routine. Dr Hextall also shares what she considers truly non-negotiable for midlife skin. Unsurprisingly, the list is much shorter than the beauty industry would have you believe.

This episode is part of our In Focus series: shorter, topic-led conversations designed to give you real clinical insight.

⚠️ For medical education only. Please consult your doctor or dermatologist for personalised advice.