Sarah Footnote a lived in a house of lovely clutter. A dog lead coiled up on a shelf belonging to her childhood pet. A framed photograph of Sarah holding her two young nieces with joyous smiles. A little metal bowl on the coffee table. An ashtray? No, she smiled, a Tibetan singing bowl.
On the same table was a pile of post. The two top-most letters were from the water company and had been thumbed open only halfway – their contents unseen and unactioned. After taking a breath, Sarah offered her story, detailing what were the worst moments of her life.
Over the previous 18 months Sarah had become unrecognisable to herself. There was anxiety, turning slowly into absolute conviction that there was some undiagnosed cancer growing inside her. A pervasive sense that work colleagues were turning on her. Then grew an inexplicable fear of her husband. Panic attacks. Emergency department visits. Fits that weren’t fits. Disorganised rage. Then a voice. More fear. Head full of it all. A need to escape. And then a kitchen knife held in her own hands, driven into her own neck – a plea for peace.
Over the weeks and months that followed, it became clear that this – episode – coincided with a great, invisible shift inside of Sarah: perimenopause. It took many months for it to be recognised. Many months of ‘treatment-resistant psychosis’ that somehow became treatment-responsive with the correction of hormonal imbalance offered by hormone replacement therapy (HRT).
Clues were buried in encounters with her general practitioner (GP) from almost 2 years earlier – newly heavy and unpredictable periods, increased health anxieties. Further back, a deep postnatal depression and a documented family history of early menopause. Those clues could have been uncovered promptly, if we had asked the right questions, if we had considered the possibility.
The statistics are sobering. Women of perimenopausal age experience higher rates of depression, anxiety, post-traumatic stress disorder (PTSD) and substance misuse than any other age group (Kulkarni Reference Kulkarni, Gurvich and Mu2024). Women over the age of 40 are diagnosed with schizophrenia at twice the rate of men of that age (Riecher-Rössler Reference Riecher-Rössler2017). In England and Wales, the highest female suicide rate is among those aged 50–54 (Office for National Statistics 2024).
Stories like Sarah’s inspired our women’s health project. All UK resident doctors need to complete a quality improvement project during training years. In taking on this challenge, we wanted to focus on something that was important, both personally and professionally. It was clear to us that Sarah’s experience was as much gynaecological as it was psychiatric and needed input from both disciplines. Could we find a way to bring the two together to improve menopausal care?
It started with a survey
We began by establishing a network of like-minded professionals. A leading gynaecologist in menopause and a GP specialist in women’s health were interested in our proposal of establishing a multidisciplinary team (MDT) integrating psychiatry and gynaecology. They directed us to the latest National Institute for Health and Care Excellence (NICE) guidance recommending menopause-specific cognitive–behavioural therapy (CBT) (NICE 2019) and individualised approaches to managing perimenopausal depression and anxiety.
We wanted to understand the current state of mental health provision and availability of menopause-specific CBT (which we have dubbed mCBT) in UK menopause clinics led by BMS members. We developed an online survey which revealed a striking range of practice and available resources (Box 1). Of the 139 respondents, more than half wanted better guidance for managing mood-related symptoms. We also collected qualitative data to give us a sense of members’ attitudes about their service provision (Box 2). More detailed results can be found in the supplementary material, available at https://doi.org/10.1192/bja.2025.10170. Given these findings, mCBT emerged as a logical starting point for local service improvement to strengthen our psychiatry–gynaecology collaboration.
Snapshot of results of a service evaluation survey sent to specialist menopause clinics across the UK
Of 139 respondents from 117 British Menopause Society clinics:
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98% believed that mental health provision could be improved for their menopause patients
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83% named improved access to cognitive–behavioural therapy (CBT) as the most helpful resource for patients
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54% do not have a mental health practitioner in their multidisciplinary team (MDT)
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1% of menopause MDTs have a psychiatrist
Voices from the menopause front-line
Comments from national service evaluation questionnaires sent to British Menopause Society clinics across the UK:
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‘We need greater access to specialist services – guidance is not helpful if you can’t access treatments that are recommended.’
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‘Waiting times for mental health input and menopause specialist services are so long as to make them practically useless.’
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‘As a regional specialist menopause clinic, I wish we could refer directly for CBT […] more work on this is needed and the survey has highlighted deficiencies in our service for me!’
Our survey demonstrated that current services nationwide were startlingly not joined up. Although mCBT is a recommended treatment for menopause symptoms, in practice patients are often signposted to primary care-level talking therapy services, which often provide only generic CBT. If mCBT services were commissioned by secondary care, women could be seamlessly referred by specialist menopause clinics. In turn this could create opportunities for improved joined-up thinking between gynaecology and psychiatry, maybe even bringing us closer to our goal of a psychiatry–gynaecology MDT.
Developing a pilot
We contacted two CBT-trained liaison psychiatry nurses with experience in delivering group therapy in perinatal settings. Through their expertise and generosity, we were able to develop and deliver a 6-week mCBT course for women who cannot receive HRT. We aimed to run three pilot groups of up to eight women, who would be invited from the combined menopause/oncology clinic at St Michaels Hospital in Bristol. Validated tools for assessing severity of menopause symptoms, as well as depression and anxiety were used to track change from baseline, to 6 and 12 weeks.
It was a rocky start. Recruitment was an issue, which surprised us. The course seemed to be difficult to ‘sell’ in the fast-paced clinic. Our first group ran with just two women after two participants dropped out before it began. Then our questionnaires, used to gather outcome measures, were not filled in correctly: it was time to reassess. We informed the clinic that uptake was low and offered to attend in person or send out letters to improve recruitment. We added a poster and changed our questionnaires from paper to digital forms, accessed via a QR code. We doubled our numbers with the second group and our outcome measures were completed properly. The attendees found the experience hugely beneficial. Friendships have been forged, stories shared, and we were delighted to hear they maintain contact through their WhatsApp group – Hot Bitches. Our third group, comprising 10 women, will start in September 2025.
Reflections
Three years in, we have done a lot, yet not enough. We have identified some gaps nationally in menopause care. We have also helped a handful of women in South West England access a therapy specifically designed for their needs. We hope the mCBT group feedback and results from their outcome measures will form the foundation of a business case to secure funding for more groups.
We are not yet even close to achieving our vision of a functioning cross-specialty MDT. Trying has taught us a valuable lesson (mainly patience) about how difficult it is to apply for funding for a new MDT, but it has also revealed how many colleagues share our interest in developing this work. We have cultivated a small but growing community of local psychiatrists and mental health practitioners who seek progress updates, teaching sessions for their teams and opportunities for patients.
A team presentation on female hormones and mental health led to another, then another. We are collecting feedback about the effectiveness of these presentations to help us turn the talks into a more formal training package with the aim of helping our colleagues feel more informed and confident when speaking to women about hormones and mental health.
We are still brimming with enthusiasm and ideas. We are furthering our own learning about the possibilities of hormonal treatments, keeping pace with the astonishing research in the field of women’s mental health and continuing to improve working relationships between psychiatry and other specialties. We routinely promote the importance of taking hormonal histories as a standard part of the psychiatric evaluation by giving educational presentations at academic meetings and conferences, with the aim of fostering a new generation of psychiatrists who will take the hormonal lives of women seriously in their formulation and treatment of mental health conditions.
This is not intended to be a solo mission, and we hope that by staying vocal we will encourage more and more of you to join us for the ride. We keep busy, for Sarah, and for the Hot Bitches who have found their voices, reclaimed their stories and built community in the face of a system that too often overlooks their needs.
Supplementary material
Supplementary material is available online at https://doi.org/10.1192/bja.2025.10170.
Author contributions
All three authors were involved in the conception, data analysis and drafting of this article.
Funding
This work received no specific grant from any funding agency, commercial or not-for-profit sectors.
Declaration of interest
None.
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