The study, led by Dr Sofie Ragnhild Aminoff of Oslo University Hospital together with international collaborators, surveyed 267 women of reproductive age with bipolar disorder. The questionnaire was distributed through the Norwegian Bipolar Association and professional networks over a ten-week period in spring 2025. Of the respondents, 166 women, or 62 percent of the sample, reported regular menstruation, while 101 women, or 38 percent, reported irregular cycles. Participants were asked about premenstrual symptoms experienced every or almost every premenstrual phase during the previous year, covering irritability, anger, relationship difficulties, physical symptoms, and significant distress or interference with work, daily activities or relationships.

The results showed a clear pattern. Women with regular menstrual cycles were more likely than those with irregular cycles to report this full cluster of severe premenstrual symptoms recurring month after month. In other words, the very group whose cycles followed the most regular rhythm reported the heaviest symptomatic burden in the days before menstruation. This was, the researchers acknowledge, an unexpected result, and one that raises questions about how hormonal stability and hormonal sensitivity interact in women living with a severe mental illness.

The survey also uncovered a second, closely related pattern involving contraception. Ninety-three percent of the women in the sample had tried hormonal contraceptives at some point, reflecting how ubiquitous these medications are in reproductive-age populations. Yet the women with regular menstruation were less likely to be current users of hormonal contraceptives than those with irregular cycles. A larger proportion of the regular-cycle group had stopped taking hormonal contraception because of side effects, and these women also expressed greater reluctance to use hormonal methods in general. Taken together, the data suggest that women with bipolar disorder who experience regular cycles may be a subgroup with particular sensitivity to hormonal medication.

Dr Aminoff described the contraceptive findings as raising important questions about whether some women with bipolar disorder may be especially sensitive to hormonal contraceptives, while others might potentially benefit from them. That distinction matters clinically. Hormonal contraceptives are among the most widely prescribed medications in the world, and for women with a mood disorder the risk-benefit calculation is far from trivial. Hormonal fluctuations are known to influence mood states, and a medication that stabilises the cycle for one patient might destabilise mood in another. The current findings hint that menstrual cycle regularity itself could serve as a marker helping clinicians identify which women fall into which group, although the researchers emphasise that much more work is needed before such guidance can be formalised.

Bipolar disorder is a serious mental health condition characterised by episodes of depression alternating with episodes of elevated or irritable mood, interspersed with periods of few or no symptoms. A majority of women with bipolar disorder experience some form of premenstrual disturbance, whether as standalone premenstrual symptoms or as premenstrual exacerbations of the underlying bipolar illness, in which depressive, manic or psychotic symptoms intensify in the days before menstruation. Despite how common these experiences are, reproductive mental health in women with severe mental illness remains an under-studied area, and the new survey adds to a small but growing body of evidence that the intersection of gynaecology and psychiatry deserves far more systematic attention.

The clinical stakes are considerable. Dr Aminoff noted that she has met many women with bipolar disorder who described changes in mood, psychotic symptoms or suicidal thoughts that varied with their menstrual cycle, experiences that can have a real impact on daily life. Clinicians, she said, currently have very limited guidance on how best to help. Her central message is that premenstrual symptoms in women with bipolar disorder need to be taken seriously, and that more research and clearer clinical guidelines are needed so that women and the health care system can make better-informed decisions about treatment, contraception and mood-stabilising medication. She argued that assessment of premenstrual symptom burden, alongside tailored advice on hormonal contraception and mood-stabilising medication, should be standard care, but that in practice it frequently is not.

The gap between what patients report and what the health system delivers emerged as a recurring theme. Many women with bipolar disorder report that their premenstrual symptoms are not taken seriously, and few experience receiving the treatment they need, according to the research team. This pattern of dismissal is not unique to bipolar disorder; it reflects a broader documented tendency for women’s reproductive and mental health complaints to be minimised in clinical settings. For women with severe mental illness, however, the consequences of inaction can be severe, given that premenstrual worsening can include suicidal ideation and relapse of psychotic symptoms, not merely discomfort or irritability.

Independent experts welcomed the study while stressing its preliminary nature. Professor Louise Howard, Professor Emerita in Women’s Mental Health at King’s College London, who was not involved in the work, said it was valuable to see preliminary research into the reproductive health of women with bipolar disorder being presented at the conference, adding that this has been an under-studied area for too long and that the relevance of menstrual cycle regularity to symptoms and to potential interventions such as hormonal contraception is poorly understood and deserves further investigation. Dr Clare Dolman, Co-chair of the Bipolar Commission and Ambassador for Bipolar UK, also independent of the study, said she agreed with the take-home message that premenstrual symptoms in women with bipolar disorder need to be taken more seriously. She pointed out that such symptoms can exacerbate bipolar illness, and that sensitivity to hormonal change can be a marker for potentially dangerous relapse at other times of hormonal upheaval, including pregnancy, childbirth and perimenopause. Women’s mental health generally, she argued, has been ignored for too long.

The authors are careful to frame the findings appropriately. The work is preliminary, based on an online survey rather than clinical assessment, and has not yet been submitted to a peer-reviewed journal. Self-reported cycle regularity and symptom severity can be influenced by recall and selection bias, and the sample was recruited through patient organisations, which may over-represent women with particularly troublesome symptoms. Even so, the study’s size for this field, its focus on a neglected population, and the consistency of its two main signals, greater premenstrual burden and greater contraceptive side-effect burden among women with regular cycles, give it a significance that extends beyond the conference hall. Dr Aminoff’s concluding call is for closer collaboration between psychiatry and gynaecology, and for research that looks not only at mental health symptoms but also at hormonal contraception and reproductive health. If subsequent controlled studies confirm these patterns, menstrual cycle regularity could become a simple, low-cost clinical marker, helping clinicians tailor contraception and mood-stabilising treatment for hundreds of thousands of women across Europe who currently navigate this intersection of hormones and mental illness with almost no formal guidance.

Subject of Research: Premenstrual symptoms and hormonal contraceptive use in women with bipolar disorder in relation to menstrual cycle regularity

Article Title: Regular periods, but worse symptoms: Women with bipolar disorder losing out on gynaecological care

Article References: Regular periods, but worse symptoms: Women with bipolar disorder losing out on gynaecological care. (n.d.). Original publication

Image Credits: AI Generated

DOI: Not provided

Keywords: bipolar disorder, premenstrual symptoms, menstrual cycle, hormonal contraceptives, women's mental health, gynaecology, psychiatry, reproductive health, ECNP Congress, mood-stabilising medication, premenstrual exacerbation, Oslo University Hospital

The research team, led by Susanna Weidlinger and colleagues, searched MEDLINE, Embase, Scopus and the Cochrane Central Register of Controlled Trials for studies published from 2013 to June 2026, a cut-off chosen to coincide with the replacement of gender identity disorder with gender dysphoria in the DSM-5. From 3,548 records identified, 2,252 unique publications were screened and 212 went to full-text assessment. Eleven studies ultimately met the inclusion criteria, drawn from five countries, six of them from the United States. Together they enrolled 4,176 transmasculine individuals, of whom 2,891 were receiving testosterone therapy. Study designs ranged from a single prospective cohort to five retrospective cohorts, three cross-sectional surveys, one retrospective case series and one qualitative interview study, with sample sizes spanning just 14 participants to more than 2,500.

The pooled prevalence of pelvic pain among transmasculine people on testosterone was 39 percent, with a 95 percent confidence interval of 23 to 55 percent. That figure exceeds the estimated 5 to 25 percent prevalence of chronic pelvic pain in cisgender women worldwide, although the authors caution that direct comparison is limited by differences in populations, pain definitions and how symptoms were ascertained. Among those on testosterone who were not scheduled for gender-affirming surgery, the pooled prevalence was lower at 28 percent, while in surgical cohorts, where pelvic pain was often documented as an indication for hysterectomy, it climbed to 50 percent. Strikingly, prevalence among those not taking testosterone was 41 percent, statistically indistinguishable from the figure in testosterone users, offering no evidence of a clear protective or harmful association.

Perhaps the most clinically consequential results concern what happens to pain over time. Among individuals with preexisting pelvic pain, symptoms persisted after testosterone initiation in a pooled 72 percent of cases, while only 26 percent experienced improvement or remission. One study reported worsening in 24 percent of participants. Meanwhile, roughly 31 percent of previously asymptomatic individuals reported new-onset pelvic pain after starting testosterone, though this estimate carries an extremely wide confidence interval of 5 to 65 percent and rests on just three studies with very different designs. A retrospective clinical cohort reported new-onset pain in 71 percent of affected patients, a cross-sectional study of adolescents found 17 percent, and a prospective online cohort found 11 percent, a spread that reflects differences in recruitment, symptom documentation and ascertainment methods.

The statistical picture is dominated by heterogeneity. The I-squared statistic exceeded 99 percent for most prevalence estimates, meaning that nearly all of the observed variation between studies reflects real differences rather than chance. Study populations ranged from highly selected surgical cohorts to large community samples recruited through online transgender health networks, and pain was variously defined as chronic pelvic pain lasting three months or longer, cyclic and acyclic lower abdominal pain, or simply any pain documented in medical records as a reason for surgery. No study used a validated pain assessment tool, and only a minority applied established time-based criteria for chronicity. The authors therefore present their pooled estimates as descriptive summaries of the literature rather than precise population-level parameters.

Methodological quality, assessed with Joanna Briggs Institute checklists, ranged from moderate to high, with three studies rated high quality and eight moderate. A consistent weakness was the failure to address confounding, even where potential confounders were identified. The authors also flag a subtler problem: confounding by indication and possible reporting bias in surgical cohorts. Because insurance coverage for gender-affirming hysterectomy varies widely and often requires documented medical indications beyond gender dysphoria itself, clinicians and patients may have incentives to record pelvic pain to facilitate approval, potentially inflating prevalence in surgical subgroups. The contrast between 90 percent prevalence documented as a surgical indication in one cohort and 7 to 16 percent in community-based samples illustrates how much ascertainment context matters.

Why might pelvic pain be so common in this population despite testosterone’s suspected pain-protective properties? The authors sketch a multifactorial and still incompletely understood pathophysiology. First, testosterone induces vaginal epithelial atrophy, analogous to the genitourinary syndrome of menopause, which may increase susceptibility to dyspareunia, bacterial vaginosis and cystitis; one large study found that nearly two-thirds of transmasculine individuals experienced vulvovaginal pain during sexual activity, with current testosterone use independently associated with increased vaginal pain. Second, testosterone does not reliably suppress the ovaries: histological signs of recent ovulatory activity have been documented in roughly 30 to 40 percent of transmasculine individuals at oophorectomy, independent of serum testosterone levels, duration or preparation type, and endometrial activity persists in a substantial proportion. One cohort found that endometrial proliferation was significantly more frequent with transdermal gel and short-acting testosterone esters than with long-acting testosterone undecanoate, plausibly because fluctuating hormone levels allow intermittent recovery of follicular activity and local aromatisation of testosterone to estradiol.

Third, pelvic floor dysfunction appears highly prevalent, reported in 94 percent of transmasculine individuals on testosterone in one study. The levator ani, the principal pelvic floor muscle, is highly androgen-responsive, and whether masculinising doses induce hypertonicity contributing to pain has not been directly studied. Fourth, psychosocial factors loom large: gender dysphoria, minority stress and barriers to care, including discrimination and discomfort with pelvic examinations, may amplify pain perception and reduce help-seeking. Notably, one study of gender minority individuals found that stress, rather than gender identity or hormone therapy type, was the factor most strongly associated with chronic pain, underscoring the relevance of a biopsychosocial framework. Endometriosis also remains relevant even under testosterone: one surgical series found intraoperatively confirmed endometriosis in nearly 27 percent of patients undergoing gender-affirming hysterectomy, with higher rates among those reporting pelvic pain.

The clinical implications are concrete. The authors recommend that clinicians counsel patients before treatment that pelvic pain is common both before and during testosterone therapy and that the hormone does not reliably resolve preexisting symptoms. Preexisting gynaecologic conditions should be evaluated where feasible before testosterone initiation, since prior pain, dysmenorrhea, endometriosis and ovarian cysts are associated with persistent symptoms. Gynaecologic follow-up should continue despite amenorrhea, given the evidence of residual ovarian and endometrial activity, and clinicians should maintain a low threshold for investigating new or worsening pain. Care environments should actively address barriers through inclusive language, trauma-informed approaches and alternatives such as self-collected specimens.

The review also maps the road ahead for research. Future studies should employ validated, multidimensional pain instruments that distinguish pain subtypes and mechanisms, and the recently validated Transmasculine and Gender Diverse Pelvic Symptom Index offers the first gender-affirming instrument designed specifically for this purpose. Prospective cohorts with standardised assessment before testosterone, during therapy and after hysterectomy or oophorectomy are needed to characterise pain trajectories and identify modifiable risk factors. The limitations are real: nearly all analyses showed extreme heterogeneity, most studies were cross-sectional, confounder control was sparse, prior hysterectomy status was incompletely reported, and the evidence base is concentrated in the United States and Australia, with no studies from low- and middle-income countries and none at all on transfeminine individuals. Publication bias also cannot be excluded. Even so, as the first quantitative synthesis of its kind, the analysis establishes that pelvic pain is a substantial and previously underappreciated burden in an underserved population, and it replaces a comforting assumption with a more honest, and more clinically useful, picture of what testosterone can and cannot do.

Subject of Research: Prevalence and clinical course of pelvic pain in transmasculine individuals receiving gender-affirming testosterone therapy

Article Title: Prevalence and clinical course of pelvic pain among transmasculine individuals on gender-affirming testosterone: a systematic review and meta-analysis

Article References: Weidlinger, S., Niggli, A., van Trotsenburg, M., Feil, K., Weidlinger, C., Vidal, A., Gulz, M., Pape, J., Laue, J., Leeners, B., von Wolff, M., Karrer, T., & Camastral-Urech, K. (2026). Prevalence and clinical course of pelvic pain among transmasculine individuals on gender-affirming testosterone: a systematic review and meta-analysis. eClinicalMedicine, 100, Article 104233. https://doi.org/10.1016/j.eclinm.2026.104233

Image Credits: AI Generated

DOI: Not provided

Keywords: pelvic pain, transmasculine, testosterone, gender-affirming hormone therapy, systematic review, meta-analysis, chronic pain, endometriosis, pelvic floor dysfunction, transgender health, gynaecology, minority stress