Women's reproductive mental health: currently available evidence and future directions for research, clinical practice and health policy

Sex and gender differences in the epidemiology of mental disorders are well documented. Less well understood are the drivers of these differences. Reproductive health represents one of the gendered determinants of mental health that may affect women throughout their life course. In this paper, we review common reproductive events that may be associated with mental ill health, including menstruation (with premenstrual dysphoric disorder appearing for the first time in recent classifications of mental disorders), contraception, abortion, sexual dysfunction, hypersexuality, sexual violence, reproductive coercion, infertility and associated gynaecological conditions, and menopause. Such reproductive events may differentially affect women globally via a range of potential biological and psychosocial mechanisms. These include, for example, vulnerability to the physiological changes in hormone levels across the menstrual cycle; side effects of treatment of mental disorders; inflammation underpinning endometriosis and polycystic ovarian syndrome as well as mental disorders such as depression; intersections with gender disadvantage manifesting, for example, as structural barriers in accessing menstrual products and sanitation, contraception and abortion, underscoring the broader social determinants impacting women's mental health. Greater understanding of these mechanisms is guiding the development of effective interventions, which are also reviewed here. However, key evidence gaps remain, partly as a result of the historic gender bias in mental health research, and the neglect of reproductive health in clinical practice. Furthermore, while several women's health strategies have recently been proposed internationally, they do not usually include a focus on mental health across the life course, particularly for women with severe mental illness. Integrating co-designed reproductive health interventions into primary and secondary mental health care settings, providing tailored care, increasing the evidence base on effective interventions, and empowering women to make informed choices about their reproductive health, could improve not only reproductive health but also women's mental health across the life course.