Female Reproductive

General Psychiatry, Initial Evaluation, Medical History|November 23, 2025|shrink_the_script

Female Reproductive History: How It Shapes Psychiatric Diagnosis and Treatment Safety

This is Part 2 in our series on the Medical History.
Read Part 1: When Psychiatric Symptoms Signal Medical Illness for the general framework on medical red flags.

In Part 1 we reviewed general medical red flags that should prompt suspicion for organic etiologies of psychiatric symptoms. This part focuses specifically on reproductive factors in women that directly impact psychiatric diagnosis, medication safety, and treatment planning. Female reproductive health, including menstrual cycles, pregnancy status, reproductive surgeries, and contraception use, significantly influences both the manifestation of psychiatric symptoms and the safety profile of psychiatric medications.

Understanding reproductive context is not optional, it is essential for accurate diagnosis (distinguishing hormonally-mediated symptoms from primary psychiatric illness), risk assessment (identifying teratogenic medication risks), and treatment planning (selecting medications compatible with pregnancy, breastfeeding, or reproductive goals). The failure to assess reproductive health comprehensively can result in missed diagnoses, preventable adverse pregnancy outcomes, and medico-legal liability.

Learning Objectives

After reading this section, you should be able to:

  • Conduct a comprehensive reproductive health assessment including menstrual history, pregnancy status, contraception use, and reproductive surgeries
  • Recognize how psychiatric symptoms fluctuate with menstrual cycles and distinguish premenstrual dysphoric disorder from other mood disorders
  • Identify pregnancy and peripartum period as high-risk times for psychiatric disorder onset or exacerbation
  • Assess teratogenic risk before prescribing psychiatric medications and ensure pregnancy testing when indicated
  • Integrate reproductive history into medication selection, recognizing which psychiatric medications require contraception counseling or are contraindicated in pregnancy
  • Screen appropriately for sexual trauma, reproductive coercion, and intimate partner violence as part of routine psychiatric evaluation

Start With Chart Review

Before interviewing the patient, review the medical record for reproductive health information that may influence psychiatric symptoms or treatment decisions.

Key elements to review:

  • Obstetrics/gynecology notes: Look for documentation of menstrual irregularities, PCOS, endometriosis, fibroids, ovarian cysts, or other gynecological conditions associated with psychiatric symptoms.
  • Pregnancy and obstetric history: Check for current pregnancy status, past pregnancies, pregnancy losses, complications, and peripartum psychiatric symptoms.
  • Reproductive surgeries: Note hysterectomy, oophorectomy, tubal ligation, or other procedures that may affect hormone levels.
  • Hormone therapy: Look for oral contraceptives, hormone replacement therapy, fertility treatments, or testosterone suppression therapy.
  • Menopause status: Check age and documentation of menopause, surgical or natural.
  • Problem list: Look for PMDD, peripartum depression, postpartum psychosis, or menopause-related mood changes.
  • Medication list: Review for teratogenic psychiatric medications (valproate, carbamazepine, paroxetine, benzodiazepines) and check if contraception is documented.
  • Sexual health screening: Note STI testing, cervical cancer screening, and any documented history of sexual trauma.

💡 Clinical Pearl: If a woman of reproductive age is taking valproate, lithium, or high-dose benzodiazepines without documented contraception counseling or pregnancy testing, this represents a treatment safety gap that should be addressed immediately. Similarly, if psychiatric symptoms began within 3 months of starting or stopping hormonal contraception, suspect hormonal contribution.

Why this matters: Many women do not spontaneously connect reproductive health changes with psychiatric symptoms. A patient may not mention that her depression began after starting oral contraceptives, that her anxiety worsens premenstrually, or that she had postpartum depression with a previous pregnancy. Chart review alerts you to these patterns before the interview.

Interview the Patient

Menstrual and Cycle History

Opening questions:

  • “When was your last menstrual period?”
  • “Are your periods regular? How often do they come?”
  • “Do you notice that your mood, anxiety, or other symptoms change at certain times in your menstrual cycle?”

Follow-up and context questions:

  • “In the week or two before your period starts, do you notice mood changes, irritability, anxiety, or physical symptoms that get better once your period begins?”
  • “Have your periods changed recently? For example, have they become more irregular, heavier, lighter, or stopped?”
  • “Have you been evaluated for any menstrual disorders like heavy bleeding, painful periods, or irregular cycles?”

Why This Information Matters

Menstrual cycle and psychiatric symptoms: Psychiatric symptoms often fluctuate with the menstrual cycle due to hormonal influences on neurotransmitter systems, particularly serotonin, GABA, and dopamine. Understanding cyclical patterns is essential for distinguishing premenstrual dysphoric disorder (PMDD) from other mood disorders.

Premenstrual Dysphoric Disorder: PMDD is characterized by severe mood, anxiety, and physical symptoms in the luteal phase (week before menses) that remit within days of menstruation onset. The diagnosis requires prospective symptom tracking over at least two cycles. PMDD affects 3-8% of reproductive-age women and is frequently misdiagnosed as major depressive disorder or generalized anxiety disorder when cyclical pattern is not recognized.

Menstrual irregularities as diagnostic clues: Changes in menstrual patterns may signal endocrine disorders (thyroid disease, hyperprolactinemia, PCOS) or be medication side effects (antipsychotics causing hyperprolactinemia). New-onset amenorrhea in a woman taking psychotropic medications warrants pregnancy testing and evaluation for hyperprolactinemia or other endocrine causes.

💡 Clinical Pearl: If a patient reports mood symptoms that consistently worsen in the week before her period and improve within days of menstruation, ask her to prospectively track symptoms for two cycles before finalizing diagnosis. What appears to be major depressive disorder may actually be PMDD, which responds better to continuous SSRIs, hormonal contraceptives, or luteal-phase dosing strategies than to standard antidepressant regimens.

Pregnancy Status and Planning

Opening questions:

  • “Is there any chance you could be pregnant, or are you currently pregnant?”
  • “Are you planning to become pregnant in the near future?”
  • “Are you currently breastfeeding?”

Follow-up and context questions:

  • “When was your last pregnancy test?”
  • “If you’re not planning pregnancy, what method of birth control are you using?”
  • “Have you discussed pregnancy planning with your other doctors?”

Why This Information Matters

Pregnancy and peripartum as high-risk periods: Pregnancy and the peripartum period are high-risk times for onset or exacerbation of psychiatric disorders. Up to 20% of women experience peripartum depression, and peripartum onset significantly increases risk of future episodes. Women with bipolar disorder have particularly high risk of postpartum mood episodes, including postpartum psychosis (1-2 per 1000 births, higher in bipolar disorder).

Untreated psychiatric illness in pregnancy: Untreated depression and anxiety during pregnancy are associated with preterm birth, low birth weight, preeclampsia, and postpartum depression. Untreated bipolar disorder and psychotic disorders carry risks of poor prenatal care, substance use, impaired judgment, and suicide. The decision to treat or not treat psychiatric illness during pregnancy requires weighing risks of untreated illness against medication risks.

🚩 Red Flag: New or worsening psychiatric symptoms in a woman of reproductive age should prompt pregnancy testing before initiating psychiatric medications, particularly mood stabilizers (valproate, carbamazepine, lamotrigine) and certain antipsychotics with known teratogenic risks.

Teratogenic medications: Certain psychiatric medications carry significant fetal risks:

  • Valproate: Highest risk. Major congenital malformations (10%), neural tube defects, cardiac defects, and decreased IQ in exposed children. Contraindicated in pregnancy and should not be prescribed to women of childbearing potential without reliable contraception and documented informed consent.
  • Carbamazepine: Neural tube defects, craniofacial abnormalities, developmental delays.
  • Lithium: Cardiac malformations (Ebstein’s anomaly), though risk lower than previously thought (0.05-0.1%).
  • Benzodiazepines: Cleft palate (low absolute risk), neonatal adaptation syndrome.
  • Paroxetine: Cardiac malformations, particularly when exposed in first trimester.

Medications with better reproductive safety profiles: SSRIs other than paroxetine (sertraline often preferred), certain SNRIs, most atypical antipsychotics (quetiapine, olanzapine), and lamotrigine (though requires dose adjustment during pregnancy due to changed metabolism).

💡 Clinical Pearl: Before prescribing valproate to any woman of childbearing potential, you must: (1) confirm negative pregnancy test, (2) ensure reliable contraception is in place, (3) document detailed informed consent discussion about teratogenic risks, and (4) provide written information about risks. This is both a medical and medico-legal requirement.

Contraception and Family Planning

Opening questions:

  • “Are you using any form of contraception? What method?”
  • “Have you changed your contraception method recently?”
  • “Are you satisfied with your current method, or would you like to discuss other options?”

Follow-up and context questions:

  • “Do you have any concerns about getting pregnant while taking psychiatric medications?”
  • “Has anyone discussed with you how your psychiatric medications might affect pregnancy or which medications are safer if you become pregnant?”

Why This Information Matters

Mental illness and contraception use: Women with mental illness have lower rates of contraception use and higher rates of unintended pregnancy compared to women without mental illness. This disparity is multifactorial: cognitive impairment, chaotic lifestyle, reduced access to gynecological care, and lack of integrated reproductive counseling in psychiatric settings.

Unintended pregnancy and psychiatric outcomes: Unintended pregnancy in women with psychiatric illness is associated with worse maternal mental health outcomes, lower rates of prenatal care, higher risk of substance use during pregnancy, and increased risk of postpartum depression.

Medications requiring contraception counseling: Women taking teratogenic psychiatric medications (valproate, carbamazepine, high-dose benzodiazepines, topiramate) require explicit contraception counseling and should have reliable contraception verified before continuation of these medications.

Hormonal contraception and psychiatric symptoms: Some women experience mood changes with hormonal contraception, particularly progesterone-only methods or high-dose combined oral contraceptives. However, most women do not experience significant mood changes, and modern low-dose formulations have lower risk of mood effects. If psychiatric symptoms began or worsened shortly after starting hormonal contraception, consider this as a contributor.

🧠 Special Consideration: Integrating reproductive planning into psychiatric care is essential. Psychiatrists should routinely ask about pregnancy plans, provide contraception counseling when prescribing teratogenic medications, and collaborate with OB/GYN to ensure patients have access to reliable contraception methods. This is standard of care, not an optional “extra.”

Reproductive Surgeries and Menopause

Opening questions:

  • “Have you had any surgeries involving your reproductive organs, such as hysterectomy or ovary removal?”
  • “Have you experienced menopause? If so, when did that occur, and did you notice any mood or behavioral changes around that time?”

Follow-up and context questions:

  • “Are you taking hormone replacement therapy? If so, when did you start, and did you notice any changes in your mood or anxiety?”
  • “If you had surgery that involved removing your ovaries, did you experience sudden menopause symptoms or mood changes afterward?”

Why This Information Matters

Surgical menopause and psychiatric risk: Surgical menopause (bilateral oophorectomy) causes abrupt cessation of ovarian hormone production, unlike natural menopause which is gradual. Surgical menopause, particularly when performed before age 45, is associated with increased risk of depression, anxiety, and cognitive changes. The abruptness and completeness of hormone withdrawal may precipitate or worsen psychiatric symptoms.

Natural menopause and mood: The menopausal transition (perimenopause) is associated with increased risk of depression, even in women without prior psychiatric history. Hormonal fluctuations during perimenopause affect serotonergic and GABAergic neurotransmission. Women with history of premenstrual mood symptoms or peripartum depression are at particularly high risk for perimenopausal depression.

Hormone replacement therapy: Some women experience mood improvements with hormone replacement therapy, while others experience mood worsening or anxiety. The relationship between HRT and mood is complex and individualized. If psychiatric symptoms began shortly after starting or stopping HRT, consider hormonal contribution.

💡 Clinical Pearl: When a woman reports new or worsening depression beginning in her late 40s or early 50s, ask specifically about menstrual changes, hot flashes, and night sweats to determine if she is perimenopausal. Perimenopausal depression may respond better to combination treatment (SSRI plus hormone therapy) than to antidepressants alone. Collaboration with gynecology is beneficial.

Gynecological Conditions

Opening questions:

  • “Have you had any gynecological conditions such as endometriosis, polycystic ovary syndrome, or fibroids?”
  • “Do you have painful periods or pelvic pain?”

Follow-up and context questions:

  • “How have these conditions affected your quality of life or daily functioning?”
  • “Are you receiving treatment for these conditions? If so, what treatments?”

Why This Information Matters

Endometriosis and psychiatric comorbidity: Endometriosis affects approximately 10% of reproductive-age women and is associated with significantly elevated rates of depression and anxiety. The association is multifactorial: chronic pain, inflammatory processes, impact on fertility, and possibly direct effects of endometriosis on brain function through inflammatory cytokines.

Polycystic ovary syndrome (PCOS) and mood: PCOS is associated with increased rates of depression, anxiety, and eating disorders. Contributing factors include hormonal imbalances (hyperandrogenism, insulin resistance), body image concerns, hirsutism, infertility, and metabolic syndrome. Some psychiatric medications (particularly antipsychotics) can worsen metabolic parameters in women with PCOS.

Chronic pelvic pain and psychiatric symptoms: Chronic pelvic pain of any etiology is associated with depression, anxiety, and somatization. Distinguishing whether psychiatric symptoms are primary or secondary to chronic pain is important for treatment planning.

🧠 Special Consideration: When treating women with endometriosis or PCOS, consider that some psychiatric medications may worsen metabolic parameters (antipsychotics) or that treatment of the underlying gynecological condition (hormonal suppression for endometriosis, metformin for PCOS) may improve psychiatric symptoms. Collaborative care with gynecology optimizes outcomes.

Sexual Trauma and Reproductive Coercion

Opening questions:

  • “Have you ever experienced sexual trauma, sexual assault, or unwanted sexual contact?” (Frame as routine screening: “This is a question I ask all my patients because these experiences are common and can affect mental health.”)
  • “Have you ever experienced pressure or coercion around reproductive decisions, such as pressure to become pregnant or to terminate a pregnancy?”

Follow-up and context questions:

  • “Have you ever felt unsafe in a relationship or experienced intimate partner violence?”
  • “Do you feel safe discussing contraception and reproductive planning with your partner?”

Why This Information Matters

Prevalence and impact: Sexual trauma is common, with approximately 1 in 3 women experiencing sexual violence in their lifetime. Sexual trauma is strongly associated with PTSD, depression, anxiety, substance use disorders, and complex trauma presentations. Reproductive coercion (interference with contraception use, pregnancy pressure, forced termination) affects 8-15% of women and is a form of intimate partner violence associated with adverse mental health outcomes.

Trauma-informed care: Asking about sexual trauma and reproductive coercion in a normalizing, routine way communicates that these experiences are common and that you are prepared to address them. Failing to ask may result in missed diagnoses (attributing PTSD symptoms to other disorders) and inadequate safety planning.

Impact on contraception and pregnancy planning: Women with history of sexual trauma or reproductive coercion may have complex feelings about contraception, pregnancy, and gynecological care. They may avoid gynecological exams due to trauma triggers, experience dissociation during pelvic exams, or have difficulty adhering to contraception due to partner interference.

🚩 Red Flag: If a patient discloses current reproductive coercion or intimate partner violence, this constitutes an immediate safety issue requiring safety assessment, safety planning, and connection to domestic violence resources. Reproductive coercion often occurs in the context of broader intimate partner violence.

💡 Clinical Pearl: When asking about sexual trauma, use a screening approach: “Sexual trauma is unfortunately common, and because it can affect mental health, I routinely ask all patients: Have you ever experienced sexual assault or unwanted sexual contact?” This normalizes the question and makes it easier for patients to disclose. Follow positive responses with empathy, validation, and assessment of current safety.

STI History and Cervical Cancer Screening

Opening questions:

  • “Have you been tested for sexually transmitted infections? When was your last test?”
  • “When was your last pap smear or gynecological exam?”

Why This Information Matters

STIs and psychiatric morbidity: Certain sexually transmitted infections are associated with psychiatric symptoms. Untreated syphilis can cause neurosyphilis with psychiatric manifestations. HIV is associated with increased risk of depression and cognitive impairment. Herpes simplex virus has been investigated as a potential contributor to mood disorders, though causality is not established.

Barriers to gynecological care: Women with severe mental illness have lower rates of cervical cancer screening and STI testing compared to the general population. Barriers include lack of transportation, chaotic lifestyle, cognitive impairment, dissociative symptoms during pelvic exams (in trauma survivors), and fragmented care. Psychiatrists can facilitate access by discussing the importance of screening, addressing barriers, and coordinating with primary care or gynecology.

🧠 Special Consideration: Asking about cervical cancer screening and STI testing demonstrates holistic care and provides an opportunity to facilitate preventive health services that patients with mental illness may not access regularly.

What to Document

Documentation LevelWhat to IncludeExampleWhen to Use This Level
MinimalBasic reproductive screening: pregnancy status or menstrual status, contraception use if on teratogenic medications“Patient is a 32-year-old woman. Last menstrual period 2 weeks ago, not pregnant. Using oral contraceptives reliably. No history of reproductive surgeries. Denies sexual trauma.”Stable outpatient, not on teratogenic medications, typical presentation
StandardAbove + detailed menstrual history, relationship of psychiatric symptoms to menstrual cycle, reproductive surgeries or menopause status, gynecological conditions, contraception counseling for teratogenic medications“Patient is a 28-year-old woman presenting with depressive symptoms that markedly worsen in the week before menses and improve within 2 days of menstruation onset. Regular 28-day cycles. No prior pregnancies. Diagnosed with PCOS 2 years ago, managed with metformin and spironolactone. LMP 1 week ago, not pregnant. Not currently using contraception as not sexually active. No history of sexual trauma.”Reproductive-age women, suspected hormonal contribution to symptoms, prescribing teratogenic medications
DetailedAbove + comprehensive reproductive history, documentation of teratogenic risk counseling and pregnancy test results, safety assessment for reproductive coercion, collaborative care plan with OB/GYN“Patient is a 35-year-old woman with bipolar I disorder presenting in acute mania, currently 6 weeks pregnant (confirmed by urine HCG today). Patient has been on valproate 1500mg daily for 3 years with good mood stability. Pregnancy was unintended; patient reports inconsistent condom use and was not on additional contraception. Patient expressed desire to continue pregnancy. Discussed significant teratogenic risks of valproate including neural tube defects (10% risk) and cognitive impacts. Reviewed safer medication alternatives including antipsychotics and lamotrigine. Patient understood risks and opted to transition off valproate. Initiated folic acid 4mg daily.”Pregnant patients on psychiatric medications, prescribing highly teratogenic medications (valproate), history of postpartum psychosis, reproductive coercion, high-risk pregnancies

Why This Information Matters

Diagnostic accuracy: Recognizing the relationship between reproductive factors and psychiatric symptoms prevents misdiagnosis. A woman with PMDD may be incorrectly diagnosed with major depressive disorder if cyclical patterns are not assessed. A woman experiencing perimenopausal depression may have symptoms attributed solely to psychosocial stressors if menopause transition is not considered. Acute psychiatric decompensation in the postpartum period requires immediate consideration of postpartum psychosis, which is a psychiatric emergency requiring hospitalization.

Medication safety and teratogenicity: Assessment of pregnancy status and reproductive plans is not optional, it is a patient safety imperative. Prescribing valproate to a pregnant woman or a woman of childbearing potential without contraception counseling represents substandard care with potential for catastrophic outcomes. The teratogenic effects of valproate are dose-dependent and time-sensitive, with neural tube closure occurring in the first 4 weeks of pregnancy, often before women realize they are pregnant.

Legal and ethical considerations: Failure to obtain pregnancy testing before prescribing teratogenic medications, failure to provide contraception counseling, or failure to document informed consent about teratogenic risks creates medico-legal liability. Many jurisdictions have specific requirements for prescribing valproate to women of childbearing potential, including mandatory pregnancy testing, contraception use, and signed informed consent.

Peripartum psychiatric emergencies: Postpartum psychosis is a psychiatric emergency with high risk of infanticide and maternal suicide. The presentation typically includes confusion, mood lability, bizarre behavior, delusions (often focused on the infant), and command hallucinations. Onset is usually within the first 2 weeks postpartum. Women with bipolar disorder have 100-fold increased risk. Recognition and immediate hospitalization (often mother-baby unit if available) can be lifesaving.

Comprehensive care and health equity: Women with severe mental illness have significant disparities in reproductive healthcare access, including lower rates of contraception use, cervical cancer screening, prenatal care, and treatment of gynecological conditions. Psychiatrists can reduce these disparities by routinely addressing reproductive health, facilitating referrals, and advocating for integrated care models that include gynecological services.

Trauma-informed approach: Recognizing and responding appropriately to sexual trauma and reproductive coercion is essential for both psychiatric treatment and patient safety. Trauma survivors may require specific accommodations (female providers for gynecological care, support persons present during exams, clear communication before physical contact) and trauma-focused psychotherapy for optimal outcomes.

The integration of reproductive health assessment into psychiatric evaluation is not an ancillary consideration, it is central to diagnostic accuracy, treatment safety, and comprehensive patient care. The reproductive system and the central nervous system are inextricably linked through hormonal, inflammatory, and psychosocial pathways that directly influence psychiatric symptomatology and treatment response.

Next in this series: Part 3 – Head Injury History: Recognizing Traumatic Brain Injury in Psychiatric Evaluation
Previous post: Part 1 – When Psychiatric Symptoms Signal Medical Illness: Key Red Flags