A qualitative analysis of the psychological impacts of menopausal transition for neurodivergent and neurotypical women

Rationale and aim for current study

There is a paucity of research in Australia that specifically explores the perspectives of women undergoing the menopausal transition ⁸ and even less research that has considered neurodivergent women’s experiences. ² This research aimed to explore neurotypical and neurodivergent women’s experiences of this life transition, and in particular, the shared and distinct psychological and mental health impacts of perimenopause and menopause.

Research design

A qualitative research approach was used to explore and understand how perimenopause and menopause is constructed and experienced by neurodivergent and neurotypical women. Social constructionism formed the epistemological foundation of the study, allowing us to explore how meaning is shared and socially constructed. ²⁵

Method

Semi-structured interviews were used to collect data, balancing an exploratory framework designed to give participants the freedom to frame their individual experiences ²⁶ with questions addressing the onset of symptoms, expectations versus reality, impact on interpersonal relationships, mental health, and other psychological impacts. The interview schedule was developed for the purposes of this study and was not tested nor validated externally prior to the commencement of this study. Purposeful sampling was used, with biological women between the ages of 35-55 years who were currently experiencing perimenopause symptoms or who had reached menopause in the previous 12-month period invited to participate. Twelve participants were interviewed for this study and demographic details for the cohort are presented below in Table 1. All participants resided in regional areas of Australia, which was relevant to their experiences of healthcare, as will be discussed. Participants were recruited via a workplace bulletin, word-of-mouth, and social media posts. Participants who reached out were sent a formal invitation via email with an Information Statement and Consent Form attached. To ensure this study upheld the principles of ethical research, approval was gained from the Charles Sturt University Human Research Ethics Committee prior to the commencement of the study [Approval Number: H25165]. The reporting of this study conforms to the COREQ 32-item checklist ²⁷ Participation was completely voluntary and no participants opted to withdraw from the study. Participants gave their informed consent in writing to participate and for the findings of the research to be presented publicly.

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Table 1.

Demographic information on participants.

Participant name	Neurodivergent	Conditions	Diagnostic status	Other health conditions
Ruby	X	Autism	Diagnosed	Cancer
Annette	X	ADHD	Diagnosed	Anxiety, Depression
Florence	X	OCD	Diagnosed	Anxiety, Depression
Elizabeth	X	ADHD	Undiagnosed	​
Caroline	X	ADHD	Undiagnosed	Cancer, Endometriosis
Julie	X	Other	Undiagnosed	Depression, Crohn’s Disease, PCOS, Endometriosis
Edith	​	​	​	​
Dorrie	​	​	​	Osteopenia
Jasmine	​	​	​	Depression
Bessie	​	​	​	​
Mary	​	​	​	Cancer
Rose	​	​	​	​

Notably, no screening tools were used to assess the neurodivergence of undiagnosed participants, nor were diagnosed participants who indicated they had a formal diagnosis required to provide evidence of the diagnoses.

Procedure for data collection

Interviews were conducted in person and online and were recorded and transcribed for analysis. Names and any other identifying information were de-identified to protect participants’ privacy and confidentiality, with each participant assigned a pseudonym.

Data analysis

Thematic Analysis (TA) was used to analyse the data. ²⁸ This involved familiarisation with audio and written recordings of the interviews, including reading and re-reading transcripts. Semantic and latent codes were then generated via thorough examination of each individual transcript and by making comparisons across transcripts. Next, codes were mapped thematically, these themes were then examined for coherence and were reviewed in relation to the entire dataset to determine if they adequately reflected the meanings evident in the data,^28,29 a process that resulted in the construction of six themes.

Intersecting contexts and dual marginalities

Both neurodivergent and neurotypical participants described menopause as intersecting with other impacting factors in their lives. Those who did not have any known conditions reflected on the life stressors that exist for them simply due to the roles they fulfill in their lives. For example, Edith, who identifies as neurotypical, noted:

Just daily life, yeah. Because you’ve got your hormones, like the fluctuation in your hormones…So I was like, the doubt and insecurity and all that kind of stuff that starts to manifest is then, compounded by just what’s going on in your life at the time, like if you’re not doing well at work or if your relationships with your partner or children or friends are, if you’re struggling there, then it just escalates,

For neurodivergent and neurotypical participants alike, conditions such as endometriosis, polycystic ovarian syndrome (PCOS), Crohn’s disease, and osteopenia were cited as some of the health-related challenges that impacted the ways in which participants understood and managed their menopausal transition. For neurodivergent participants, the menopausal transition was automatically marginalised due not only to the taboo nature of menopause but the invisibility of neurodivergence in common health narratives. ² Ruby stated, “so you turn the estrogen off, and you have a neurodiverse brain…No one’s even studied this”, exemplifying the complexity of and intersectionality between menopause and neurodivergence.

Evolving expressions of neurodivergence

For neurodivergent participants, notable changes in their neurodivergent experiences across the menopausal transition were evident. Ruby was diagnosed with autism at a young age and her menopause was surgically induced due to endometrial cancer. She described her brain as “fast-wired”, noting:

Your typical brain has dial-up, and I have DSL, so I could be talking to you, I could be writing a thesis in my brain and thinking about if… I mean, I can do all those things [at once]. That, to me, is like a yoga class for my brain.

Because of her cancer experience, Ruby knew definitively when she entered menopause, and of her neurological functioning, she noted, “[it’s like] someone’s just turned the faucet off [in my brain] overnight”, further noting, “[my brain] is not the same as it was before I had surgery”. Here she describes the change in her functionality:

I was very high functioning, right? It's not like I had ADHD, where I couldn't focus and get something done, but generally… if it was something that I was interested in, you know, I'd be an expert on it, and the things that didn't interest me, I could get those tasks done… Now [in perimenopause], if it's something that doesn't interest me, and I really don't want to do it. But I have to do it. Um, I will put it off like someone that has ADHD…until it's the 11th hour, I won't do it. Whereas before, I was like, okay, these are things I have no patience to do, I don't like to do them, but I'd get them done first, so it's out of the way, so it's not going to annoy me. Now, I cannot do that. Now I'll put it off, and I will put it off, and I will put it off. And I don't have ADHD. But my brain has changed now that I can’t knock those things out of the park the way I used to. I'll only seek out things that bring me joy, and things that I want to do.

Despite the commonality Ruby highlights here between perimenopause and ADHD, not all participants considered the symptomatology of both conditions so synonymous. Annette was diagnosed with ADHD in later life and was careful to contrast the difference between her experiences of ADHD such as disorganisation and forgetfulness with menopausal brain fog. Whilst Annette had become accustomed to her neurodivergence, the experience of brain fog left her feeling disoriented:

Just being in that space where you just can't get your shit together because you don't know. And being ADHD as well. [Partner’s name] like that’s just you anyway, but just absolutely forgetting. And not being able to navigate my day-to-day. That was… that was… that's horrible. I hate that.

Annette described this as a new experience as opposed to an amplification of her ADHD, in contrast to extant research which has drawn a connection between ADHD and the cognitive symptoms often experienced throughout perimenopause. ¹⁸ In contrast to Annette and in line with extant literature, Florence had diagnoses of OCD, depression, and anxiety, and framed the intersectionality of those conditions and menopause as “constant” and “bloody exhausting”. For Florence, menopause exacerbated her extant mental health and neurodivergence-related challenges, while for Annette a clear distinction existed between the two. For Florence, this symptom exacerbation was intense and debilitating:

Brain fog, oh my god…I sit there and I’m like what the fuck was I doing. Like I’ll sit at my computer screen, how do I even go into that to look that up, “oh my god Florence” and then it comes to you, but it is, it’s intense.

Neurodivergent participants understood themselves deeply in relation to their various diagnosis, but for some, menopause amplified their existing neurodivergence and mental health symptoms, while for others, menopause was a distinct experience, even accounting for a degree of interaction and amplification between symptoms. This meant that menopause disrupted self-understanding and was consequently constructed as a confusing and at times distressing period, capable of shifting how participants functioned and behaved, and fundamentally, how they saw and understood themselves.

Unmasking and self-reclamation

This theme explores the ways in which the menopausal transition prompted a re-evaluation of the self for both neurodivergent and neurotypical participants. Neurodivergent participants framed this in terms of unmasking and accepting their authentic selves, while neurotypical participants tended to focus more on relational and role-based adjustments. For example, Annette spoke about her ADHD and how she experienced rejection sensitivity dysphoria (RSD). She positioned this in relation to her perceived need to mask her symptoms not only of her ADHD but also perimenopause:

I went through a stage of like wanting to… try and kind of hide that, and… you know, dress in a particular way, and act in a particular way, so that, you know, because, you know, you're getting more mature.

Florence, who was also neurodivergent, echoed this struggle when discussing her management of both her mental health and her perimenopausal symptoms:

Because we’re strong independent women and we don’t like to let anybody know that we're failing, or feeling down, I don’t anyway. Um and when you go through something like this, you do, you put that façade up. And it’s like “nah I’m fine”. And then that creeps in the panic attacks, that creeps in, you go home and you’re an arsehole because out in the world you’ve been this great amazing person all day.

For Annette, the perception of women in menopause was, “just crazy bitches” but when she became fatigued from masking her symptoms she was able to accept that, while that may be the perception, “that’s not my reality” and she became empowered to embrace who she was becoming:

I think that's where I am at this point …I'll just put on more black eyeliner and dress even more like a witch, and get out there and just, you know, hobble around. So, yeah, it's kind of…I'm in my crone stage. You know, the maiden, mother, crone, I'm now transitioning into crone, and I have wisdom to share.

Similarly, Julie constructed herself as transitioning from insecurity to empowerment through menopause, noting, “I’ve been a wife, I’ve been a mother…the whole menopause thing, that’s given me…the reason to say, you know what? This is my time, and it’s my turn”. It was common among both neurodivergent and neurotypical participants to experience a disruption of identity, resulting in a reassessment of self. Neurodivergent participants experienced this more at an individual level whilst neurotypical participants positioned the disruption as a relational entity. Edith, who did not identify as neurodivergent, highlighted the relationality of her experience, noting, “The pressure of…you’re supposed to be this everything to everyone, but to yourself you’re nothing”. There was a spoken and at times unspoken sense of negotiation between the self and others, which for Rose, a neurotypical participant, manifested in context to her roles as mother, stepmother, and wife.

Neurodivergent participants often positioned themselves in opposition to prescriptive gender norms and generational silence around menopause. Their narratives emphasised resistance, rebellion, and self-definition in contrast to neurotypical participants who viewed cultural change as a gradual social evolution. For many, menopause symbolised an act of resistance against expectations of emotional regulation, productivity, and femininity. Annette highlighted the generational shift from tolerance of suffering, or as she describes it, “just going through it”, to revolt:

….if we… if we can get this stuff [understandings of menopause] right, and if we can start to talk about it, like, that's why I say, you know, Gen X, we're not taking this shit lying down anymore. My sisters are boomers, so it's like… in that generation, where I think there was a lot more… [we] would we just go through this? Um, whereas I think, yeah, seeing women in podcasts that on, you know, in different videos talking about this stuff, I was like, yeah, you… you're stomping your feet and lighting a match, because we're not being told anymore. The way we should be behaving, and the way that we should be reacting and acting with what we're going through in our bodies, particularly now.

Physiological experiences of the menopausal transition and positions on treatment

Both neurodivergent and neurotypical participants reported on multiple physiological symptoms, as noted in Table 2 below.

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Table 2.

Physiological symptoms.

Participants	Physiological symptoms
	Hot flushes/Night sweats	Sleep disturbances	Weight gain	Joint pain	Vaginal dryness	Brain fog	Other*
Annette	X	X	​	X	​	X	X
Julie	X	X	​	​	X	​	​
Caroline	X	X	​	​	​	X	​
Ruby	X	X	​	​	​	​	​
Elizabeth	X	X	​	X	​	​	​
Florence	X	X	​	X	X	X	X
Jasmine	X	X	X	​	​	​	​
Bessie	X	X	X	​	​	​	X
Dorrie	​	X	X	X	X	​	X
Edith	X	X	​	X	​	X	X
Mary	X	X	X	​	X	X	​
Rose	X	X	X	​	​	​	​

The only symptom notably absent for neurodivergent participants, in contrast to neurotypical women, was weight gain. Previous research suggests that neurodivergent women may have more problematic menopausal transitions with regards to physiological symptoms, however, the findings of the current study suggest no notable differences in number or severity of symptoms, in contrast to extant literature.^2,3

The most notable treatment for perimenopausal and menopausal symptoms is HRT. ⁹ Dorrie was a huge advocate of HRT and called it “a little miracle”, while many of the other participants were ineligible for HRT. Gaps in medical knowledge created a double jeopardy problem for neurodivergent participants. As one example of this, Ruby was apprehensive to use treatments like HRT that are under researched with regards to neurodivergence:

…even with, say, supplements, or even medical interventions, that's not studied on people who are neurodivergent. And so, like, for me, a cup of coffee makes me sleepy, right? It's the opposite. So, it's the same when I had surgery. They didn't even consider some of the drugs they wanted to give me, what it would do to my brain. And so, it's another reason why I don't like to take pills, because, I don't know, they don't test them on neurodiverse people before…so…no!

Both neurodivergent and neurotypical participants used a mixture of herbal and natural remedies, exercise, diet and lifestyle changes to manage menopausal symptoms. These management strategies suggest that both neurodivergent and neurotypical women alike are positioning themselves in a more active role when navigating the treatment and management of perimenopause and menopause.

Positive experiences with HCPs

Interestingly, many of the neurodivergent women in this study had positive relationships with their HCPs, perhaps reflecting continuity of care that may in some respects be more commonly experienced in regional and rural areas. For example, Annette noted a long-standing positive relationship with her doctor, and despite his lack of knowledge around the menopausal transition, she deeply valued his honesty and resourcefulness:

And I like my doctor as well, because he's not one of these…he's been my doctor for over 10 years now, and he… if he doesn't know. He will say, “I don't know”. And then he'll go and find out about it.

Similarly, Ruby discussed positive relationships with multiple HCPs, both when she was living overseas and since being home in Australia, reporting feeling “understood” by the GP who first identified her perimenopausal symptoms. Here she highlights how a lack of knowledge can be offset by a constructive patient-doctor relationship:

It's my GP who's been more helpful, but still, she says, “Ruby, we have nothing on neurodiversity and menopause”. She was honest.

Honesty and candour conveyed respect and so too did listening attentively, with Julie stating that her “great female doctor” was “wonderful…she actually believes me”. Caroline, a neurodivergent participant with a terminal cancer diagnosis, commented that her medical team were “fantastic”. This theme sits in contrast with extant research that suggests that neurodivergent people tend to have negative experiences with HCPs, and to a greater degree than their neurotypical counterparts due to negative prior experiences and diagnostic overshadowing.^13,30 Possible explanations for these findings could be the rural context noted above and the continuity of care, as well as the care and management of already recognised diagnoses. ³¹ In small regional Australian towns, single GP medical practices are not uncommon, and while resources may be fewer in regional areas, greater continuity and relationality of care may also exist compared to metropolitan contexts. These findings suggest strong doctor-patient relationships and continuity of support may be fundamental to providing menopausal support, especially for patients with extant medical, mental health, and neurodivergence diagnoses.

Frustration over medical ambiguity

Counter to the previous theme, for neurodivergent participants, frustration over medical ambiguity and lack of clarity in the menopausal diagnostic processes existed. This frustration stemmed from a need for logic, clarity, and empirical grounding. These needs currently conflict with the medical system’s lack of definitive diagnostic tools, as Julie articulated:

I think my biggest issue. And I brought it up early, and it's the one that, you know? Gets to me the most is the fact that there is no test. You know, if I have the flu, I can go to the doctor, get a test done…and having knowledge is power, and I can say, you know what, I'm feeling bad because I have the flu.

Julie further reflected that a lack of certainty breeds self-doubt to the point where she would tell herself, “You’re being lazy, you’re being silly!”, because she could not attribute her symptoms to a concrete diagnosis. Ruby’s frustration was due to the lack of education women are given in detecting signs of the transition themselves, alongside a lack of preparation from HCPs. Ruby likened this type of conversation and preparation to the kinds of care and preventative measures taken for women’s cancers, noting that just like with mammograms, “maybe these are yearly conversations that we should be having with the GP, but they don’t really exist”.

Implications, limitations and future directions

The data from this study has implications for both neurotypical and neurodivergent women. The lack of education around both the menopausal transition and neurodivergence highlights the need for more accessible education for HCPs, particularly those working as GPs who are often tasked with providing frontline support prior to a patient seeking out specialist psychiatric or other medical support. More education would allow both menopause and neurodivergence to be normalised in public discussion, reducing the perpetuation of negative stereotypes related to the perimenopausal and menopausal experience, particularly for neurodivergent women. The medical ambiguity of perimenopause and menopause appears to undermine women’s ability to effectively identify and address both their physiological and psychological symptoms. Whilst education can increase knowledge and understanding, proactive methods such as earlier conversations with GPs and routine hormone testing could better prepare women for the transition and reduce the occurrence of confusion and frustration around the diagnostic process.

Once detected perimenopause should be treated by way of the biopsychosocial (BPS) model. ³⁴ This model is concerned with not only the biological but the psychological and social aspects of health ³⁴ and emphasizes the need for integration of biological, psychological, and social factors when providing support. Using this lens HCPs in all fields may better address the complex nature of perimenopause and the intersecting factors that shape individual experience. Given the intersectionality of issues that may impact upon the menopausal transition, such as pre-existing or emerging mental or physical health issues, relational issues, financial stress, parenting/caring responsibilities, and neurodivergence, the biopsychosocial model may provide a valuable contextual lens to healthcare for women and their HCPs. Use of this model may reduce the financial and time burden faced by HCPs and their patients in determining the most effective interventions for women. ¹²

In contextualising the findings of this study, it is important to note that one limitation was the predominance of ADHD in the sample of neurodivergent participants, compared to other forms of neurodivergence. Given the particular relationship that may exist between ADHD and menopausal symptoms, study findings must be interpreted cautiously, and research is warranted to further explore the relationship between menopause and other forms of neurodivergence. Participants were also drawn from regional and rural communities in Australia, and the regional healthcare context of these participants may not be reflective of rural and regional healthcare practices in other countries. Furthermore, it must be noted that participants were predominantly white, middle-class women who experienced potential disadvantage in their geographic location and for some in their neurodivergence, but also experienced economic and cultural privilege. The findings of this study do not necessarily apply to the experiences of culturally diverse and/or economically disadvantaged women, as medical marginalisation likely uniquely affects women of colour during menopause and this warrants further exploration, alongside issues of racial bias.

Finally, participants in this study were not required to have a formal diagnosis which allowed us to include important perspectives from a range of participants who might otherwise have been excluded from research, however, this did limit our ability to explore the impact of a formal diagnosis of ADHD, ASD, OCD, or other related condition, in context to menopause. Future research might distinguish between the menopausal experiences of formally diagnosed and self-diagnosed neurodivergent women, especially when exploring the influence of medication and identity navigation. Much of the previous research around neurodivergence and the menopausal transition has focused on autism. ² Studies that focus on ADHD note the increase in late diagnosis of ADHD and raise questions around whether this is due to the similarities in cognitive symptoms between ADHD and menopause. ¹⁹ Future research should consider individual forms of neurodivergence separate to one another in order to develop a full, nuanced understanding of the connection between neurodivergence and menopause. Previous research suggests that neurodivergent women will experience more severe symptoms and potentially earlier onset and longer menopausal transitions than neurotypical women. ³⁵ Given we did not find such a pattern in our study, further research is warranted to explore this.

Finally, future research would benefit from moving beyond cross-sectional designs to longitudinal studies that capture the menopausal transition for neurodivergent women over time, including exploration of the identity arc of disruption to empowerment described earlier. This would allow for more in-depth knowledge and understanding of the psychological and cognitive experiences of neurodivergent women. Collaborative research designs in which neurodivergent women are directly involved in shaping the research would also provide richer and more authentic insights that challenge the dominance of male-centred, neurotypical medical frameworks.