There is a quiet gap in the middle of psychiatric education — and women have been paying the price for it for decades.
Whether you train as a doctor, a psychiatrist, or a mental health nurse, you will spend thousands of hours learning about neurotransmitters, mood disorders, personality structures, and psychopharmacology. What you will rarely, if ever, be formally taught is how hormones — specifically oestrogen and progesterone — shape the brain, regulate mood, affect concentration, and drive emotional stability.
This is not a minor oversight. It is a systemic blind spot with real consequences.
Hormones Are Not “Women’s Business” — They Are Brain Science
Oestrogen is neuroactive. It influences serotonin, dopamine, and noradrenaline — the very same systems that psychiatric training centres on. It affects the prefrontal cortex, the hippocampus, and the amygdala. It modulates sleep, anxiety, working memory, and emotional regulation. When oestrogen fluctuates — across the menstrual cycle, in the perimenopause, or after surgical menopause — it does not stay neatly in the body. It moves through the brain.
Progesterone similarly has its own neurological profile. Its metabolite allopregnanolone acts on GABA receptors, the brain’s primary calming system. When progesterone drops sharply, as it does premenstrually and throughout perimenopause, the result can be anxiety, insomnia, irritability, and a feeling of psychological unravelling — symptoms that look, to an untrained eye, very much like a mood disorder.
A Case That Stays With Me
A year ago I assessed a woman in her mid-forties. She presented with longstanding difficulties — chaotic functioning, emotional dysregulation, and a reliance on alcohol that had quietly become the scaffolding holding her life together. I diagnosed her with ADHD, combined presentation, and started her on lisdexamfetamine. The effect was transformative. At 70mg she became calmer, more organised, and — significantly — she stopped relying on alcohol. Her life, by her own account and by clinical observation, changed.
At the same time, she was assessed by a clinical psychologist who diagnosed her with Emotionally Unstable Personality Disorder.
I disagreed then, and I disagree now. My reasoning is straightforward: if someone takes a high dose of a stimulant medication and becomes calmer, stops misusing alcohol, and regains function — that is not a personality disorder responding to placebo. That is ADHD responding to the correct treatment. The medication told us something the assessment alone could not.
I want to be clear: this is not about criticising one clinician. After 38 years in psychiatry, I have enormous sympathy for how genuinely difficult these assessments are. ADHD and EUPD share a striking number of surface features — emotional dysregulation, impulsivity, unstable relationships, difficulty with identity. In a standard assessment, without a full developmental history or an understanding of hormonal context, the two can look nearly identical. I have managed a personality disorder service. I know how easy it is to reach for that diagnosis when the presentation is complex and the history is chaotic.
But that sympathy has limits. When the clinical evidence — the patient’s response to medication — is sitting right in front of us, it becomes indefensible to disavow it.
The EUPD Diagnosis Is Not Neutral
A diagnosis of Emotionally Unstable Personality Disorder carries weight that follows a woman through her care for years. It is, in many clinical settings, deeply stigmatising — shaping how future presentations are received, how much credibility she is given, and what treatments are considered appropriate.
Critically, if you are treating someone for a personality disorder rather than neurodiversity, you would not prescribe stimulant medication. The diagnostic label actively closes off the treatment pathway that could change her life. In this woman’s case, the correct diagnosis and the correct treatment were available. The gap between them was not a lack of evidence. It was a lack of knowledge around neurodiversity, female hormones, and what happens to a neurodivergent woman’s brain when she becomes perimenopausal.
Neurodivergent Women: A Particularly Vulnerable Group
Women with ADHD or autism are especially at risk of this misdiagnosis. There is growing evidence that neurodivergent women are more sensitive to hormonal fluctuation — that the dopamine system, already operating differently in ADHD brains, is more vulnerable to the drops in oestrogen that come with perimenopause. Coping strategies that held for years can abruptly collapse. Symptoms that were previously manageable — even on medication — can suddenly worsen. Emotional dysregulation intensifies. The life that was, just about, being held together begins to fall apart.
When a woman arrives at that point and her clinician does not know to ask about perimenopause, the hormonal history, or the interaction between her neurodivergent profile and her changing biology — the risk of a wrong diagnosis is not theoretical. It is very real.
What Needs to Change
I am currently training with the British Menopause Society specifically because I believe this knowledge should be standard, not specialist. Every clinician working with women should understand the hormonal architecture of the female brain. Every assessment of a woman presenting with emotional dysregulation should include a menstrual and hormonal history. And every woman who has been handed a psychiatric diagnosis without anyone asking about her hormones deserves to have that question asked — even now, even late.
The diagnostic tools we use were largely built on male presentations. And women — particularly neurodivergent women navigating the hormonal upheaval of perimenopause — are still paying the price for that.
It is time our training reflected that.
If this resonates with you or someone you know, please share it. The more women and clinicians who understand this intersection, the fewer women will spend years in the wrong treatment for the wrong diagnosis.