Hidden in plain sight: recognising women's mental health conditions

Women’s mental health frequently hides behind physical symptoms, so conditions such as premenstrual dysphoric disorder, perinatal OCD and postnatal PTSD may only be recognised after multiple repeated appointments

Women are more likely than men to be diagnosed with common mental health conditions such as depression and anxiety, with 24.2% of women in England affected compared with 15.4% of men.¹ However, in the reality of a typical general practice consultation, mental health difficulties rarely present in the textbook way that we might expect. General practice nurses (GPNs) are well placed to respond to women's health presentations. They are used to seeing women for reasons that appear purely physical such as fatigue that will not lift, headaches, bowel symptoms, disrupted sleep or a menstrual cycle that has become unmanageable. What is less often recognised is how frequently these physical complaints are the visible edge of something psychological underneath.

Hormonal change, caring responsibilities, stigma, past trauma and the everyday pressure of gendered expectation all shape how women experience distress and whether they feel able to recognise it and name it. The result is that conditions such as premenstrual dysphoric disorder, perinatal OCD and birth related PTSD are frequently missed or picked up only after months or years of repeated appointments.

This article looks at why women's mental health so often hides behind physical symptoms, works through several conditions that are particularly easy to miss in a busy general practice environment that is often restricted timewise by meeting QOF targets, and sets out what GPNs are well placed to do differently. My argument throughout is a simple one, with the right kind of professional curiosity and enough continuity of care, general practice nursing is one of the best positioned parts of the NHS to catch these presentations early. Time spent building psychological safety now is not time lost from the target driven parts of the appointment, it is what stops today's unexplained symptom becoming next year's crisis.

Why women's mental health can be hard to recognise

Women's mental health is shaped by the interaction of biology, psychology and social circumstance, which is why it's not always possible to capture during routine screening. Biologically, hormonal shifts across the menstrual cycle, pregnancy, the postnatal period and perimenopause can affect mood and emotional regulation in women who are vulnerable to them.^2,3 Psychologically, patterns such as perfectionism, rumination and a tendency to internalise difficulty appear to shape how women experience and describe symptoms in the first place.⁴ Socially, caring responsibilities, financial pressure, gender-based violence and the everyday expectations placed on women all feed into whether and how they seek help. No single checklist question can capture all three at once.

Put these influences together and it becomes easier to see why a consultation built around fatigue, insomnia, headaches or bowel symptoms can quietly contain an unspoken mental health problem. If we only address the presenting complaint then the psychosocial context around it goes unexplored, and the underlying condition stays hidden. An approach that holds all three of these together and treats the physical complaint as a possible doorway rather than the whole story, gives us a much better chance of noticing what is really going on.

This pattern is seen clearly in premenstrual dysphoric disorder, perinatal OCD, eating disorders, trauma related presentations and menopause related anxiety, where psychological symptoms are frequently masked by physical ones, dismissed as a normal part of reproductive life, or kept quiet out of fear and stigma. Understanding these hidden presentations matters because timely recognition changes outcomes.

Hidden presentations in general practice

Premenstrual dysphoric disorder (PMDD)

PMDD is easy to mistake for depression, generalised anxiety, recurrent mood swings or even a personality difficulty, because the pattern only becomes obvious once you look for it across the cycle. Women may come in with migraines, fatigue, insomnia, irritability or relationship strain rather than describing mood symptoms directly. The clue that ties it together is the timing, as symptoms cluster in the luteal phase and settle once menstruation begins.

A simple prospective symptom diary kept across two menstrual cycles is often the single most useful diagnostic step and is recommended in UK guidance on premenstrual disorders.⁵ Once PMDD is recognised, SSRIs, hormonal treatment and psychological approaches are all evidence-based options. The barrier is rarely treatment, it is recognition of the issues being presented.

Contraception reviews and pill checks are a natural opening here, since GPNs are already discussing the menstrual cycle. A short follow-up question, ‘Does your mood change around your period?’, costs nothing extra in a routine review. But it can open a conversation a woman didn't know they were allowed to have.

Many women have simply come to accept these symptoms as a normal part of life, something to get through every month. They may not realise that real improvement is possible. A UK study interviewing women later diagnosed with PMDD found this exact pattern: symptoms were often dismissed as ‘just PMS’, leading many to accept them as normal for years before receiving an accurate diagnosis.⁶ Professional curiosity and asking the right questions to open up conversations is often the first step in changing that.

Perinatal OCD

Perinatal OCD is worth discussing precisely because so many GPNs have had limited training in it.⁷ Women may disclose intrusive, unwanted thoughts, sometimes about harming their baby. This can sound alarming out of context: ‘I keep having horrible thoughts’ or ‘I’m scared I’ll hurt my baby.’ Fear of how that will be received is why many women say nothing at all.⁸ A recent systematic review confirms this remains an under-recognised and under-researched presentation.⁹

The distinction that matters clinically is insight. In perinatal OCD the thoughts are unwanted and distressing. Crucially, the woman recognises them as wrong. This is fundamentally different from the loss of insight seen in postpartum psychosis.¹⁰ Two things make the biggest difference here, asking sensitively without assumptions, and knowing the route into urgent assessment when needed, alongside referral to specialist perinatal mental health services.

GPNs often see new mothers more often than anyone else in the surgery in the first year, through baby immunisations, contraception reviews and cervical screening. These repeat contacts are a genuine opportunity to notice a mother who seems unusually anxious, avoidant or reluctant to be alone with her baby. Staying aware of this, rather than making assumptions, means GPNs can stay open to these difficult consultations and give a woman the chance to speak openly without fear of judgement.

High functioning anxiety

‘High functioning anxiety’ isn’t a formal diagnosis, but it’s a practical way to think about a pattern GPs and GPNs see often: women who meet the criteria for generalised anxiety disorder (GAD), but whose presentation looks nothing like the textbook description. Research shows this is the norm rather than the exception in primary care. Only around one in eight people with GAD present with anxiety as their main complaint, while the rest describe physical symptoms such as pain, fatigue and sleep disturbance instead.¹¹

These are the women who appear capable, organised and calm on the outside while carrying chronic worry, insomnia, muscle tension, perfectionism and exhaustion underneath.¹² They are far more likely to present with headaches, irritable bowel symptoms, palpitations or fatigue than to say, ‘I feel anxious’, partly because their coping has, until now, looked like success. These women are easy to miss in an NHS Health Check or a long-term condition review because they present as the model patient, who are on top of their medication, their appointments and their life.

Eating disorders

Eating disorders are often missed because most people, including clinicians, picture someone with an eating disorder as severely underweight. Most patients with an eating disorder do not present that way. Fewer than 6% are medically underweight,¹³ yet weight stereotypes measurably reduce recognition and diagnostic confidence, even among healthcare professionals.¹⁴ Atypical anorexia, binge eating disorder and bulimia can all present with a body weight in an average or higher weight range, alongside amenorrhoea, abdominal pain, fatigue, osteoporosis or electrolyte abnormalities. A recent primary care review found that binge eating disorder and bulimia, in particular, are still poorly identified in general practice, with both clinicians and patients wanting clearer, more usable screening approaches.¹⁵ Routine consultations, cervical screening, contraception reviews and chronic disease checks all offer natural opportunities to ask about eating patterns without it feeling like an interrogation. GPNs are also often the ones recording weight over time which puts them in a good position to notice an unexplained pattern of loss, gain or fluctuation that a single appointment would miss.

PTSD following childbirth

Birth trauma is increasingly recognised as a distinct presentation. It’s often triggered by an emergency caesarean, haemorrhage, neonatal admission, a feeling of loss of control during labour or poor communication from the clinicians postnatally.¹⁶ Symptoms tend to surface months later, well past the point where anyone is still routinely asking about the delivery. Women can experience nightmares, avoidance, hypervigilance and often relationship strain.¹⁶ A recent UK parliamentary inquiry described access to appropriate perinatal mental health support after a traumatic birth as a postcode lottery.¹⁷

Women rarely begin a consultation by saying, ‘I think I have PTSD.’ More often, it may present through symptoms such as anxiety, sleep disturbance, or reluctance to attend follow-up appointments. These subtle signs are also important to recognise during routine clinics. For example, repeatedly cancelling a contraception review or a first cervical screening following childbirth, or appearing particularly anxious or distressed about attending, may indicate an underlying trauma response rather than simply disorganisation.

Domestic abuse

Domestic abuse is one of the most important, yet often challenging, presentations to recognise in primary care. Women rarely present by directly asking for help with domestic abuse. Instead, it may manifest through repeated consultations for chronic pain, headaches, insomnia, anxiety, depression, unexplained injuries, or a pattern of frequent and complex appointments where the underlying cause is not immediately clear. NICE guidance supports sensitive, routine enquiry, alongside clear and appropriate referral pathways.¹⁸ Recent UK primary care research also highlights the value of structured training and support programmes in improving identification and referral, benefiting not only women but also men and children affected by domestic abuse.¹⁹

Trauma-informed care means approaching every consultation with the awareness that the person may have experienced trauma, regardless of whether they have disclosed this. GPNs can shape the interaction around three key principles:

• Safety – creating an environment where a woman feels physically and emotionally safe enough to speak openly.
• Trust – building a relationship where she feels listened to, respected and confident that she will not be judged or have decisions made without her agreement.
• Control – ensuring the woman remains in control of what happens following any disclosure, including what information is shared and what support she chooses to access.

Evidence from primary care consistently highlights these factors as important in creating the conditions for disclosure.²⁰

Nursing consultations can provide a valuable opportunity for this. They often allow more time and privacy than a standard 10-minute GP appointment. This additional space can create an opportunity for a woman to disclose experiences she may never have spoken about before, particularly when questions are asked sensitively and she is given the time and control to respond.

Menopause-related anxiety

Menopause-related anxiety is often overlooked or reframed as burnout or generalised anxiety disorder. Symptoms such as palpitations, panic attacks, poor concentration, insomnia and irritability can all appear during perimenopause as oestrogen levels fluctuate. When this connection is missed, women are often prescribed antidepressants rather than treatment aimed at the underlying hormonal cause. One UK study found that over half of women aged 45–54 diagnosed with a common mental health condition during the menopause transition were prescribed antidepressants, while fewer than 3% received HRT²¹. NICE guidance now gives clearer direction on assessment and treatment, including cognitive behavioural therapy alongside HRT where appropriate²². Asking about the menstrual pattern and vasomotor symptoms alongside mood is often what reveals the connection. Contraception reviews, cervical screening, HRT reviews and long term condition clinics, where perimenopausal women are already a large part of the caseload are all natural places to ask about mood alongside hot flushes and sleep, rather than treating them as separate problems.

Common themes in hidden presentations

The same patterns keep recurring across all these conditions. Most consistently, psychological distress shows up as fatigue, insomnia, headaches, bowel symptoms or chronic pain driving repeated consultations long before anyone considers a mental health cause.^4,23

Shame and stigma can also have a significant impact on disclosure, particularly in areas such as perinatal OCD, eating disorders and domestic abuse, where women may fear judgement, concerns about losing custody of their children, or not being believed. ^2,24 Hormonal transitions including puberty, menstruation, pregnancy, the postnatal period and menopause are also important considerations across many of these conditions, influencing when symptoms emerge, their severity and how women experience and describe them.^2,3

It is not any one of these factors alone that matters, it is the combination.
When unexplained physical symptoms, repeated appointments and a significant reproductive life-stage change occur together, it is worth pausing and asking ‘What might I be missing?’

Practical implications for general practice nursing

Recognising hidden presentations is less about using a specific screening tool and more about developing a habit of mind, looking beyond the presenting complaint and considering what else may be happening in a woman’s life. GPNs often have regular contact with women through contraception, cervical screening, long-term condition reviews and vaccinations. This continuity provides valuable opportunities to recognise patterns across consultations that may not be apparent during a single appointment (Box 1).

Future development

Better undergraduate and postgraduate education for GPNs and GPs could help bridge the gap between how these conditions present and the clinicians’ confidence in recognising them. This is particularly important for PMDD, perinatal OCD and menopause-related mental health where education and training have historically been limited.²⁵

Access to specialist perinatal mental health services also remains inconsistent across the UK, despite continued NHS investment, with referral pathways varying considerably between areas.^2,17 Greater recognition of PMDD as a genuine and treatable condition, rather than simply severe PMS, could help reduce the number of women who experience years of recurrent symptoms and are treated primarily for depression.

Menopause education for clinicians has strengthened following the 2024 update to NICE guidance however translating this knowledge into routine clinical practice will take time.^22,26

There is also a need for wider adoption of trauma-informed practice and continued research into how sex and gender influence the presentation, diagnosis and treatment of mental health conditions. Strengthening these areas would improve clinical practice and address some of the gaps in the evidence base underpinning this article.^27,28

Conclusion

Hidden presentations of women’s mental health are common in general practice and often arise for understandable reasons. Hormonal changes, stigma, trauma and wider social circumstances can all influence how distress is experienced and expressed, with psychological difficulties sometimes presenting through physical symptoms instead.

Recognising how these factors interact can help GPNs identify concerns earlier and provide more appropriate, compassionate care. Staying curious, asking the broader question when it feels right, and offering the continuity that general practice nursing does so well, is often enough to uncover what might otherwise have stayed hidden for years.

References

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