Obsessive-compulsive disorder and menopause: a scoping review

Abstract

Importance and objective:

Obsessive-compulsive disorder (OCD) is a psychiatric condition marked by intrusive thoughts and compulsive behaviors. Female-born individuals are more likely to develop OCD; reproductive events such as menarche and the peripartum are also associated with increased symptom severity. This scoping review identified existing literature on the impact of menopause on OCD onset and symptoms.

Methods:

We conducted a scoping review following Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for scoping reviews reporting guidelines. Four electronic databases (MEDLINE, Embase, PsycInfo, and CINAHL) were searched from inception to April 15, 2025, for original research studies examining the association between menopause and new onset or changes in preexisting obsessive-compulsive symptoms. We described study characteristics, main findings, and gaps in the existing literature.

Discussions and conclusion:

Eight studies met criteria for inclusion in this review. All studies used quantitative methods, were cross-sectional, and relied on self-reported retrospective assessment of changes or onset of obsessive-compulsive symptoms in relation to the onset of menopause. Of 373 participants reporting on OCD onset, 17 (4.6%) reported that the initial appearance of their OCD symptoms had coincided with the onset of menopause. Of 265 participants reporting on symptom changes, 72 (27.2%) reported an exacerbation of their symptoms with the onset of menopause, while 30/265 (11.3%) reported an improvement in symptoms. Cross-sectional research suggests that OCD symptoms may change in severity or start with menopause in a subset of individuals. Longitudinal studies prospectively tracking OCD symptoms in the premenopause, perimenopause, and postmenopause phases are needed to confirm these findings. In the meantime, increased symptom monitoring of midlife female-born individuals with OCD is warranted.

Obsessive-compulsive disorder (OCD) is a debilitating chronic psychiatric disorder characterized by obsessions, or repetitive intrusive thoughts, and compulsions, which are behaviors or mental acts performed to reduce distress.¹ The lifetime prevalence of OCD is estimated to be 1.6 times higher in women than in men.² Reasons for the heightened prevalence of OCD among women are unclear, though may be partially explained by increased exposure to ovarian hormone fluctuation in the context of reproductive events. Administration of estradiol has been shown to reduce compulsive behaviors in rats, supporting the role of estradiol in OCD pathophysiology;³ exposure to fluctuations in estradiol may therefore increase one’s propensity to experience OCD symptoms. Indeed, menarche^4,5 as well as the peripartum and postpartum periods^6,7 are associated with an increased risk of OCD onset and exacerbation.

Considerably less research has examined OCD in relation to menopause in humans despite the plausible link between menopause and new onset or exacerbation of OCD symptoms.⁸ To systematically identify and map the available evidence on the association between menopause and OCD onset and symptoms, we conducted a scoping review. Since limited research has examined menopause in relation to OCD onset and symptoms, our first objective was to identify and summarize literature examining OCD status or obsessive-compulsive (OC) symptom onset, exacerbation, or experiences in relation to menopause. Second, we sought to identify gaps in the existing literature pertaining to this association and suggest areas for future research to advance current understanding of OC symptoms in relation to menopause.

METHODS

Study design and protocol

We conducted a scoping review, which aims to provide an overview of available evidence and identify knowledge gaps.⁹ We followed the JBI guidance for scoping reviews¹⁰; the Population, Concept, and Context framework¹¹; and Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for scoping reviews reporting guidelines.¹² The protocol for this scoping review is available (at https://osf.io/h3ca8/). No ethics board approval was required.

Eligibility criteria

We included peer-reviewed and grey literature (specifically: theses and dissertations and conference abstracts) reporting on the association between peri/postmenopause and OCD onset, symptoms (severity or type), or experiences. Specifically, eligible types of literature were: (1) peer-reviewed studies, (2) abstracts, (3) conference proceedings, and (4) theses and dissertations. We did not place any restrictions on the publication date or study design. We excluded studies not published in English, review articles, editorials, letters to the editor, book chapters, book reviews, commentaries, studies in non-human samples (eg, animal models), and studies that did not report on OCD in relation to perimenopause and postmenopause as defined by the Stages of Reproductive Aging Workshop staging system.^13,14

Information sources and search strategy

We searched MEDLINE, Embase, CINAHL, and PsycINFO for literature published from database inception to April 15, 2025. In consultation with a reference librarian at the University of Saskatchewan, we included relevant subject headings and keyword terms for the concepts “obsessive-compulsive symptomatology” and “menopause” in our search strategy. We identified grey literature (ie, difficult to locate or unpublished literature) using the following approaches: (1) to identify abstracts and conference proceedings, we additionally searched Web of Science’s Conference Proceedings Citation Indices and (2) to identify theses and dissertations, we searched ProQuest Theses and Dissertations Global. We also identified relevant literature through backward citation chaining by hand-searching the reference lists of eligible studies to identify any potentially relevant articles missed by our original search.¹⁵ Finally, we performed forward citation chaining using Web of Science to identify relevant literature that cited included studies. Our search strategy for MEDLINE is shown in Supplemental Table 1 (Supplemental Digital Content 1, http://links.lww.com/MENO/B431; search strategies for other electronic databases are available upon request).

Study selection process

All records identified through our search strategy were imported into Covidence, an online systematic review software.¹⁶ Two reviewers (C.M.A. and G.A.) screened the title and abstract of each record for mention of the concepts OC symptomatology and menopause. Records discussing mental health in relation to reproductive cycle events were also retained for full-text review. Next, both reviewers examined the full text of records for which the initial title and abstract review indicated were potentially relevant. Studies meeting the inclusion criteria detailed above were included in this review. Discrepancies that arose during the study selection process were discussed by reviewers (C.M.A. and G.A.) until consensus was reached.

Data charting process

Two reviewers (C.M.A. and G.A.) independently abstracted data on study characteristics (authors, year of publication, study location, and methods), sample characteristics (sample size, etc), and the main findings pertaining to the examination of the association between menopause and OCD. Both quantitative data or qualitative data describing women’s experiences with OC symptomatology or with OCD in relation to menopause were eligible for extraction. We used a data collection form that we designed a priori. Discrepancies were resolved through discussion by study authors (C.M.A. and G.A.) until consensus was reached. No data were sought from investigators, nor were published data confirmed with study authors.

Critical appraisal (eg, quality assessment, risk of bias assessment) is not required in the context of scoping reviews, according to recent methodological guidelines for the conduct of scoping reviews.^10,12 Because our aim was to map all original research (regardless of study design or approach) on the association between menopause and OCD or OC symptomatology,⁹ we did not perform a critical appraisal of selected studies for this review.

RESULTS

Study characteristics

The study selection process is shown in Figure 1. We included 7 full-text original research studies⁴,⁵,⁸,¹⁷,¹⁸,¹⁹,²⁰ and one abstract.²¹ One study included participants from the United States,⁵ 2 studies recruited participants from the Netherlands,^5,20 2 from Turkey,^19,21 1 from Mexico,¹⁷ 1 from India,⁸ 1 from South Africa,¹⁸ and 1 was presumed to have recruited participants from Spain.⁴ All studies were cross-sectional, with assessment of change in OC symptoms or timing of new onset diagnosis reported retrospectively after the onset of menopause in 7 studies^4,5,8,18-21 while one study compared OC symptoms between premenopausal and postmenopausal participants.¹⁷ All 7 studies that retrospectively assessed the associations of changes in OC symptoms or new onset diagnosis in relation to the timing of menopause required a clinical diagnosis of OCD according to the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV), confirmed by study investigators, as an inclusion criterion for participation in the study.⁴,⁵,⁸,¹⁸,¹⁹,²⁰,²¹ Of the 8 included studies, 5 explicitly defined menopause as ≥12 months of amenorrhea (or the absence of menstrual periods),^5,8,17,19,20 while 3 studies^4,18,21 did not provide a clear definition. In all 8 studies, menopause was self-reported by participants based on the study definition. Study characteristics and main findings are described in greater detail in Table 1.

FIG. 1.

PRISMA-ScR flow diagram illustrating the study selection process. OCD, obsessive-compulsive disorder; PRISMA-ScR, PRISMA extension for scoping reviews.

TABLE 1.

Characteristics of included studies (n = 8)

Citation	Objective	Study participants	Study design	Geographical location	Outcome definition and measurement a	Menopause definition	Main findings
Alpak and Karamustafalioglu21	To assess retrospective reporting of the impact of menopause onset on OCD symptoms	108 women (46 with complete data) b meeting DSM-IV criteria for OCD, outpatient setting	Cross-sectional	Turkey	Retrospective investigation of OCD symptom changes and onset of OC symptoms in relation to reproductive events, including menopause Standardized telephone interview administered by psychiatry resident	Not reported	1/46 (2.2%) participants reported OCD onset at menopause onset 1 participant reported exacerbation of OC symptoms with menopause onset
Carranza-Lira and Pablo-Cruz17	To compare OCD symptom severity in pre vs postmenopausal women	202 premenopausal and 164 postmenopausal women ages 45-55 y attending an endocrine gynecology consultation without history of hysterectomy; mean time since menopause was 2 y (range: 1-13)	Cross-sectional	Mexico	“What’s My M3?” OCD domain score	Minimum of 12 m of amenorrhea	Higher median scores in postmenopausal relative to premenopausal women (P < 0.001)
Guglielmi et al5	To assess retrospective reporting of the impact of menopause onset on OCD onset and symptom change	542 women (187 postmenopausal; 30.5% surgical menopause) meeting DSM-IV criteria for OCD, from outpatient and inpatient clinics	Cross-sectional	USA and Netherlands	Participants asked if OCD onset coincided with pregnancy, after childbirth, or menopause, and to assess the severity (none, mild, moderate, severe) of change in preexisting OCD symptoms	Minimum of 12 mo of amenorrhea; natural or surgical menopause	7/187 (3.7%) of women without preexisting OCD reported OCD onset during menopause Of those with OCD, 56/171 (32.7%) reported an exacerbation, 94/171 (46.7%) no change, and 21/171 (12.2%) improvement in symptoms with the onset of menopause Of participants reporting exacerbation in symptoms, 44.6% (n = 25) considered this change to be severe
Labad et al4	To assess retrospective reporting of the impact of menopause onset on OCD symptoms	46 female outpatients meeting DSM-IV criteria for OCD (12 participants in perimenopause or postmenopause; mean age at menopause 46.9 y; 0 participants on hormone replacement therapy)	Cross-sectional	Spain	Participants asked about onset of OCD or changes in OCD symptoms (worsening, improvement, or no changes) at reproductive cycle events including perimenopause and menopause, through semistructured interview	Natural menopause or surgical menopause; age at menopause reported by participant in semistructured interview	1/11 (9%) postmenopausal participants experienced onset of OCD diagnosis with onset of menopause 1/12 (8%) perimenopausal or postmenopausal participants experienced worsening of preexisting OCD at menopause
Lochner et al18	To investigate the role of sex in OCD	89 females with OCD aged 18-75 y (18 postmenopausal) c meeting DSM-IV criteria for OCD from the community	Cross-sectional	South Africa	Impact of menstrual/reproductive cycle changes on OCD symptom fluctuation assessed using semi-structured questions	Definition not reported Self-reported (retrospective assessment)	5/18 (27.8%) of postmenopausal women indicated their OC symptoms started with the onset of menopause
Paul et al8	To study the prevalence of reproductive events among women with OCD in comparison with those in men with OCD	92 femalec outpatients meeting DSM-IV criteria for OCD	Cross-sectional	India	Women were asked about onset of OCD or changes in OCD symptoms (nature and severity) in relation to perimenopause or menopause during assessment with first or second author	Minimum of 12 mo of amenorrhea Participants’ recollection of events was validated using anchoring points on a calendar and corroboration by accompanying family member	1/92 (1.08%) of femalesb reported the occurrence of menopause in the year preceding onset of OCD
Uguzet et al19	To examine the prevalence rate, clinical features, related factors, and comorbidity of OCD in postmenopausal women	269 postmenopausal women (mean age at menopause 46.5 y; 21.2% surgical menopause; 7.4% taking hormone replacement treatment) in gynecology outpatient clinic (19 meeting DSM-IV criteria for OCD; 63.2% with comorbid mood/anxiety disorder), mean duration of postmenopausal period 46.6 mo	Cross-sectional	Turkey	Course of preexisting OCD and onset time of OCD were determined based on retrospective reports given by the participants	Minimum of 12 mo of amenorrhea and serum hormonal levels; natural or surgical menopause Menopause assessed through retrospective assessment (last menstrual period)	2/19 (10.5% of OCD participants) reported that their OCD began within the first 6 mo of the postmenopausal period 5/17 (29.4%) participants with preexisting OCD before menopause described exacerbation of symptoms during postmenopause, 8/17 (47.1%) a decrease in OCD symptoms, and 4/17 (23.5%) no change
Vulink et al20	To assess retrospective reporting of the impact of reproductive events, including menopause onset, on OCD symptoms	350 female outpatients (19 postmenopausal) meeting DSM-IV criteria for OCD	Cross-sectional	The Netherlands	Participants assessed the severity of change of their OCD symptoms (absent, little, moderate, severe) during menopause through questionnaire	Minimum of 12 mo of amenorrhea Self-reported (retrospective assessment)	9/19 (47.4%) postmenopausal participants reported an exacerbation of OCD symptoms with the onset of menopause, 9/19 (47.4%) no change, and 1/19 (5.3%) improvement

DSM, Diagnostic and Statistical Manual of Mental Disorders; OC, obsessive-compulsive; OCD, obsessive-compulsive disorder; USA, United States of America.

^a Describes how the study investigators measured new onset OCD or change in symptoms in individuals with preexisting OCD before menopause.

^b Unclear how many participants were in perimenopause or postmenopause stages.

^c The sample for analyses relevant to this review is reported.

Relationship between menopause and obsessive-compulsive disorder

Across 6 studies reporting on the onset of OCD, a total of 17 out of 373 participants (4.6%) reported that the initial appearance of their OCD symptoms had coincided with the onset of menopause, with study-specific rates ranging from 2.2% to 27.8% (Fig. 2). Across 6 studies reporting on the change in symptom severity with the onset of menopause, a total of 72 out of 265 participants (27.2%) reported an exacerbation of their symptoms with the onset of menopause (study-specific proportions ranging from 2.2% to 47.4%). In contrast, a total of 30 out of 265 (11.3%) reported an improvement in symptoms with the onset of menopause (study-specific proportions ranging from 0% to 47.1%).

FIG. 2.

Self-reported impact of menopause on OCD symptom onset and severity. OCD, obsessive-compulsive disorder.

DISCUSSION

OCD is a debilitating psychiatric disorder that has significant impacts on quality of life and functioning. This study is the first scoping review to systematically identify and map the existing literature on the potential association between menopause and OCD. We found that OCD was rarely (4.6%) reported to first appear with the onset of menopause; however, an exacerbation of OCD symptom severity with menopause onset in those with an established diagnosis was commonly reported (27.8% across all studies). A smaller but notable proportion of participants (11.3%) reported that their symptoms improved with the onset of menopause.

By suggesting that the onset of menopause may change OCD symptom severity, this study adds to the current evidence identifying the onset of menarche and perinatal period as times of potential OCD exacerbation.⁴,⁵,⁶,⁷ This is valuable information for clinicians who care for mid-life women with an established OCD diagnosis, suggesting that increased monitoring of symptoms may be warranted to facilitate early intervention. First-line treatments for OCD include cognitive behavior therapy and selective serotonin reuptake inhibitors (SSRIs)^22,23—changes in treatment intensity or dosage may be warranted in some women with the onset of menopause.

Current evidence suggests that estradiol and progesterone modulate neurotransmission in serotonergic, dopaminergic, and glutamatergic neurotransmitter systems, all of which are implicated in the pathophysiology of OCD.^2,24,25 Specifically, estradiol and progesterone may be associated with improved OCD symptoms by enhancing serotonin signaling, while the impact of ovarian hormones on dopaminergic and glutamatergic systems is less clear.²⁴ The finding that over one in 4 women with OCD reported a worsening of symptoms with the onset of menopause is consistent with this neuroprotective effect of estradiol and progesterone given that menopause is accompanied by an overall decline in ovarian hormones. Then again, the observation that a subset of participants reported an improvement in OCD symptoms is not altogether surprising given that the perimenstrual phase of the menstrual cycle has been associated with an exacerbation of OCD symptoms^4,20—the elimination of cyclical ovarian hormone changes across the menstrual cycle may eliminate these perimenstrual exacerbations in some, resulting in an overall improvement in OCD symptoms.

While this scoping review was based on the theory that hormonal changes that occur with the menopause transition (an event unique to individuals born with ovaries) could influence vulnerability to OC symptoms during reproductive life events, other biological and sociocultural factors might contribute to previously reported sex differences in risks for and presentation of OCD across the life course.²⁶ Differences in the age of onset and symptom types observed between women and men suggest that while hormonal factors likely contribute to observed sex differences in OCD presentation, other biological and sociocultural factors likely also contribute to sex differences in OCD. For example, on average, women experience a later age of onset of OCD symptoms than men.² However, before puberty, boys are at greater risk of developing OCD, suggesting that hormones are a critical driver of sex differences in age at OCD onset.²⁷ Pregnancy and the postpartum period also represent important periods of vulnerability associated with new onset OCD^6,7 and, therefore, reinforce the potential role of hormones, but also suggest that the increased responsibility associated with caring for a new child may be a contributor to OCD—the latter of which can also explain new onset OCD in the nonbirthing parent (eg, father) during the postpartum period.²⁸ Contamination obsessions and impulse control symptoms (eg, compulsive buying) are more prevalent in women than among men, which is believed to be due to a complex interplay of biological, psychological, and sociocultural factors associated with the female role in various societies.²⁶ Familiality is strongest for contamination and hoarding symptoms, with research suggesting that both genetics (heritability) and shared environmental factors or “learning” of these behaviors may contribute to prominence of OCD symptom types.^29,30

Knowledge gaps and areas for future research

The results of this scoping review identify several limitations in the existing research on OCD and menopause. First, potential symptom changes during the menopause transition were not assessed in any of the included studies. Studies either compared OCD symptoms in postmenopausal women to those of premenopausal women¹⁷ or retrospectively asked women about symptoms in relation to menopause, which was either not clearly defined in the study,^4,18,21 described as the last menstrual period,¹⁹ or defined as 12 months of amenorrhea.^5,8,20 None of the studies assessed menstrual bleeding patterns with sufficient detail to identify the menopause transition, which is associated with perhaps the most erratic ovarian hormone patterns and has been found to be most strongly associated with mental health outcomes such as depressive symptoms.³¹ Since studies were conducted among postmenopausal women and relied on retrospective recall of OC symptoms, it may be that the time associated with peak vulnerability is not captured in the studies included in this review.

Furthermore, all identified studies used retrospective participant self-report to measure the timing of OCD symptom onset and changes in OCD symptom severity in relation to menopause, an approach that is subject to recall bias.³² Future research using prospective study designs that follow at risk individuals from the reproductive life stage through the perimenopausal period could contribute to current understanding of this association by characterizing different stages of reproductive aging, including the menopause transition. In addition, prospective longitudinal assessments of OCD symptoms using validated measures or clinical assessment would reduce propensity for recall bias that is likely to be present in existing studies.

This review did not identify any studies examining characteristics of menopause such as age at natural menopause, type of menopause, stage of menopause, or vasomotor symptoms in relation to OCD. Studying associations between these factors and OC symptoms may represent an important avenue for future research, as other epidemiologic literature has identified important relationships between such characteristics and chronic disease risk^33,34 and such research may help identify who is at highest risk of experiencing new onset or worsening OC symptoms at menopause.

In addition, none of the studies included in this review assessed sex hormone levels in relation to OC symptoms, despite recognition that hormone fluctuations are likely to be the underlying mechanisms linking reproductive cycle events with changes in OC symptoms.^24,31 Relatedly, a limitation of prior research on this topic is the lack of consideration of treatment for menopause symptoms, such as hormone replacement therapy, which works by stabilizing hormone levels and could therefore reasonably impact OC symptoms, which literature suggests may be modulated by estradiol and progesterone.^3,24,25 Indeed, the efficacy of hormone replacement therapy in treating depression among perimenopausal and postmenopausal women is conflicting across studies, but may be beneficial at alleviating depressive symptoms when onset coincides with menstrual irregularity;³⁵ therefore, future research should consider the possible impact of hormone replacement therapy on OC symptoms or onset when examining OC symptom onset or exacerbation associated with menopause.

Other factors rarely considered in prior literature and not reported with sufficient detail to make meaningful conclusions with respect to such factors include medications participants were using for OCD, menopause symptoms, or other indications, as well as the presence of comorbid conditions, such as mood and anxiety disorders or neurodevelopmental conditions, that commonly co-occur alongside OCD and could impact symptom severity.³⁶ Comorbid psychiatric disorders are associated with both severity and with distinct types of OCD symptoms and therefore warrant further consideration in future research as possible moderators of OC symptoms during the menopause transition and other reproductive life events.^37,38 Further, differences in OC symptomatology based on race,³⁹ ethnicity,⁴⁰ or cultural subgroups⁴¹ were not considered in prior literature—important limitations of prior work considering their influence on the presentation of OCD symptoms and implications for treatment. Future research exploring these as additional explanatory or moderating factors in the context of menopause is warranted to advance understanding of OC symptom onset or changes associated with reproductive life events.

Strengths and limitations

This scoping review likely captured most research studies on the association between OCD and menopause. However, our search results indicated that there is a broader literature examining OC symptoms in different population subgroups among postmenopausal individuals, which was not included in this review. For example, Zhang⁴² compared mental health symptoms in menopausal individuals with and without osteopenia. Other literature picked up by our search examined OC symptoms in relation to lifestyle interventions to treat menopausal symptoms or treatment for chronic conditions other than OCD.^43,44 While our search retrieved such studies, these studies did not meet our prespecified inclusion criteria because they did not explicitly examine menopause as an exposure which could induce, exacerbate, or otherwise influence OC symptoms. Therefore, we excluded them from our review but acknowledge that such literature exists.

Our search strategy was developed in consultation with a reference librarian and included searching several library databases, as well as forward and backward citation chaining. Despite this robust approach, it is possible that we missed some relevant literature on the topic. Furthermore, our review was limited to English language studies, meaning we may have missed relevant literature published exclusively in other languages. Despite these limitations, our findings are valuable for clinicians treating individuals in perimenopause as well as for researchers interested in reproductive life events and OCD.

CONCLUSIONS

OCD appears to be influenced by reproductive life events such as menarche, pregnancy, and the postpartum period; however, literature examining OCD in relation to perimenopause is scarce. Furthermore, existing research has been in small samples and relied on retrospective recall reports, which are subject to information bias. Future research is warranted, especially using prospective study designs, objective measures of stages of reproductive aging, and valid measures of OCD symptoms to further characterize the relationship between perimenopause and OCD.

Supplementary Material

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