Bloody Hell: Menstruation and the Challenges it Presents to Girls with ASD

Menstruation is a natural process which can present unique challenges for people with ASD. Given the neurodevelopment and physiological factors as explored during this piece, a greater understanding is needed to support girls and women with ASD. As it is now known, autism spectrum disorder, or ASD, is defined by the World Health Organisation as a diverse group of conditions characterised by some degree of difficulty with social interaction and communication, with atypical patterns of activities and behaviours [1]. It is important to emphasise that whilst people with ASD have a single unifying diagnosis, it is not a case of one size fits all – ASD is after all, a spectrum, and the lived experiences of people with a diagnosis of ASD will vary from one person to the next. ASD is now a relatively common condition, with prevalence currently sitting at around 1.1% in the UK, compared to the previous 1978 estimate of approximately 0.04% [2]. ASD has had its moments in the media spotlight as of late, with conversations about over-diagnosis and waiting lists being examined by both physicians and the public. Whilst debates rage on, the reality of ASD is that whilst there is a rapid expansion of education linked to the condition, there is an increasing proportion of both adults and children falling through the healthcare and research cracks: One systematic review reports that up to 66% of autistic people had suicidal ideation [3]. Another study explains that autistic females are more likely to have cardiovascular conditions, respiratory conditions, asthma, low blood pressure, arrhythmias and prediabetes than non-autistic females, attributed to behavioural differences and systemic issues. [4]. Examination of such information points towards significant difficulties for autistic people concerning healthcare and wellbeing. 

Diagnosing women and girls with ASD

In recent years, more researchers and clinicians are stressing difficulties in diagnosing ASD in female patients compared to their male counterparts [5,6]. A systematic review involving over 23,000 participants differentiated such barriers into two key areas – symptoms and behaviours, and perceived barriers to diagnosis (figure 1) [7].

Figure 1: Flow chart highlighting barriers to diagnosis for girls and women with ASD [7]. 

Another qualitative study, which interestingly studied 9 healthcare professionals’ perspectives on assessing autism in girls, identified that ‘many professionals either held, or were of, views which saw autism presentation as inherently gendered’. The author explains that this was often phrased as girls deviating from male norm. Somewhat reassuringly, despite concerns of disparities between genders, a 2021 study has highlighted that female diagnoses since 2000 have increased at a far faster rate than male. They attribute this to a ‘drive toward referral of more females’ (figure 2) [9].

Figure 2: graph representing percentage increase in diagnosis of ASD, comparing male and female incidents from 1998 to 2018 [9].

Initially, it may seem that this information is contradictory – it appears there is a struggle to diagnose women and girls, and yet the number of diagnoses attributed to the female gender is increasing at a greater rate than the male gender. Consolidating these two perspectives, it emphasises that clinicians are becoming more adept at recognising the presentation of autism in girls (particularly masking of symptoms [9]). The recognition of such characteristics in larger numbers has simultaneously led to a greater group of women or girls who were previously deemed neurotypical and have been potentially misdiagnosed in the past – many of whom may still struggle with symptoms and a lack of support as a result. On reflection, progress has been significant, yet this subsequently creates a need for rapid growth of assessment availability and support to women and girls.

Wider views on menstruation 

The word ‘period’ has long since been making people blush. In a way not too dissimilar to the taboo surrounding ASD, there is a real, almost tangible taboo around menstrual cycles within the wider public. During menstrual cycle education at school, girls said that they preferred same-sex education, small group teaching to reduce awkwardness and that they found education by male teachers lacked knowledge and confidence and they also displayed discomfort during menstrual education. One student said, ‘because they make fun of it [menstruation], some people don’t change [period products] in school’ [10]. If discussions around period health generate such embarrassment in neurotypical populations, it is plain to see that those with ASD might find such education and the following conversations it entails more challenging. A report interviewing 136 autistic adults showed that healthcare professionals (during consultations focused on sexual health) do not accommodate sensory needs, communication preferences and are unaware of the impacts of ASD on reproductive and sexual health [11]. As previously mentioned, a possible lack of understanding of ASD by neurotypical populations (and also possibly from within neurodivergent communities too), compounded with the concurrent taboo regarding menstruation, leaves girls with a diagnosis of ASD who are having periods in a worrying isolation. 

Menstruation as a girl with ASD

Menstruation and periods are widely known as being hugely variable from girl to girl. Cycle length, heaviness, pain or no pain – there is no one-size-fits-all view on periods. However, some similar elements of periods can present challenges to girls with ASD. 

As outlined previously in WHO’s definition, ASD can come with varying reactions to sensory experiences. A survey on women and girls with autism found that it became harder to regulate responses to sensory overwhelm whilst menstruating. This was widespread across all senses, with respondents commenting that it was more difficult to manage pain; sensitivity to smell increased; touch and skin in general was more sensitive and that they struggle to block out excessive noise as opposed to when they are not on their period [12]. Furthermore, whilst just menstruating within itself presents significant sensory challenges, period products add another layer of sensory discomfort to autistic girls. Research on this topic is significantly limited, but one study has elicited that there is little consensus on a preferred product. Disposable sanitary pads are generally disliked due to the skin contact and their bulky nature. Similarly, tampons and menstrual cups are not preferred due to internal application frequently being associated with pain and discomfort. The study suggests reusable sanitary pads and period underwear as acceptable alternatives [13]. There are currently no period products tailored to, or targeted at, girls with autism. 

Further to this, many techniques used by neurotypical women and girls who have periods may be largely inaccessible or overstimulating to girls with autism. For example, it is estimated that 50 million women world-wide use period tracking apps [14]. Whilst period tracking is widely regarded as beneficial, one of the most popular period tracking apps, Flo, can require up to 15 pieces of information to be inputted per day, including mood, sex drive, discharge and physical activity. Within each of these subsections, there can be up to 13 options to pick from. This can be overstimulating, confusing and time-consuming for neurodivergent and neurotypical people alike, but with many autistic people self-reporting struggles in decision-making [15], such apps seem to present another difficulty for women and girls with autism. 

Lastly, an element of ASD diagnosis which is becoming more widely recognised is emotional dysregulation. Defined as difficulties in effectively regulating one’s own emotions in response to a changing environment [16], emotional dysregulation has been linked to co-occurring mental health conditions and occurs at around 4 times higher rates in people with ASD compared to neurotypical peers [16]. As was explored in an aforementioned survey, women and girls highlighted increased problems with emotional regulation in the luteal phase (immediately before menstruation) and during menstruation [12]. One participant describes that ‘understanding my own emotions has always been difficult for me so any mood swings made life even more difficult’ [12]. Difficulties in regulating emotions already has significant daily impacts on women and girls with autism, and this is aggravated by hormonal changes and mood swings, particularly leading up to and throughout menstruation.

Menstrual abnormalities 

Menstrual cycle abnormalities are receiving increasing exposure in the healthcare world. These include menorrhagia (heavy periods), dysmenorrhea (painful periods) and long periods. The incidence of period irregularities varies greatly by location and age, and it’s hard to pin down a number for the amount of women who experience abnormal periods. However, the impact of such irregularities cannot be understated: a 2020 prospective cohort study found that women with irregular menstruation were associated with greater risk of premature mortality [17]. With period irregularities causing not only day to day discomfort, but also worse health outcomes, there may be a need for women and girls to seek medical advice. Yet, this again poses additional challenges for women and girls with autism. Everything about booking, attending and following up a primary care appointment can be difficult, including complex booking systems, jargon during consultations and struggle to access secondary care [18]. From a physician perspective, there is also a lack of personalisation of appointments for patients with ASD, with some practitioners assuming every person with ASD needs a face-to-face appointment, rather than asking the patient their preference [18]. 

Presenting to GPs already poses a challenge, yet the question arises of whether women and girls with autism are able to identify what is abnormal with their periods, both for their own cycles and also within medical boundaries. Medical information is generally disseminated through websites and leaflets, often using complicated medical language and with word-heavy styles and this information can be inaccessible for neurodivergent populations. A common way that women and girls normalise periods is through conversation – discussions and comparisons with friends about cycles. Yet this can continue to exclude girls with ASD, who sometimes struggle to maintain friendships and get lost in social interactions due to misunderstanding of social cues [19]. 

Next steps

As discussed throughout this essay, it is becoming more obvious that for a girl with ASD who is having periods, there are many more elements to managing them which result in difficulty when compared to neurotypical patients. These start right from receiving a diagnosis, to normal versus abnormal menstruation and accessing medical advice. Whilst it is proven that research has been completed into some niche areas of this topic, there is a genuine need for not only research teams, but also physicians, to examine current healthcare practices holistically and to work on improving their care for girls with ASD once they begin, and throughout, menstruation. Currently, the NHS has accessibility standards which are applicable to people with disability, impairment and sensory loss. This includes making information more accessible and improving access to services [19]. However, there is not currently any specific advice or guidance for either healthcare professionals, or service users with ASD, to make healthcare tailored to their needs. Establishing clearer communication, creating routines and adapting environments to support sensory requirements are just some suggestions of how to improve consultations for patients with ASD, and these are really seen in practice. It is key to remember that whilst a woman or girl may have a diagnosis of ASD, this does not mean they will all present the same or have the same needs. 

With neurodivergence and ASD gaining further understanding and exposure, now is a pivotal and key time to assess whether medicine is meeting such patients’ needs, and how we can get this right moving forward.

References

1. WHO. Autism Spectrum Disorders [Internet]. World Health Organization. World Health Organization; 2023 [cited 2025 Aug 27]. Available from: https://www.who.int/news-room/fact-sheets/detail/autism-spectrum-disorders

2.  Pilling S, Baron-Cohen S, Megnin-Viggars O, Lee R, Taylor C. Recognition, referral, diagnosis, and Management of Adults with autism: Summary of NICE Guidance. BMJ [Internet]. 2012 Jun 27 [cited 2025 Aug 27];344(jun27 1):e4082–2. Available from: https://www.bmj.com/content/344/bmj.e4082

 3. Hedley D, Uljarević M. Systematic Review of Suicide in Autism Spectrum Disorder: Current Trends and Implications. Current Developmental Disorders Reports [Internet]. 2018 Jan 18 [cited 2025 Aug 27];5(1):65–76. Available from: https://link.springer.com/article/10.1007/s40474-018-0133-6

4. Weir E, Allison C, Warrier V, Baron-Cohen S. Increased prevalence of non-communicable physical health conditions among autistic adults. Autism. 2020 Sep 9;25(3):136236132095365.

5. Hutson J. Autism in Females Understanding the Overlooked Diagnoses Unique Challenges and Recommendations. Journal of Clinical and Medical Images Case Reports. 2023 Jun 6;3(3).

6. Young H, Oreve MJ ., Speranza M. Clinical characteristics and problems diagnosing autism spectrum disorder in girls. Archives de Pédiatrie [Internet]. 2018 Aug;25(6):399–403. Available from: https://www.sciencedirect.com/science/article/abs/pii/S0929693X18301477

7. Lockwood Estrin G, Milner V, Spain D, Happé F, Colvert E. Barriers to Autism Spectrum Disorder Diagnosis for Young Women and Girls: a Systematic Review. Review Journal of Autism and Developmental Disorders [Internet]. 2021 Oct 29;8(8):454–70. Available from: https://link.springer.com/article/10.1007/s40489-020-00225-8?wt_mc=Internal.Event.1.SEM.ArticleAuthorOnlineFirst&utm_source=ArticleAuthorOnlineFirst&utm_medium=email&utm_content=AA_en_06082018&ArticleAuthorOnlineFirst_20201030&error=cookies_not_supported&code=c240a368-71e6-4971-80ee-93ca04ac4302

8. Russell G, Stapley S, Newlove‐Delgado T, Salmon A, White R, Warren F, et al. Time trends in autism diagnosis over 20 years: a UK population‐based cohort study. Journal of Child Psychology and Psychiatry [Internet]. 2022 Aug 19;63(6):674–82. Available from: https://acamh.onlinelibrary.wiley.com/doi/10.1111/jcpp.13505

9. Brown N, Forrest LJ, Williams R, Piasecki J, Bruinvels G. “Everyone needs to be educated”: pupils’ voices on menstrual education.. PubMed. 2024 Aug 20;21(1):121–1

10. Richard, Mosely R, Gamble-Turner J, Hull L, Sedgewick F, Featherstone C, et al. Unmet need for autism-aware care for gynaecological, menstrual and sexual wellbeing. Autism. 2024 Oct 15;29(4).

11. Steward, Robyn, et al. ““Life Is Much More Difficult to Manage during Periods”: Autistic Experiences of Menstruation.” Journal of Autism and Developmental Disorders, vol. 48, no. 12, 7 July 2018, pp. 4287–4292, link.springer.com/article/10.1007%2Fs10803-018-3664-0, https://doi.org/10.1007/s10803-018-3664-0.

12. McCulla Lundy, Keely . Young Autistic Menstruators’ Product Preferences and Caregivers’ Buying Influences . May 2024.

13. Kelly, Bridget G., and Maniza Habib. “Missed Period? The Significance of Period-Tracking Applications in a Post-Roe America.” Sexual and Reproductive Health Matters, vol. 31, no. 4, 8 Sept. 2023, https://doi.org/10.1080/26410397.2023.2238940.

14. Vella, Lydia, et al. “Understanding Self-Reported Difficulties in Decision-Making by People with Autism Spectrum Disorders.” Autism, vol. 22, no. 5, 20 Apr. 2017, pp. 549–559, https://doi.org/10.1177/1362361316687988.

15. McDonald, Rachel G, et al. “Emotion Dysregulation in Autism: A Meta-Analysis.” Autism, vol. 28, no. 12, 30 July 2024, https://doi.org/10.1177/13623613241257605.

16. Wang, Yi-Xin, et al. “Menstrual Cycle Regularity and Length across the Reproductive Lifespan and Risk of Premature Mortality: Prospective Cohort Study.” BMJ, vol. 371, 30 Sept. 2020, www.bmj.com/content/371/bmj.m3464, https://doi.org/10.1136/bmj.m3464.

17. Chown, Nick, et al. “Healthcare Barriers, Health Outcomes, and Annual Health Checks for Autistic Adults: A Cross-Sectional Study of General Practitioners’ Knowledge, Attitudes and Practices.” Canadian Journal of Educational and Social Studies, vol. 2, no. 4, 1 July 2022, pp. 179–199, sro.sussex.ac.uk/id/eprint/106928/, https://doi.org/10.53103/cjess.v2i4.57. Accessed 2 Sept. 2022.

18. Cook, Anna, et al. “Friendship Motivations, Challenges and the Role of Masking for Girls with Autism in Contrasting School Settings.” European Journal of Special Needs Education, vol. 33, no. 3, 11 Apr. 2018, pp. 302–315, www.tandfonline.com/doi/full/10.1080/08856257.2017.1312797, https://doi.org/10.1080/08856257.2017.1312797.

19. England, NHS. “NHS England» Accessible Information Standard – Requirements (DAPB1605).” England.nhs.uk, 2025, www.england.nhs.uk/long-read/accessible-information-standard-requirements-dapb1605/.