The impact of hormonal changes on Functional Neurological Disorder: An International Online Survey

IntroductionFunctional Neurological Disorder (FND) affects women approximately three times more often than men. This disparity has largely been attributed to higher trauma prevalence and diagnostic bias, while the potential contribution of hormonal influences has received little attention. MethodsAn online questionnaire was distributed through FND clinics in thirteen countries, assessing self-reported symptom change across five hormonal events: hormonal contraception, pregnancy, the menstrual cycle, menopause, and gender-affirming hormone therapy. Eligible participants were cisgender women with a diagnosis of FND, or gender minority individuals (transgender or non-binary). Perceived symptom change was rated on a five-point scale ranging from large improvement to large worsening. ResultsAmong 262 respondents (96% female; mean age 39 years), several hormonal contexts were associated with self-reported symptom changes. Overall, hormonal contraception and pregnancy were frequently associated with worsening of motor and cognitive symptoms, and menopause with worsening across all symptom domains. Menstrual cycle analysis revealed a phase-dependent pattern: worsening was most frequently reported during menstruation and the luteal phase, whereas improvement was most frequent during the follicular phase. Reported changes were not uniform, with a substantial proportion of participants describing no change or improvement. ConclusionSelf-reported FND symptom severity appears to vary with hormonal context, with motor and cognitive symptoms most consistently affected. Given the retrospective, self-report design, these findings are hypothesis-generating and support prospective research into the role of hormonal transitions in FND. What is already known on this topicFND affects women around three times more often than men, a disparity usually attributed to trauma exposure and diagnostic bias. Sex hormones modulate neural excitability and are established drivers of symptom variation in migraine, epilepsy and affective disorders, yet their relationship to FND symptom expression has not been systematically examined, leaving clinicians little evidence when patients ask how contraception, pregnancy or menopause might affect them. What this study addsWe surveyed 2c2 people with FND internationally, who reported that symptoms varied with hormonal events, with motor and cognitive symptoms most consistently affected and a phase-dependent pattern across the menstrual cycle. Responses were heterogeneous rather than uniform, with a substantial proportion reporting no change or improvement in every context. How this study might affect research, practice or policyHormonal context may warrant consideration in FND assessment, and transitions such as pregnancy and menopause may merit closer monitoring and recognition at onset of FND symptoms. The heterogeneity observed argues against prognostic generalisation to individual patients. Prospective studies with objective hormonal measures are needed to establish whether these associations reflect hormonal mechanisms, broader sensitivity to physiological change, or recall effects.