Reconstruction of past changes in monsoon climate from speleothem oxygen isotope (δ18O) records is complex because δ18O signals can be influenced by multiple factors including changes in precipitation, precipitation recycling over land, temperature at the moisture source, and changes in the moisture source region and transport pathway. Here, we analyse > 150 speleothem records of the Speleothem Isotopes Synthesis and AnaLysis (SISAL) database to produce composite regional trends in δ18O in monsoon regions; compositing minimises the influence of site-specific karst and cave processes that can influence individual site records. We compare speleothem δ18O observations with isotope-enabled climate model simulations to investigate the specific climatic factors causing these regional trends. We focus on differences in δ18O signals between the mid-Holocene, the peak of the Last Interglacial (Marine Isotope Stage 5e) and the Last Glacial Maximum as well as on δ18O evolution through the Holocene. Differences in speleothem δ18O between the mid-Holocene and the Last Interglacial in the East Asian and Indian monsoons are small, despite the larger summer insolation values during the Last Interglacial. Last Glacial Maximum δ18O values are significantly less negative than interglacial values. Comparison with simulated glacial–interglacial δ18O shows that changes are principally driven by global shifts in temperature and regional precipitation. Holocene speleothem δ18O records show distinct and coherent regional trends. Trends are similar to summer insolation in India, China and southwestern South America, but they are different in the Indonesian–Australian region. Redundancy analysis shows that 37 % of Holocene variability can be accounted for by latitude and longitude, supporting the differentiation of records into individual monsoon regions. Regression analysis of simulated precipitation δ18O and climate variables show significant relationships between global Holocene monsoon δ18O trends and changes in precipitation, atmospheric circulation and (to a lesser extent) source area temperature, whereas precipitation recycling is non-significant. However, there are differences in regional-scale mechanisms: there are clear relationships between changes in precipitation and δ18O for India, southwestern South America and the Indonesian–Australian regions but not for the East Asian monsoon. Changes in atmospheric circulation contribute to δ18O trends in the East Asian, Indian and Indonesian–Australian monsoons, and a weak source area temperature effect is observed over southern and central America and Asia. Precipitation recycling is influential in southwestern South America and southern Africa. Overall, our analyses show that it is possible to differentiate the impacts of specific climatic mechanisms influencing precipitation δ18O and use this analysis to interpret changes in speleothem δ18O.