Approximately 50% of the world’s population will menstruate during their lifetime, but for many, this normal physiological experience can pose immense challenges. The impact of menstruation extends far beyond the common cramps, cravings, and mood swings. This natural process is deeply interwoven with our psychological well-being and the distress we may experience can be profoundly confounded by existing mental health conditions. Not only can menstruation exacerbate psychological symptoms, but various psychiatric disorders can also influence the menstrual cycle itself. Shedding light on the intricately dynamic relationship between menstruation and mental well-being will empower us to better support ourselves and others through a compassionate lens.
The menstrual cycle involves a multitude of hormonal, physical, and emotional changes that vary greatly during different phases. Further, growing research has pointed to menstrual cycle-dependent variations in psychological symptoms that most often occur directly prior to and during menstruation. [5] Fluctuating hormone levels throughout the menstrual cycle are suggested to be a potential driving force behind the impacts of menstruation on mental well-being.[7] These psychological changes may also be attributed in part to the distress associated with experiencing physical discomfort and the existence of stigmatized views surrounding menstruation.
To understand how hormonal changes may play a role, let’s first go over a brief breakdown of what these fluctuations look like, on average, throughout the menstrual cycle.
Figure 1. The cyclical patterns of estrogen (teal) and progesterone (dark blue) levels across the menstrual cycle. [2]
There are two major phases that make up the menstrual cycle: the follicular phase and the luteal phase. [5]
Follicular Phase - menstruation to ovulation (first half of cycle)
As you can see on the figure above, the relative levels of estrogen and progesterone are quite low during menstruation. However, just before ovulation, estrogen levels spike in preparation for an egg to be released.
Luteal Phase - ovulation to menstruation (second half of cycle)
After ovulation, estrogen levels drop. As the uterus prepares for a potential pregnancy, progesterone levels increase and a moderate amount of estrogen continues to be produced. If the egg is not fertilized, estrogen and progesterone levels will drop and remain low into menstruation.
Premenstrual Syndrome (PMS) & Premenstrual Dysphoric Disorder (PMDD)
Premenstrual syndrome (PMS) describes the physical and emotional symptoms experienced prior to menstruation. At some point in their lifetime, 3 in 4 women have experienced symptoms of PMS which include cramping, swollen or tender breasts, bloating, irritability, appetite changes, and mood swings.[9] The drop in estrogen and progesterone levels leading up to menstruation are thought to be responsible for these characteristic symptoms.[6] In fact, PMS symptoms tend to dissipate a few days after a period begins when hormone levels start to creep up again.[9]
Similarly to PMS, the onset of premenstrual dysphoric disorder (PMDD) occurs during the luteal phase leading up to menstruation when hormone levels start to fall. However, PMDD is a recognized condition in the DSM-5 that evokes more severe symptoms and causes significantly greater impairment to affected individuals. Along with the common physical symptoms of PMS, about 5% of women will experience strong feelings of despair (including potential suicidal thoughts), anxiety and panic attacks, lasting irritability, frequent mood swings, and feeling out of control.[8]
Overall, there is a higher prevalance of premenstrual disorders in those who experience high levels of stress or have a history of depression, indicating some interaction between psychiatry and menstrual experience.[9] In addition, depression and anxiety disorders are common comorbidities with PMS and PMDD.[8, 9]
Dynamic Cycle, Dynamic Symptoms
Research has demonstrated an intensification of the psychological manifestations of psychosis, depression, suidicial behaviour, anxiety disorders, and substance use during menstruation.[5] Pre-existing mental health conditions not only have the capacity to be exacerbated directly, but may also be influenced by the emotional symptoms commonly experienced as a result of menstruation. A meta-analysis indicates that throughout the menstrual cycle, serious mental health outcomes are most notably associated with menstruation, including a 26% increased risk of death by suicide during this time.[7]
I’ve outlined how the aggravation of different mental health conditions is linked to hormonal fluctuations during the menstrual cycle, but how and why does this connection exist? The piece tying the two together lies in the mediating effects of estrogen and progesterone on our neurochemistry. These ovarian hormones have the ability to modulate various neurotransmitters, which are implicated across many psychiatric conditions.[1] Estrogen regulates serotonin by encouraging its production and preventing reuptake, which elevates serotonin availability.[4] Low serotonin levels are linked to mood disorders, including depression and bipolar disorder. Similarly, estrogen may also increase dopamine synthesis and hinder its re-uptake to improve dopamine availability.[4] Low dopamine levels are seen in various conditions, such as ADHD, schizophrenia, and binge eating disorder. Progesterone works alongside estrogen to modify our neurochemistry and can exert anti-anxiety effects through the neurotransmitter GABA.[5] All in all, estrogen and progesterone can have protective psychological benefits by enhancing neurotransmitter availability. Thus, it is understandable that when hormone levels take a dive during menstruation, the symptoms of numerous psychiatric conditions characterized by neurotransmitter deficits are amplified.
The Mind-Body Connection
Our minds undoubtedly influence our bodies across a multitude of domains. In terms of menstruation, mental well-being has the capacity to alter characteristics of the menstrual cycle. It is widely understood that stress has profound impacts on our physiology, with menstruation being no exception. Experiencing stress may shorten or delay menstruation and could lead to more painful periods.[3] Furthermore, the duration and regularity of your menstrual cycle is significantly associated with the presence of various psychiatric disorders.[1] More specifically, women who experience shorter menstrual cycles have up to double the risk of exhibiting a mood disorder, anxiety disorder, or substance use disorder at some point throughout their life.[1]
Menstruation and mental health are deeply interconnected and understanding this relationship is integral in fostering a more supportive and empathetic environment where we can feel empowered to prioritze our psychological well-being throughout the menstrual cycle. Menstruation isn’t merely a physical process but is a journey that impacts both the body and mind through hormonal and physiological changes. Encouraging conversations surrounding mental health as it pertains to menstruation brings us one step closer to ensuring that no one feels alone when navigating the impacts of this natural process.
References
Barron, M. L., Flick, L. H., Cook, C. A., Homan, S. M., & Campbell, C. (2008). Associations between psychiatric disorders and menstrual cycle characteristics. Archives of Psychiatric Nursing, 22(5), 254–265. https://doi.org/10.1016/j.apnu.2007.11.001
Boutot, M. (2018). Hormone changes in an average cycle. Clue. Retrieved July 23, 2023, from https://helloclue.com/articles/cycle-a-z/the-immune-system-and-the-menstrual-cycle.
Broster, A. (2020). How your mental health & menstrual cycle are linked. Forbes. https://www.forbes.com/sites/alicebroster/2020/07/09/how-your-mental-health--menstrual-cycle-are-linked/?sh=698714146370
Del Río, J. P., Alliende, M. I., Molina, N., Serrano, F. G., Molina, S., & Vigil, P. (2018). Steroid hormones and their action in women’s brains: The importance of hormonal balance. Frontiers in Public Health, 6. https://doi.org/10.3389/fpubh.2018.00141
Handy, A. B., Greenfield, S. F., Yonkers, K. A., & Payne, L. A. (2022). Psychiatric symptoms across the menstrual cycle in adult women: A comprehensive review. Harvard Review of Psychiatry, 30(2), 100–117. https://doi.org/10.1097/hrp.0000000000000329
Hofmeister, S., & Bodden, S. (2016). Premenstrual syndrome and premenstrual dysphoric disorder. American Family Physician, 94(3), 236–240. https://www.aafp.org/pubs/afp/issues/2016/0801/p236.html
Jang, D., & Elfenbein, H. A. (2018). Menstrual cycle effects on mental health outcomes: A meta-analysis. Archives of Suicide Research, 23(2), 312–332. https://doi.org/10.1080/13811118.2018.1430638
Office on Women’s Health. (2021). Premenstrual dysphoric disorder (PMDD). Office on Women’s Health. https://www.womenshealth.gov/menstrual-cycle/premenstrual-syndrome/premenstrual-dysphoric-disorder-pmdd
Office on Women’s Health. (2021). Premenstrual syndrome (PMS). Office on Women’s Health. https://www.womenshealth.gov/menstrual-cycle/premenstrual-syndrome
Comments