Mood and the menstrual cycle; a missing link in understanding depression and anxiety

20 September 2016.

UPDATE: Since I first wrote this blog, further research has refined my position on this topic. It’s worth noting that the menstrual cycle itself is more of a ‘trigger’ of symptoms, rather than the direct cause. For example, research suggests that it is not the level of sex hormones an individual has that influences their health, but their reaction to the changing levels of various hormones, as stimulated by the menstrual cycle. Sex hormone changes seem to influence other hormonal pathways involved in the immune, metabolic, and stress pathways, which may then cause various symptoms in a minority of people who menstruate…

It is well known that the menstrual cycle can affect an individual’s mood and anxiety levels…

However, the potential relationship between sex hormones and anxiety and depression, has largely been ignored within medical practice. This blog post highlights why we ought to pay more attention to the role of the menstrual cycle in the study, diagnosis, and treatment of anxiety and depression, for the benefit of all people suffering from these issues.

1. The crossover of menstrual cycle-related symptoms with those of anxiety and depression

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The majority of the most commonly experienced menstrual cycle-related symptoms are also those associated with depression and anxiety (see table above). This suggests that they may share a common underlying cause, perhaps directly, or indirectly, relating to changes in ‘female’ sex hormone levels (oestrogen and/ or progesterone).

In fact, it is known that if a cyclical pattern in an individual’s symptoms of anxiety and/ or depression is identified (by tracking symptoms over time), then hormonal therapy can be a more effective course of treatment than antidepressants, or anti-anxiety medication [1].

Note: All humans have both ‘male’ and ‘female’ hormones, in varying levels. Male humans tend to have much higher levels of testosterone and other androgens, and female humans tend to have much higher levels of oestrogens and progesterone (see point 4 for further information).

2. The prevalence of anxiety and depression in the general population

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Women (or, more specifically, people with a female reproductive system) are statistically more likely than men (people with a male reproductive system) to suffer from a range of mental health issues. In fact, a recent investigation into 12 different national population studies [2] revealed that:

  • Women are significantly (up to 40%) more likely to experience anxiety and depression.
  • Women are also more likely to experience a phobia, eating disorder (anorexia and bulimia), PTSD (Post Traumatic Stress Disorder), and insomnia.
  • Men and women are more equally at risk of psychiatric disorders such as schizophrenia, OCD (Obsessive Compulsive Disorder), or bipolar disorder.
  • Men are more likely to be affected by antisocial personality disorders, or alcohol and substance abuse.

The authors suggest that while some of these sex differences can be explained by social and environmental factors, the consistent results found across cultures and geographical locations, indicate that there might also be physiological factors (e.g. genetic, or hormonal) at work.

Adding to this evidence base, is a study on transgender mental health, revealing that transgender women (taking oestrogen) are up to twice as likely as transgender men (taking testosterone) to suffer from depression.

3. The timing of mental health issues

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  • The female-prevalence of anxiety and depression is known to start at puberty, with this gender difference absent in child mental health, and reducing in older age (from approx. 65 years) [3].
  • We also know that in people who menstruate, depression is far more likely to occur at times of hormonal flux- puberty, during the menstrual cycle, after giving birth, and in the 1 or 2 years before periods cease (known as the perimenopause) [1].
  • Some research even suggests that people who menstruate are more likely to attempt suicide at certain times of their menstrual cycle – when oestrogen and serotonin levels are both at their lowest (see point 4) [4].

These patterns suggest a relationship between fluctuating levels of ‘female’ sex hormones and symptoms of anxiety and depression (among others). This helps to explain why improved hormone balance (through diet, or hormonal therapy) can significantly alleviate these symptoms.

4. Sex hormones influence stress and depression-related hormonal pathways

hormone_pills

  • There is some evidence to support the idea that testosterone therapy might work as a treatment for depressed men, although studies have produced inconsistent results. It is, however, more generally agreed that testosterone may act as a ‘protective’ factor against developing depression in both women and men [5].
  • Oestrogen can alleviate the symptoms of depression [6], and boost both dopamine [7] and serotonin [8] levels, which are critical hormones involved in mood regulation [9].
  • Oestrogen levels have been found to be lower in people who experience severe depression during particular times of the menstrual cycle [10].
  • The sudden reduction in the levels of both oestrogen and progesterone is linked to the depression and anxiety experienced by some individuals after giving birth [11]. Oestrogen withdrawal is linked to low mood, whereas progesterone withdrawal is linked to anxiety [12].
  • Both testosterone and oestrogen affect the response of the ‘stress axis’ (technically known as the hypothalamic-pituitary-adrenal (HPA) axis), but in women, the stress response tends to activate more rapidly and produces a greater output of stress hormones [13].
  • Interestingly, repeating or chronic activation of the stress axis, decreases oestrogen and testosterone production [11]. This may explain why people suffering from stress can become trapped in a vicious cycle, as constant anxiety levels reduce their ability to produce anti-anxiety hormones.

brainSo, there is quite possibly a relationship between [changing levels of] sex hormones, and the symptoms of depression and anxiety.

Considering all that we have learnt above, the menstrual cycle, rather than being a taboo subject, should be seen as offering a plentiful and regular opportunity for researchers to further investigate the underlying causes of anxiety and depression.

Doctors should be more aware of the relationship between the menstrual cycle (and hormonal medications) and the symptoms of anxiety and depression. For example, tracking symptoms over time can help establish if hormones are playing a role in poor mental health.

If so, treatment options can include hormone-balancing dietary changes, and/ or hormonal therapy, rather than the more usual prescription of antidepressant, or anti-anxiety, medication, which may be less effective and more likely to result in unwanted side-effects [1].

anxiety-sources


1 Replies

  1. Hi! You’ve expressed a lot of your views really well here and backed them with substantial facts, which is really cool. I read in the update that your views are different now, do you have them written down like this somewhere? or could you share the source of the information that has changed your views? I’m a psychology student in Hyderabad, India working in a study regarding premenstrual mood swings and emotional regulation and I’m looking to form a comprehensive base of knowledge on the subject. I’d really appreciate it if you could help! Thanks!

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