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

20 September 2016.

2018 UPDATE: Since I first wrote this blog, further research has refined my position on this topic. It’s worth noting that the menstrual cycle 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 that influences an individual’s health, but it could be related to the physiological changes involved in the menstrual cycle e.g. water retention, blood sugar changes, blood pressure changes, and reactions to pain and inflammation. This is why most people who menstruate do not experience significant symptoms, or mood changes. However, I still believe that further research on the menstrual cycle could be invaluable in learning more about such physiological ‘triggers’ of mental health disorders.

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

However, the potential relationship between what happens during the menstrual cycle and anxiety and depression, has largely been ignored by medicine. 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

symptoms-1

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 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 suppressing ovulation (i.e. using hormonal medications or devices) 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

blue_woman

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 some of these sex differences can be explained by social and environmental factors, but there might also be physiological factors at work.

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, pregnancy, 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 the symptoms of anxiety and depression (among others). This helps to explain why improved overall 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 the menstrual cycle 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 the menstrual cycle is triggering, or worsening, a mental health condition.

If so, treatment options can include 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].

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3 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!

  2. Thanks for getting in touch. To begin with, if you look at any review of recent clinical research on ‘PMS’ or ‘PMDD’, you will see that various trials since the 1980’s have established that the ‘sex hormones’, specifically oestrogen and progesterone, do not influence (mood-based or most physical symptoms (with the possible exception of breast swelling/ pain)) cyclical symptoms directly. i.e. the levels of these particular hormones found in ‘PMS’ patients are just as diverse as those who do not experience symptoms. Some clinicians still believe that there is an ‘indirect’ relationship i.e. that the sex hormones may interact with other hormones, especially neurotransmitters, resulting in symptoms in some people (who have some as yet unknown ‘sensitivity’ to such changes)- see the 2017 Royal college of Obstetricians and Gynaecologist’s ‘Green top guideline 48 on PMS’- https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg48/
    However, no ‘causal’ relationship has been proven- meaning that cyclical symptoms only ‘might’ be triggered by indirect (sex) hormonal changes because the research has failed to identify the mechanism(s) by which this happens. Based on a high quality review of ‘mood studies’- Romans et al- http://einsteinlab.ca/wp-content/uploads/2016/07/7-Mood-and-the-menstrual-cycle.pdf – It is clear that actually, there is no conclusive evidence of a specific ‘premenstrual’ mood disorder in menstruating people. Not to say that nobody experiences symptoms premenstrually, but that when comparing data between men and women, or between phases of the menstrual cycle, there are often no statistically significant differences (aside from day of the week- we are typically all more stressed on Sundays and Mondays due to the Mon-Fri work week!). This casts SERIOUS doubt on the sex hormone explanation for cyclical symptoms- since there are substantial hormonal differences between menstrual phases and between men and women. So, I now prefer an alternative theory about the cause of cyclical symptoms- based on what physically happens to the body during the menstrual cycle. This idea is also ‘not proven’- even though it has been around in the form of ‘water retention explanations for PMS’ for over 90 years- so please do not quote me as any sort of reference. I just think it makes more sense as an explanation and deserves further investigation. For example, cyclical blood sugar changes could explain dizziness, changes in appetite, fatigue, headache/ migraine, and even trigger epilepsy-related seizures. Likewise, cyclical water retention could explain swelling, constipation, acne, weight gain, and thirst. Cyclical blood pressure changes could explain dizziness, feeling tense, and may even effect mood. All of these combined (plus pain, inflammation responses and blood loss) could definitely affect mood, since all humans experience irritability if hungry, tired, or in pain- especially when external factors annoy them! What is good about this explanation is that it complements what we already know about non-menstruating women and men’s experiences of these same symptoms- while they don’t have a menstrual cycle- they can experience blood pressure/ sugar changes, water retention, and anaemia/ pain etc. and subsequently experience the same symptoms that some women do on a cyclical basis. I am currently conducting research on this topic but it won’t be published until 2021. So, until then, it is just my opinion! I edited the blog to remove all the bits that I had previously attributed to ‘sex hormones’ so this version is the best I can offer until the research data are published. Definitely check out the Romans article- it is of most relevance to your work. Sally King- MM

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