magazine issue 5 2021 / Issue 45

How Much Does the Menstrual Cycle Affect Emotional Life?

• written by Maria Gröndal
• edited by Mitch Brown

Around 1.6 billion women of fertile age currently have an ongoing menstrual cycle, and a larger group of women will experience or have already experienced this. Everyone probably knows a fertile woman in some way. Despite this, general knowledge about how the menstrual cycle affects women emotionally is scarce. At the same time, there are beliefs and misconceptions about the menstrual cycle’s effect on women. This article will unravel whether emotional premenstrual symptoms are a biological, psychological or sociocultural phenomenon. After reading this article, one will have a better understanding of how premenstrual symptoms can affect women and what can be done or suggested to someone thought to be emotionally affected during the premenstrual phase.

As with many female-dominated psychiatric and medical conditions throughout history, society’s way of understanding the emotional and behavioral effects of the menstrual cycle have continuously caused negative effects for women. In the following section, we will briefly discuss two beliefs about how the menstrual cycle affects women that generate misconceptions and have damaging consequences for women. The first that all menstruating females have similar symptoms and are all negatively affected in terms of their mood and behavior during the premenstrual phase. This belief was used to prevent women from working and studying at universities in the 19^th century (1). It has also been used to try to prohibit women from doing work that involves cognitive and motor abilities (2), for example working as a pilot (3). This belief has appeared not only in research, but also in the media and among the general population, (1). Both women and men have tried to explain bad moods and unusual behaviors in women caused by the menstrual cycle (4,5). This overgeneralizing belief that premenstrual symptoms are viewed as “time of the month” that drives women crazy is (6,7). One risk of this belief is that women will interpret normal and adequate feelings in a certain situation as a form of hormonal craziness, which in the long term can make them believe they have premenstrual symptoms even though they do not. A contrasting view is the belief that the menstrual cycle has no biological effect at all, and is merely a cultural phenomenon caused by patriarchal structures. From this perspective, the belief that premenstrual symptoms are neither a biological issue nor a diagnosis will impede the research field and put suffering women in a problematic situation. To be able to carry out medical and clinical psychological research on the menstrual cycle and premenstrual symptoms, we need to both localize typical symptoms among this group and agree on inclusion and exclusion criteria for various premenstrual conditions (8,9). Not surprisingly, this assumption is also wrong (10). Since 1931, it has been consistently proven that there is an important link between hormonal fluctuations and premenstrual symptoms (11). In a worst-case scenario, these symptoms will be undiagnosed and the treatment for women who are suffering will be ineffective (12). I hope it is now clear that neither of the two extreme misconceptions described above are helpful and it is time to talk about premenstrual symptoms in a nuanced way, which includes severely affected women, non-affected women, and everyone in between. Furthermore, it is important to highlight that there is a difference between gender identity and sex. People talking about the menstrual cycle often refer to something that only occurs among females. However, people with gender identities other than female can have ovaries and a uterus and mainly produce ‘female’ hormones (13).

The menstrual cycle and premenstrual symptoms

The average length of a menstrual cycle is 28 days, and during a lifetime the average time spent having periods is 2585 days, or a total timespan of nearly seven years (14). The most important aspect of the menstrual cycle is that it includes cyclical hormonal fluctuations. The menstrual cycle starts with the first day of menstruation and lasts until the next menstruation begins. In the middle of the cycle, during ovulation, an egg is released from the ovary and starts its journey to the uterus, which opens up for a chance to fertilize. If the egg is not fertilized, the body will shed the uterine lining and begin a new cycle starting with menstruation. The time period when premenstrual symptoms appear usually starts when the body recognizes that the egg is not fertilized and lasts until the first day of menstruation (15). This is usually around five days, but for some women it can last up to two weeks. During this phase, there is a hundredfold increase in the hormone progesterone, a hormone that has been linked to negative mood (16). Progesterone prepares the body for a possible pregnancy. If the egg is fertilized progesterone levels will increase further, but if the egg is not fertilized levels will drop during the days leading up to the first day of menses. Since hormones are transported in the blood, they can easily reach the brain and affect various functions controlled by the brain (17). Previous studies show that women with severe mood symptoms immediately before their menses react more easily in emotional centers of the brain when exposed to hormonal changes (18). Women who experience severe premenstrual symptoms are also more sensitive to emotional stimuli during the days before menses compared to women without premenstrual symptoms (19). The premenstrual emotional symptoms are most likely due to hormonal fluctuation in the days before onset of menses (20). However, hormonal levels in a woman with severe premenstrual symptoms will probably not be different from a symptom-free woman in the same cycle phase. Instead, women with premenstrual symptoms seem to be more sensitive to these hormonal fluctuations, as if they have an ‘allergy’ to hormonal changes. Current research suggests that it is the residual products of progesterone (allopregnanolone) that are essential to experiencing premenstrual mood symptoms (21). Serotonin also seems to play an important role in premenstrual symptoms, and the currently recommended treatment for severe emotional premenstrual symptoms is antidepressant medication (selective serotonin reuptake inhibitors, SSRIs) (22,23). It is evident that hormonal changes linked to the menstrual cycle seem to have an important impact on why some women experience emotional symptoms immediately before menses. The next section will examine how individual sensitivity to hormonal changes generates different types and severity of premenstrual symptoms among women.

Severity of premenstrual symptoms

The majority of women, up to 80 percent (24), report some observational physical or mood changes connected to the premenstrual phase. The most common changes are of a physical nature, such as feeling swollen or bloated during the days before the onset of menses. Twenty to thirty percent report at least one mood symptom connected to the menstrual cycle (25,26). However, the majority of fertile women do not need treatment or professional help for these changes (24). Many of these women note the changes without being seriously affected. While most women only experience minor changes during the premenstrual phase, around 5 percent of fertile women are severely affected (27). This severe form of premenstrual symptoms is now regarded as a psychiatric disorder, and is included in the international diagnostic manual (DSM-V) under the name Premenstrual Dysphoric Disorder (PMDD) (28). The characteristics of PMDD are severe, causing emotional changes typically a few days before the onset of menses and some days after the onset of menses, while the rest of the menstrual cycle is relatively symptom-free (29). However, for some women, symptoms begin right after ovulation and are persistent for a two weeks time period. The diagnosis includes four main mood symptoms: irritability/anger, depressed mood/hopelessness, anxiety, and mood swings/lability. Additional cognitive and behavioral symptoms include decreased interest in everyday activities, subjective experience of concentration difficulties, lethargy and lack of energy, appetite change and increased cravings, hypersomnia or insomnia, and feeling overwhelmed or out of control. Additional physical symptoms include tenderness or swelling of the breasts, joint or muscle aches, feeling swollen, and weight gain. The diagnosis requires at least five symptoms, including at least one of the main mood symptoms. The symptoms of PMDD are similar to the symptoms of depression and anxiety disorders, and are therefore not typical. Instead, it is the time, duration, and severity of symptoms that define the diagnosis. The link between premenstrual mood symptoms and hormonal fluctuations is evident in this group. When ovulation is inhibited, either naturally or medically, there is a dramatic relief of premenstrual symptoms in this group. The reason for this is that when an egg is not released, the body does not prepare for pregnancy, which will affect the cyclical hormonal production. This group also seems to be extremely sensitive to hormone therapies and more sensitive to oral contraceptives (16). This small group of seriously affected women needs to be correctly diagnosed and offered evidence-based treatment. This is a suffering group where the symptoms lead to major problems in daily life, such as conflicts in close relationships, impaired work capability (30), and a higher risk of suicidal thoughts and attempts compared to the general population (31,32).

Psychological and sociocultural aspects of premenstrual symptoms

Although medical research has identified biological explanations for premenstrual symptoms, such as various degrees of sensitivity to hormonal changes among females, there are also several important psychological and sociocultural aspects of symptom expressions (33). One important aspect associated with affecting the pattern and severity of premenstrual symptoms is perceived stress (34). Women diagnosed with PMDD or PMS are, compared to healthy controls, more likely to have a history of childhood trauma, including both emotional, physical and, sexual abuse (35,36). Trauma exposure do also increase the risk for developing PMDD (37) and it is also suggested to affect the severity and number of symptoms (38). The severity of problems in the premenstrual phase also seem to be dependent on how the individual and her social environment react and relate to the emotional changes. Even though the prevalence of premenstrual symptoms is relatively consistent worldwide (30), experiences and types of symptoms during the premenstrual phase differ. In Western societies, more women report mood symptoms compared to women in other parts of the world (39,40). This difference may be due to culturally bound ways of expressing feelings and discomfort. One theory is that social support from close relatives has an impact on the severity of premenstrual symptoms, and when surrounded by understanding individuals the experienced suffering decreases (41). When women with premenstrual symptoms experience support and acceptance from a partner, they are also more likely to show awareness, acceptance, and self-care to themselves (42). Experiences of negative consequences of premenstrual emotional symptoms have also been reported in the work environment (32). Women with PMDD report that premenstrual symptoms, such as feelings of self-doubt, problems with concentration, and fatigue, affect their work capability during the premenstrual phase (43). This can lead to compensatory behaviors when the premenstrual symptoms disappear, such as working extra hours. If the experience of negative consequences and guilt goes on for a long time, it will most likely generate additional negative consequences for the woman’s wellbeing. The degree of suffering in the premenstrual phase has also been correlated with perfectionism and self-silencing due to fear of losing emotional control (44). Women who experience premenstrual symptoms are, compared to women without, more worried that they might lose control of themselves if they become too angry, anxious, depressed, or happy. Another psychological factor that seems to be important in the understanding of premenstrual symptoms is the level of rumination, where females with high levels seem to experience longer periods of suffering (45). It appears possible to alter the experience of premenstrual symptoms to varying extent. Therefore, the hormonal changes need to be understood from a biopsychosocial framework in which psychological and sociocultural factors interact in a complex interplay with the biology. By highlighting many aspects in order to understand premenstrual symptoms, a better understanding of the condition and opportunities for various types of effective treatment can be created.

Conclusion

The majority of women do not have impairing emotional and behavioral symptoms directly connected to their menstrual cycle. However, a minority of fertile women are severely affected, and this group needs to be correctly diagnosed and professionally treated. Premenstrual symptoms involve changes that occur in a specific time frame immediately before the onset of menses, and should therefore be considered as a cyclical hormone-based condition. However, these symptoms can be influenced to varying extent by sociocultural and psychological factors, which in turn can increase or decrease the experience of suffering.

What you can do if you think you are affected

• Premenstrual symptoms and PMDD cannot be diagnosed via blood, hormone, or saliva tests. Instead, a diagnosis is based on symptom tracking (37). If you think that your menstrual cycle affects your mood and behavior, a good start is to track your symptoms in relation to your menstrual cycle to ensure that your mood follows your menstrual cycle. Nowadays, there are many useful apps you can download to help with this. In addition, a positive side effect of tracking your premenstrual symptoms is that this can help you to become familiar with your symptoms and understand why they occur at a certain time. This is turn can lead to a better understanding of why you react or feel a certain way, and you can plan your life according to your menstrual cycle, for instance by asking for extra help with your children immediately before the onset of menses.           
                   
• Emotional premenstrual symptoms are very simila to symptoms of anxiety and depression, which can be reduced effectively by therapy, particularly cognitive behavioral therapy (CBT). CBT focuses on understand how feelings, thoughts, behavior, and physical reactions affect your life, and helps you to gradually change negative behavioral patterns and improve your mental flexibility. The current evidence for CBT specifically in premenstrual symptoms is scarce, but this is probably due to a lack of research rather than suggesting that the treatment does not work.        
                   
• If you experience unbearable symptoms which have an impact on your daily life during the premenstrual phase, you should contact a gynecologist, psychiatrist, or physician and set up an appointment to discuss medical treatment options. Currently recommended treatments include intermittent treatment with antidepressant medication (meaning that you only medicate during the premenstrual phase), but there are also other options such as oral contraceptives (e.g., Yaz).            
                   
• If you want to find out more about PMDD, you can also visit the website of the non-profit International Association for Premenstrual Disorder (IAPMD). They provide education, support, advocacy, and resources for those    affected by PMDD. (https://iapmd.org/)
                   
• Finally, the most important thing to remember if you suffer from premenstrual symptoms is that you are not alone and help is available.             
  
  

References

1. Delaney, J., Lupton, M. J., & Toth, E. (1988). The curse: A cultural history of menstruation. University of Illinois Press.
2. Smith, A. J. (1950). Menstruation and industrial efficiency, II, quality and quantity of production. Journal of Applied Psychology, 34 (3), 148-152.
3. Sommer, B. A. (1973). The effect of menstruation on cognitive and perceptual-motor behavior: A review. Psychosomatic Medicine, 35 (6), 515-535.
4. Figert, A. E. (2005). Premenstrual syndrome as scientific and cultural artifact. Integrative Physiological & Behavioral Science, 40(2), 102–113. https://doi.org/10.1007/BF02734245
5. Thornton, L.J. (2013). “Time of the Month” on Twitter: Taboo, Stereotype and Bonding in a No-Holds-Barred Public Arena. Sex Roles, 68(1), 41–54.
6. Gehlert, S., Song, I. H., Chang, C.-H., & Hartlage, S. A. (2009). The prevalence of premenstrual dysphoric disorder in a randomly selected group of urban and rural women. Psychological Medicine, 39(1), 129–136.
7. Freeman, E. W. (2003). Premenstrual syndrome and premenstrual dysphoric disorder: definitions and diagnosis. Psychoneuroendocrinology, 28, 25-37.
8. Sveindóttir, H., & Bäckström, T. (2000). Prevalence of menstrual cycle symptom cyclicity and premenstrual dysphoric disorder in a random sample of women using and not using oral contraceptives. Acta obstetricia et gynecologica Scandinavica, 79(5), 405-413.
9. Eisenlohr-Moul T. (2019). Premenstrual Disorders: A Primer and Research Agenda for Psychologists. The Clinical psychologist, 72(1), 5–17.
10. Schmidt, P. J., Nieman, L. K., Danaceau, M. A., Adams, L. F., & Rubinow, D. R. (1998). Differential behavioral effects of gonadal steroids in women with and in those without premenstrual syndrome. New England Journal of Medicine, 338(4), 209-216.
11. Frank, R. T. (1931). The hormonal causes of premenstrual tension. Archives of Neurology & Psychiatry, 26(5), 1053-1057.
12. Osborn, E., Wittkowski, A., Brooks, J., Briggs, P. E., & O’Brien, P.(2020). Women’s
13. experiences of receiving a diagnosis of premenstrual dysphoric disorder: a qualitative investigation. BMC Women's Health, 20(1), 1-15.
14. Schmalenberger, K. M., Tauseef, H. A., Barone, J. C., Owens, S. A., Lieberman, L., Jarczok, M. N., ... & Eisenlohr-Moul, T. A. (2020). How to study the menstrual cycle: Practical tools and recommendations. Psychoneuroendocrinology, 104895.
15. Chiazze, L., Brayer, F. T., Macisco, J. J., Parker, M. P., & Duffy, B. J. (1968). The length and variability of the human menstrual cycle. Jama, 203(6), 377-380.
16. Pearlstein, T., Yonkers, K. A., Fayyad, R., & Gillespie, J. A. (2005). Pretreatment pattern of symptom expression in premenstrual dysphoric disorder. Journal of Affective Disorders, 85(3), 275-282.
17. Gingnell, M., Engman, J., Frick, A., Moby, L., Wikström, J., Fredrikson, M., & Sundström Poromaa, I. (2013). Oral contraceptive use changes brain activity and mood in women with previous negative affect on the pill—a double-blinded, placebo-controlled randomized trial of a levonorgestrel-containing combined oral contraceptive. Psychoneuroendocrinology, 38(7), 1133-1144.
18. Melcangi, R. C., Panzica, G., & Garcia-Segura, L. M. (2011). Neuroactive steroids: focus on human brain. Neuroscience, 191, 1-5.
19. Gingnell, M., Morell, A., Bannbers, E., Wikström, J., & Poromaa, I. S. (2012). Menstrual cycle effects on amygdala reactivity to emotional stimulation in premenstrual dysphoric disorder. Hormones and Behavior, 62(4), 400-406.
20. Protopopescu, X., Tuescher, O., Pan, H., Epstein, J., Root, J., Chang, L. & Silbersweig, D. (2008). Toward a functional neuroanatomy of premenstrual dysphoric disorder. Journal of Affective Disorders, 108(1-2), 87-94.
21. Hantsoo, L., & Epperson, C. N. (2015). Premenstrual dysphoric disorder: epidemiology and treatment. Current Psychiatry Reports, 17(11), 87.
22. Bixo, M., Johansson, M., Timby, E., Michalski, L., & Bäckström, T. (2018). Effects of GABA active steroids in the female brain with a focus on the premenstrual dysphoric disorder. Journal of Neuroendocrinology, 30(2), e12553.
23. Eriksson, E., Ekman, A., Sinclair, S., Sörvik, K., Ysander, C., Mattson, U. B., & Nissbrandt, H. (2008). Escitalopram administered in the luteal phase exerts a marked and dose-dependent effect in premenstrual dysphoric disorder. Journal of Clinical Psychopharmacology, 28(2), 195-202.
24. Cunningham, J., Yonkers, K. A., O’Brien, S., & Eriksson, E. (2009). Update on research and treatment of premenstrual dysphoric disorder. Harvard Review of Psychiatry, 17(2),120-
25. Yonkers, K. A., O’Brien, P. S., & Eriksson, E. (2008). Premenstrual syndrome. The Lancet, 371(9619), 1200-1210..
26. Borenstein, J. E., Dean, B. B., Endicott, J., Wong, J., Brown, C., Dickerson, V., & Yonkers, K. A. (2003). Health and economic impact of the premenstrual syndrome. The Journal of Reproductive Medicine, 48(7), 515-524.
27. Biggs, W. S., & Demuth, R. H. (2011). Premenstrual syndrome and premenstrual dysphoric disorder. American Family Physician, 84(8), 918-924.
28. Epperson, C. N., Steiner, M., Hartlage, S. A., Eriksson, E., Schmidt, P. J., Jones, I., & Yonkers, K. A. (2012). Premenstrual dysphoric disorder: evidence for a new category for DSM-5. American Journal of Psychiatry, 169(5), 465-475.
29. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.
30. Hartlage, S. A., Freels, S., Gotman, N., & Yonkers, K. (2012). Criteria for premenstrual dysphoric disorder: secondary analyses of relevant data sets. Archives of general psychiatry, 69(3), 300-305.
31. Halbreich, U., Borenstein, J., Pearlstein, T., & Kahn, L. S. (2003). The prevalence, impairment, impact, and burden of premenstrual dysphoric disorder (PMS/PMDD). Psychoneuroendocrinology, 28, 1-23
32. Pilver, C. E., Libby, D. J., & Hoff, R. A. (2013). Premenstrual dysphoric disorder as a correlate of suicidal ideation, plans, and attempts among a nationally representative sample. Social psychiatry and psychiatric epidemiology, 48(3), 437-446.
33. Wittchen, H. U., Becker, E., Lieb, R., & Krause, P. (2002). Prevalence, incidence and stability of premenstrual dysphoric disorder in the community. Psychological Medicine, 32(1), 119-132.
34. Taylor, D. (2006). From “it’s all in your head” to “taking back the month”: premenstrual syndrome (PMS) research and the contributions of the society for menstrual cycle research. Sex Roles, 54(5), 377-391.
35. Gollenberg, A. L., Hediger, M. L., Mumford, S. L., Whitcomb, B. W., Hovey, K. M., Wactawski-Wende, J., & Schisterman, E. F. (2010). Perceived stress and severity of perimenstrual symptoms: the BioCycle Study. Journal of women's health, 19(5), 959-967.
36. Soydas, E. A., Albayrak, Y., & Sahin, B. (2014). Increased childhood abuse in patients with premenstrual dysphoric disorder in a Turkish sample: a cross-sectional study. The primary care companion for CNS disorders, 16(4).
37. Pilver, C. E., Levy, B. R., Libby, D. J., & Desai, R. A. (2011). Posttraumatic stress disorder and trauma characteristics are correlates of premenstrual dysphoric disorder. Archives of women's mental health, 14(5), 383-393.
38. Azoulay, M., Reuveni, I., Dan, R., Goelman, G., Segman, R., Kalla, C., ... & Canetti, L. (2020). Childhood trauma and premenstrual symptoms: the role of emotion regulation. Child Abuse & Neglect, 108, 104637.
39. Eisenlohr-Moul, T. A., Rubinow, D. R., Schiller, C. E., Johnson, J. L., Leserman, J., & Girdler, S. S. (2016). Histories of abuse predict stronger within-person covariation of ovarian steroids and mood symptoms in women with menstrually related mood disorder. Psychoneuroendocrinology, 67, 142-152.
40. Pearlstein, T. (2007). Prevalence, impact on morbidity, and disease burden. In The Premenstrual Syndromes (pp. 49-66). CRC Press.
41. Ussher, J. M., & Perz, J. (2013). PMS as a gendered illness linked to the construction and relational experience of hetero-femininity. Sex Roles, 68(1-2), 132-150.
42. Ussher, J. M., & Perz, J. (2008). Empathy, egalitarianism and emotion work in the relational negotiation of PMS: The experience of women in lesbian relationships. Feminism & Psychology, 18(1), 87-111
43. Ussher, JM, Perz, J& Mooney-Somers, J (2007) The Experience and Positioning of Affect in the Context of Intersubjectivity: The Case of Premenstrual Syndrome. International Journal of Critical Psychology (now Subjectivity), 21, 144-165.
44. Hardy, C., & Hardie, J. (2017). Exploring premenstrual dysphoric disorder (PMDD) in the work context: a qualitative study. Journal of Psychosomatic Obstetrics & Gynecology, 38(4), 292-300.
45. Chrisler, J. C., Gorman, J. A., & Streckfuss, L. (2014). Self-silencing, perfectionism, dualistic discourse, loss of control, and the experience of premenstrual syndrome. Women’s Reproductive Health, 1(2), 138-152.
46. Craner, J. R., Sigmon, S. T., Martinson, A. A., & McGillicuddy, M. L. (2014). Premenstrual disorders and rumination. Journal of Clinical Psychology, 70(1), 32-47.