Menstrual Cycles and Mental Health
Judith H. Gold
This chapter is a revised, expanded, and updated version of a paper “Premenstrual dysphoric disorder: an update” published in the Journal of Practical Psychiatry and Behavioral Health 1999;July:1-7. (permission from Lippincott Williams & Wilkins, publishers of JPPBH)
The author is in private practice, and was the Chair of the LLPDD work group of the American Psychiatric Association Task Force for DSM-IV.
Menstruation marks the beginning of fertility and of womanhood. At the same time, it is an event surrounded by myth, ceremony, and controversy. Over the ages, menstruating women have been viewed as unclean in many cultures and religions. Taboos and rituals still exist in some societies, and papers continue to be published that explore the topic of menstrual meaning within a society (1,2). Since the middle of the 1900s, researchers have also been interested in the factors related to the complaints of some women of negative symptoms in conjunction with the menstrual cycle. Concepts such as premenstrual tension (PMT), premenstrual syndrome (PMS), premenstrual exacerbation of preexisting mental and physical disorders, and premenstrual dysphoric disorder (PMDD) have engendered considerable research and, in some instances, controversy. This chapter discusses these concepts.
PREMENSTRUAL DISORDERS
First, it is important to outline the events of the menstrual cycle. Beginning with the onset of menstruation, during the follicular phase the gonadotropins, folliclestimulating hormone and luteinizing hormone (FSH and LH), stimulate the ovarian follicle. This phase lasts approximately 14 days until ovulation occurs. Progesterone and estrogen are produced in the second phase of the cycle, the luteal phase. If the egg is not fertilized, estrogen and progesterone levels fall and menses begins. The cycle then repeats every 28 to 30 days unless pregnancy ensues. Research into the chemistry of this cycle and into biochemical, social, and psychological factors affecting it is discussed below.
The psychosocial meaning of menstruation and the changes that occur in a woman’s body have imposed limitations upon women throughout the ages. Many see the woman as unclean during menstruation, and, in some societies, she is then segregated. In Western countries, comments and jokes about a woman’s expected premenstrual behavior are commonplace. Discussion about the association of premenstrually attributed behaviors includes social constructs about a woman’s place in society and in a culture and her emotional expressiveness. Anger and irritability are the emotions usually associated negatively with the premenstrual period. As noted in the DSM-IV Sourcebook, a woman’s expression of anger is often “blamed” on premenstrual hormonal changes rather than on the social circumstances in which she exists (3). For some women, the premenstrual period becomes, therefore, a safe time to show anger and dissatisfaction because then, as at no other time, she may be excused for so doing. Instead of examining and rectifying the social practices that forbid women to protest their circumstances, describing anger as pathologic reinforces its proscription. However, for a significant number of women, cyclical symptoms appear to be mediated not by sociocultural influences but by biochemical changes beyond the woman’s control. (See Box 18.1.) The debate about such cyclical symptoms being a medical concern and a possible mental disorder continues among those involved with women’s health and women’s studies (4).
Medical interest in premenstrual disorders was stimulated by the work in the 1930s of R. T. Frank, who began exploring the role of estrogen on women’s mood changes. Later, Dalton popularized the use of progesterone to treat premenstrual negative behaviors (5). As debate about the validity of premenstrual disorders grew, clinicians and researchers struggled to find treatments for the women who complained of such symptoms. Many of these symptoms centered on anger, but symptoms also included cyclic depression (even, at times, suicidal thoughts) and marked loss of functioning in daily life.
The course of menstrual cycle symptomatology is not clearly defined by research to date but, clinically, it appears to begin in adolescence, increase in the late twenties to early thirties, and disappear with menopause, whether menopause is induced or naturally occurring (3,5). It has been noted by many that a woman’s experience of menstrual symptoms is related to that of her mother and culture. An increasing number of studies from diverse cultures continue to investigate this theory, with some finding a genetic rather than a social influence (1,2,3,5).
In an attempt to stimulate research into the menstrual cycle and associated (disabling) psychological changes, The Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, Revised (DSM-III-R) included a proposed new diagnosis in an appendix for further research: late luteal phase dysphoric disorder (LLPDD) (6).
LLPDD was defined as a dysphoric disorder associated with the menstrual cycle that caused significant impairment in a woman’s social and occupational functioning. It was, thus, distinguished from the more common minor premenstrual symptoms experienced by many women and from variously, often imprecisely, defined premenstrual syndromes (PMS) (5). The premenstrual syndromes consist of a variety of both physical and behavioral symptoms showing varying degrees of severity; the 1983 guidelines from the National Institute of Mental Health required a 30% increase in the intensity of symptoms for six days prior to the onset of menses before a diagnosis of PMS could be made. The mainly dysphoric disorder causing severe impairment (LLPDD) was seen as a distinct, severe, psychological, and far less frequent, premenstrual disorder. This chapter focuses on that disorder rather than on the less severe premenstrual disorders (PMS).
LLPDD was defined as a dysphoric disorder associated with the menstrual cycle that caused significant impairment in a woman’s social and occupational functioning. It was, thus, distinguished from the more common minor premenstrual symptoms experienced by many women and from variously, often imprecisely, defined premenstrual syndromes (PMS) (5). The premenstrual syndromes consist of a variety of both physical and behavioral symptoms showing varying degrees of severity; the 1983 guidelines from the National Institute of Mental Health required a 30% increase in the intensity of symptoms for six days prior to the onset of menses before a diagnosis of PMS could be made. The mainly dysphoric disorder causing severe impairment (LLPDD) was seen as a distinct, severe, psychological, and far less frequent, premenstrual disorder. This chapter focuses on that disorder rather than on the less severe premenstrual disorders (PMS).
BOX 18.1
Case Example
A 35-year-old woman was asked by her supervisor if she was having problems at home because she was frequently irritable or absent from the workplace and her behavior seemed to change unpredictably. She noted that her husband and young daughter had made similar observations on many occasions over the past few years. Concerned about the number of sick days she was taking from the workplace and about her interpersonal relationships at home, she consulted her family physician. An additional history of appetite change, sleep disturbance, and suicidal ideation led to a psychiatric referral. The sporadic and unpredictable course of her symptoms led to further questioning. It appeared that she felt sad and angry around the time of her menstrual period; this was confirmed by charting the symptoms over several months. Discussion meanwhile explored her marital relationship, her feelings about her job, and her personal and family background. When symptom free, she was productive, known for her humor, and enjoyed her family and her work. She noted upon reflection that the symptoms had started during her late adolescence but had not affected her life and functioning until recent years. She would be feeling well and would awaken one morning and have difficulty getting out of bed. For the next eight to ten days she would be tearful, have difficulty concentrating, feel irritable, awaken early, have a great desire for chocolate and other sweets, lose interest in her usual activities, argue with her husband, and struggle with hopelessness and thoughts of self-harm. Then her menses would start, her mood would lift, and she would feel renewed energy and pleasure in life.
The decision to introduce a description of a mental disorder that could occur only in women was controversial. However, it was hoped that research using the LLPDD criteria would resolve the arguments for and against such a diagnosis. In 1992, the World Health Organization (WHO) published the tenth edition of the International Classification of Diseases (ICD-10). In the ICD-10, premenstrual disorders were listed only as “premenstrual tension” under “Diseases of the Genitourinary System (N00-N99): N94, Pain and other conditions associated with female genital organs and menstrual cycle” (7). In contrast, the LLPDD criteria
did not include pain or dysmenorrhea, nor were physical symptoms required for the diagnosis to be made. In 1994, the DSM-IV was published. Here, the proposed diagnosis of LLPDD was renamed premenstrual dysphoric disorder (PMDD) and was described in Appendix B, “Criteria Sets and Axes Provided for Further Study.” PMDD was also listed as a differential diagnosis under Depression Not Otherwise Specified (8). The new name, premenstrual dysphoric disorder, reflected the fact that this dysphoria seemed to be linked to the menstrual cycle since it appeared in the late luteal phase and disappeared with the onset of menses. Placing it as a differential diagnosis for depression emphasized the predominant mood disorder component, reflecting etiologic research that implicated the serotonergic system, as in other mood disorders (9).
did not include pain or dysmenorrhea, nor were physical symptoms required for the diagnosis to be made. In 1994, the DSM-IV was published. Here, the proposed diagnosis of LLPDD was renamed premenstrual dysphoric disorder (PMDD) and was described in Appendix B, “Criteria Sets and Axes Provided for Further Study.” PMDD was also listed as a differential diagnosis under Depression Not Otherwise Specified (8). The new name, premenstrual dysphoric disorder, reflected the fact that this dysphoria seemed to be linked to the menstrual cycle since it appeared in the late luteal phase and disappeared with the onset of menses. Placing it as a differential diagnosis for depression emphasized the predominant mood disorder component, reflecting etiologic research that implicated the serotonergic system, as in other mood disorders (9).
The criteria for this research diagnosis require that the symptoms be present during the last week of the cycle, remit with the beginning of the follicular phase, and be absent in the postmenses week. The symptoms must include either depressed mood, marked anxiety, marked lability of mood, or marked anger or irritability or increased interpersonal conflicts. In addition, at least four more symptoms are necessary. These can be symptoms such as decreased interest, poor concentration, fatigue, appetite changes, feeling out of control, and somatic symptoms. In addition, there must be marked interference with work, school, and social interactions. The symptoms must not be an exacerbation of a preexisting illness. Finally, the criteria must be confirmed by prospective daily ratings for at least two cycles.
The literature review, published in 1994 by the DSM-IV work group, noted that a small but significant number of women (4.6%) met the criteria for PMDD but did not meet the criteria for other concurrent mental disorders (10). The symptoms of PMDD in women responded most consistently to medications affecting serotonin pathways and also to ovarian suppression. No other medications or supplements were found to be effective in alleviating symptoms of PMDD. A database reanalysis conducted for the Work Group clarified the set of symptomatic criteria for this proposed diagnosis (11).
Among the important questions requiring answers was why only about 5% of women develop the severe symptoms of PMDD while the vast majority of women do not. Was PMDD indeed a distinct, cyclical mood disorder or a dysphoric variant of PMS? The actual prevalence of PMDD was not known; neither was the familial pattern nor the course of the disorder over a woman’s lifetime. What was the biologic basis of the disorder, given that effective treatments for PMDD were medications that either suppressed ovulation or affected the serotonergic system? What were the interactions or links between events of the ovulatory cycle and serotonin? Were the symptoms of PMDD due to abnormalities triggered by the hormonal changes of the menstrual cycle? And if so, were they linked to estrogen or progesterone or both? Did women with PMDD have a biologic trait abnormality that was present constantly, or was the abnormality specific to the luteal state (12)?
REVIEW OF THE LITERATURE SINCE DSM-IV
A search of the literature from 1994 to 2004, using Medline and the Cochrane Library, revealed numerous publications of research studies employing the DSM-IV definition of PMDD.
PREVALENCE
One prospective community study of young women and adolescents over 48 months found a 5.8% baseline prevalence of PMDD, or 5.3% when concurrent major depressive disorder was excluded. The diagnosis remained stable over the 48 months’ duration of the study. A further 18.5% had premenstrual symptoms that did not meet PMDD impairment criteria (13). In another small study, women with prospectively diagnosed PMS or retrospectively confirmed PMDD were followed for 5 to 12 years and, in this small group, the PMS symptoms were stable over time (14). Data from many countries and cultures now support the existence of negative premenstrual symptoms, including PMDD (15,16). One such study, of women aged 15 to 52, found significant somatic and psychological premenstrual symptomatology in 52% of the women sampled with no difference between age groups except for the greater frequency of pain in adolescents (17).
Another study examining symptom stability across cycles in women with prospectively confirmed PMDD, during symptomatic cycles only, concluded that mood symptoms, including irritability, anxiety, and affective lability, showed the most stability, and that somatic symptoms, while also stable, were not associated with functional impairment (18). The authors stated that their data supported PMDD as a mood disorder and suggested further that, because of the stability of its symptoms, PMDD might prove to be a model for the study of mood disorders in general.
CRITERIA
Somatic symptoms discriminated the least between women who met PMDD criteria and those who did not, while anger, irritability, and conflict; a sense of being out of control; markedly depressed mood; and decreased interest in usual activities were the most discriminating symptoms (19). Tension, being on edge, and increased interpersonal conflict were also important.
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