Menstruation and mental wellbeing

To discuss the relationships between the menstrual cycle and mental health, GP and women's health specialist Hannah Short spoke to Adam Murphy and Katie Haylor. Firstly, Katie asked whether the cessation of periods (the menopause) can have an impact on how someone might feel...

Hannah - Yeah, they certainly can. I think there's two main aspects. The emotional and psychological impact of changing hormones in itself can have an effect because the changing levels affect your brain and so it can lead to symptoms like mood swings and insomnia, anxiety, loss of confidence and irritability. But then there's also the psychological side of it directly by the fact you've stopped your periods. Some women will mourn their loss of fertility or they see it as a sign that they've now passed their youth. And obviously that's particularly problematic for women or girls who have gone through a very early menopause or lost their ovaries as a result of surgery.

Katie - In general, how well do scientists understand the relationship between your mental wellbeing and your menstrual cycle?

Hannah - There's a general appreciation that there is a connection, but to be honest, I don't think it's understood well enough or the severity that can occur is not really fully understood or recognised. I mean, the Royal college of Obstetricians and Gynaecologists have guidelines for PMS, which is premenstrual syndrome. And that's where women will struggle with symptoms in the two weeks leading up to their period. There's a recognition that there's some degree of severity. So for some women it will just be mild unpleasant symptoms and others will be really quite severe. Not everybody's aware of these guidelines. So I think the scientific and medical community needs to do a lot more kind of work around it, but I think it is gaining recognition and understanding.

Katie - Is there a sort of a correlation that we can appreciate between hormonal variation and moods specifically?

Hannah - There's no such thing as typical, I suppose, but often people will associate the first part of the menstrual period - so just the day that your period starts and for the first two weeks of oestrogen rising - their mood tends to improve, their energy tends to be better. Libido is often increased around ovulation. Then the second part of the cycle, when the oestrogen is dropping and the progesterone is rising, a lot of women might feel a bit more irritable, may feel more tearful. Again, this, as I was saying, the severity of that really varies. In about one in 20 women will struggle with very, very severe symptoms. They say it's almost like a switch has been flipped and they're a different person in the second part. And that's when you have something called premenstrual dysphoric disorder or PMDD.

Adam - And, what would you do to advise people to seek help with how they're feeling and what kind of problems can arise for them?

Hannah - Well, I was just saying about the PMDD for the 1 in 20 women, or those who are born female who still have their ovaries, it can be really quite debilitating the symptoms. So they can have suicidal thoughts, it's not just feeling a little bit low. Very severe anxiety. If that's happening, that's obviously not normal and needs help and recognition. Going to see your GP would be the first port of call and keeping a track of your symptoms to kind of show that there's a cyclical kind of nature and that you're not feeling like that all the time. There isn't like an underlying psychiatric diagnosis there.

Katie - What can be done to help? Are there medications that would be appropriate? How do you help as a doctor?

Hannah - It depends on the severity. So women who are having milder symptoms, lifestyle changes like regular exercise, sleep, eating a fibre rich diet can help. Vitamin B6 and magnesium supplements - there's some evidence for those. With people with the more severe symptoms, where they're having to miss school or work or it's affecting their relationships, then things like the SSRI antidepressants can help stabilise the brain and reduce those mood side effects. And things like the contraceptive pill, or HRT can help as well. In some severe cases, having an induced medical menopause - so you have injections to switch off the ovaries - can help. And you're given some HRT to help protect your bones and things like that. And in very severe cases, some women have their ovaries removed, but that's at the very extreme end.

Katie - The menstrual cycle and wellbeing isn't a subject that is talked about loads. As a woman's health doctor, how would you summarise the societal perception of menstruation and mood?

Hannah - I think it's probably still viewed as quite a taboo, I think. Because you've got two kinds of taboos there anyway. I mean, hopefully things are changing, but historically menstruation and mental health are things that people steer away from so when you get that combination I think there's quite a reluctance to talk about it. Unfairly women have often been viewed as quite hysterical, it's probably where the word comes from - stereo and hysterectomy when you're talking about removal of the womb. I think things are getting better, but because it's not fully understood, I don't think women are often believed when people say that their menstruation is really affecting their mental wellbeing. And I'm hopeful that will change as the conversation opens up around it. There's the lack of acceptance really on the societal level, that our moods do change - it's a normal part often of being female. I mean, obviously if it's affecting your day to day life in a very difficult way, that's different. But I think that there's definitely room for society to kind of embrace the fact that women are generally cyclical creatures and not going to feel the same from one day to the next and that's not how we've evolved to be.