The Menstrual Cycle as an Overlooked Vital Sign in Psychiatry | Ep. 588

Episode 588

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Friday Podcast, episode number 588.
I’m excited to share today’s episode with you. Today we’re getting into a really
interesting topic. We’re getting into the topic of the menstrual cycle as a vital
sign in psychiatry. And so as some of you may know, several months ago,
I shared a podcast episode based on a research paper that I came across.
And the title of the research paper is “The Menstrual Cycle and Overlooked Vital
Sign in Psychiatry.” And so I went through that paper and what was really
interesting was that The researcher who was sharing this information was making this
connection and really asking why we are not looking at the menstrual cycle. When we
look at specific conditions, there is actually a common cycle of exacerbation of
symptoms related to where the patient is in their menstrual cycle. And those
conditions range from pressure and anxiety and also including PMDD and other known
kind of cyclical issues. But I think what was interesting about that paper wasn’t
just PMDD. It was across the board, and there were many other conditions that seemed
to have this association with the menstrual cycle, where if somebody’s condition
really worsened and they were hospitalized, it was more likely to be happening around
their pre -menstrual phase. So even conditions that are not traditionally thought of
as related to the menstrual cycle, like as the case of PMDD. So today I’m really
excited to welcome the lead researcher who shared this information and we are going
through and she shares with us her findings. So I really think you’re gonna find
this conversation fascinating, interesting, and it’s really lovely to see how various
other professions are starting to make this connection that we actually should be
paying attention to the menstrual cycle. Now, of course, from my perspective, I think
of things cyclically, and I think of things that way. And so, if given just my own
experience of how connected the cycle is to a variety of different issues, I feel
like, to me, that seems natural. Like, of course, you’d want to know if the
condition worsens around that time, especially when we think of the menstrual cycle
as a vital sign. If you are noticing this trend that a person’s symptoms are always
worsening during the premenstrual phase, then that’s an established issue,
at least partially related to hormone imbalances and things like that. And many women
find that when that kind of foundation is improved, they see an improvement as well.
So it’s like, this is a rocket science, but it’s certainly not the norm to be
looking at this aspect of things in the field. So before I jump into today’s
episode, let me introduce my guest to you. So my guest is Dr. Katie Marwick. She
is a medical doctor and researcher working in Edinburgh, UK. She is a psychiatrist
who specializes in supporting women’s mental health during times of reproductive
transition, such as premenstrually, postpartum and perimenopausal. Her research explores
the biology of reproductive transitions and severe mental illness. She aims to improve
care by routinely asking about any links between a person’s menstrual cycle and
mental health symptoms. So with that said, let’s go ahead and jump into today’s
episode.
And I’m excited to be here today with Dr. Katie Marwick. Thank you so much for
joining us today. Thank you for having me. I’m excited to be here. Well, I’m
excited to have you. As I was sharing in the kind of pre -chat before we started
recording, I typically released several kind of what I call my FAM research series
episodes where I go and find new and interesting research and share it with my
audience. And I stumbled across your study, the menstrual cycle and overlooked vital
sign in psychiatry. So I actually did a podcast on kind of my thoughts on your
research, and I was really excited that you decided to join us and share. And of
course, I’ve been saying for a long time that I think the menstrual cycle should be
looked at as a vital sign. And I think the implications in psychiatry are really,
really fascinating. And it’s certainly not an area that I’ve specifically spent a lot
of time focusing on. So before we get into it, I’d love for you to share a little
bit about yourself, your work, and what drew you to this particular topic. >> Yeah.
So I’m a psychiatrist and a researcher working in Edinburgh, Scotland. I’m working as
a reproductive psychiatrist, which is a relatively new concept in the UK. I think
you have it more in the States. At least I’m trying to understand the intersection
of menstrual and mental health across the life course working with people around
pregnancy and postpartum, the premenstrual phase and also the menopause. And I guess
I just was drawn to this topic because once you start looking, you see it’s really
important actually. And I was reflecting on my own training and practice and how it
probably could have been better. I’d like to help things change going forward.
Well, I would love to touch on that for a little while. I mean, that’s certainly a
topic we talk about a lot here, the gaps in whether it’s the care, the education,
the training that a lot of women’s health professionals receive. So just based on
your experience, you mentioned that you felt like there could have been other things
that you learned. What was missing, knowing what you know now? What do you feel
like are some of those gaps? We just don’t bring menstrual cycle or menopause into
the conversation. We just don’t ask about it. I think that’s probably the number one
thing which I would like to change. It’s not always going to be relevant. It’s not
relevant for all people, but I think it’s relevant for quite a lot and it opens up
new treatment avenues and new understanding which I think could really help people.
That was something that really struck me when I read your paper because for in my
world it’s second nature, it’s what I do. So everything I do is informed by the
menstrual cycle charts, if I’m working with a client or in our practitioner program,
that’s kind of like the center and that’s how we gauge how a person’s doing, how
they’re responding to different changes that they might be making. So it’s pretty
wild, especially when it comes to things like PMDD, because it’s obviously cyclical.
It’s part of the definition. So it’s wild that when women are experiencing some of
these things that it’s not even looked at at all. Based on everything that you’ve
seen in your work, why do you think that the menstrual cycle should be considered
as a vital sign in psychiatry in particular? I mean, defining a vital sign as an
aspect of physiology that can give you helpful information about someone’s condition,
I think that applies when someone’s presenting with mental health symptoms. I think
understanding the presence of any links between the menstrual cycle and mental health
can give you improved understanding as to the patterns and the diagnosis and give
you some directions to try for treatment. Mm -hmm. Well, and I think one of the
things that struck me as well was the connections that you were making between, I
mean, PMDD is kind of an obvious, like we know that it’s linked to the cycle.
We know that the symptoms worsen during that week in particular before a woman’s
period, but there were other conditions outside of PMDD that you noted that are
known to worsen around this time. So, did you want to talk about some of those
things and the implications, I suppose, of this? It’s kind of like, to me, it’s
like this obvious like, obviously, if it’s a worse thing around this time, we should
be looking at it, but obviously, not obvious to your typical practitioner here. Yeah,
so you’re right. There’s kind of two main ways that menstrual cycle mental health
can interlink. One is the reasonably well -known PMS, PMDD,
where people have symptoms before a period and then feel pretty fine the first half
of the cycle. But what’s less well -known is what’s called premenstrual exacerbation,
where people might have symptoms of an underlying condition all the time, but they
wax and wane in sync of the cycle. And that seems to show a slightly different
pattern of where it gets worse before a period is due. It could often persist a
bit into the actual days of having a bleed. So it sometimes gets called
perimenstrual exacerbation rather than pre. That doesn’t matter that much. I guess the
point is that this seems to happen in a lot of psychiatric conditions to the point
that it’s probably transdiagnostic. It’s been found in people with depression, panic
disorder, eating disorder, borderline personality disorder, changes in use of
substances, psychotic disorders, including schizophrenia, and probably bipolar disorder.
Well, that may show a slightly different pattern of some people experiencing symptom
or seen around ovulation as well. >> I mean, there’s a few things that came to
mind as you were going through that list. Once upon a time, I was contemplating
going into psychology, not psychiatry. And I did take a pretty significant intro to
psychology class in university. And I remember they went through all of these
different conditions. And obviously, that was never even a thought that the
symptomology could be impacted by the cycle. It never came up at all. So at what
point did you start to see these connections? So how did you, ’cause there’s a lot
of, if we think about the history of psychiatry, there’s probably millions of
psychiatrists that have worked with females for many years, their whole careers, and
they never came to this conclusion. So what was it that prompted you or kind of
eluded, like what made this come to the forefront in your work? – A couple of
things. One is I was caring for women experiencing postpartum psychosis,
a really severe psychiatric complication of childbirth and around 70 % of people who
have that go on to have a diagnosis of bipolar disorder and I was interested to
know whether other times of reproductive change were associated with worsening of
bipolar symptoms too. So I was interested interesting perimenopause and also the
perimenstrual phase and started looking into it from a, trying to get a mechanistic
understanding as to why these get a reproductive transitions or times of risk and
severe mental illness. – That is really fascinating. And one of the things I love
about podcasting is that I have the opportunity like we’re doing now to kind of, to
talk to people. And over the years, what I find fascinating is that you can have a
whole field where people are not picking up on this, but it just takes a few keen
observers to start asking questions of, like, wait a minute, why does this issue
seem to be getting worse around this time for us to start to see change?
And so in the paper, I think you talked a little bit about some of the ways that
you’ve observed this and I feel like what was interesting about the paper as well
as it was kind of intermixed with a narrative of personal experience of these
changes related to the cycle. So although you kind of described how you made that
link, how do you know that these symptoms are worsening? Is it because of patients
who are sharing that information? Are there studies that have shown it? Maybe share
a little bit about how do we know that these symptoms, like it doesn’t surprise me,
but what are some of those tangible pieces of data that show us that this is
really happening? Yeah, well, there’s there’s two ways for that. I cited a study in
my perspective piece, which was a systematic review of prospectively recorded symptom
tracking. So a perspective as in going forward over time and recording symptoms
alongside menstrual cycle. And the offers of that study gather together all the
studies they could find and looked across all the studies and all these different
disorders to come to these conclusions. And that’s important because it is a
developing field. Small studies, it’s easy to find false positives or false negatives.
And it does seem to be the case It’s just looking back over time. It’s easy to
see associations that maybe aren’t actually there between how you feel and your
period. We tend to remember when things are the case, rather than when they aren’t
the case in our own memory. So there’s that pretty solid set of science supporting
it. And the other aspect, as you mentioned, is the lived experience. As soon as I
start asking people or mentioned to people that I’m even interested in this area, it
just comes spilling out. People are so fascinated and really notice it. It was
pushing against an open door really and it was great having the lived experience
account from my co -author just to kind of give, I think most doctors like having a
case to hang things on. It’s easier to remember things with a patient example, and
it’s easy to find that when you start looking in this area. It definitely, I would
imagine that to have this conversation with highly trained professionals, having that
story within the research, like you said, it makes it more memorable and also helps
to drive the point home and potentially help them to make some of those connections
or even just to understand the value of simply asking a woman about her cycle and
understanding that there could be that connection there. I enjoy both types of
research. You know, I enjoy the data and all of that as well, but I really do, I
love it. I always feel like when I find a qualitative study, it’s like, because
it’s really fun to be able to actually see that person -to -person data.
Although we can’t make all the conclusions in the world based on that, I feel like
when you have a field where you do have that evidence, but you also have those
qualitative pieces, it really paints a full picture. And especially as someone who is
sharing information, it helps to make it more real for people. Yeah. And a couple
of things, I guess, my own assumptions got next by talking to people who’ve lived
experience. You, for example, that I guess I kind of assumed people would have
noticed themselves any patterns already, not the case. Sometimes it is helpful having
an external person ask or comment. And I think also, I think maybe one of the
reasons psychiatrists aren’t great at asking about periods is feeling it’s kind of
icky, a bit intrusive. And again, my co -author was just, you know, very down to
earth. She’s like, you know, you ask me if I’m suicidal.
That’s pretty intrusive too. You ask me how my sleep is. Having a period it’s just
another aspect of physiology and in some ways we’re kind of blaming the fans of
stigma by not asking.
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Oh my goodness. I love that so much and it’s it’s so interesting to hear you to
hear you say that because of course being that this is what I do and I’m very
comfortable I will tell the mailman right like if someone asked me about it I’m
because the periods and the vaginas and all the things but I did go to in my mind
before you said that like I would imagine that you’re asking way more intrusive
questions than when your last period was when you’re working with someone who’s
dealing with some major psychiatric disorder. So that’s really cool that it was able
to challenge some of your assumptions. And I did also want to kind of go back to
what you said about your assumption being that people would make the connection. And
I emphatically agree with you that no, even if a person has four years of their
life, I would imagine, had this exacerbation of symptoms specifically around their
periods. Many women, even if they have that for years, until someone points it out
to them, they’re not really thinking about it. So I’ve definitely found that as
well, where just having the experience if you, because also we haven’t been taught
about our cycles and we’re not really thinking about them unless we’ve been taught
about them. So I think, and you’re just experiencing it, and I think a lot of
women, their cycles aren’t great. So they are also just trying to get through it as
survival. So I feel like those are huge pieces. And it’s also really interesting for
me to hear your perspective on that, because it also shows me where the assumptions
of various practitioners could be as well. Like, well, if this was really an issue,
she would bring it up. when she probably wouldn’t bring it up. Yeah.
Oh, sorry, go ahead. Yeah, no, yes, I guess I suppose we do say to people, what
makes it better or what makes it worse? We ask these very broad questions, but then
we can have a bit of a mental checklist you might run through like relationship
problems or money problems or physical health problems, but tend not to explicitly,
yeah, we don’t explicitly ask, how about your periods and I just feel like we
should add it to our checklist. Yeah, absolutely. And so when I think of the
menstrual cycle as a vital sign, I mean, I’m coming at that with a certain
perspective. So my perspective on it is that a vital sign, if it was your blood
pressure or your heart rate, there’s an ideal, there’s an optimal, there’s a normal.
And so if we know what that normal is, and then it’s off, it’s telling us, okay,
there’s an issue. So one of the concepts I want to ask you about, so I’ll try to
frame the question in a way that makes sense, is every woman who has a menstrual
cycle doesn’t necessarily have or so I’ll try to phrase this question and I’m
putting in maybe a little bit some assumptions or something like that. So first of
all, every woman with a menstrual cycle doesn’t have severe PMS symptoms. So I’ll
put because it’s because they don’t like there’s some women who don’t have We’re not
even talking about psychiatric disorders yet. We’re just talking about PMS. So some
women don’t even have severe PMS symptoms and one of the arguments that I make is
that if we’re looking at it as a vital sign if a woman has PMDD to the point
that she it’s an impacting her daily life. She can’t function That tells us that
there’s something wrong with Her like her cycle like there’s something wrong because
it’s not supposed to be like that So I guess what I’m trying to ask is what are
the implications then of this because I think one way people could look at it It’s
like well the cycle is Just so bad and everyone with this psychiatric disorder.
It’s gonna make it way worse as Opposed to looking at like well, this is a sign
that there’s something wrong. And if it was rectified, maybe it wouldn’t get so bad
around the cycle. So I hope that that made sense, but I’d love to hear your
thoughts on it. Yeah, interesting. Yeah. I suppose another possibility is it
potentially people have some sort of genetic vulnerability or early life exposures,
which make them predisposed to have a difficult menstrual cycles and there may be
things you can do to improve and optimize in the moment, but some people perhaps
are more prone to that than others. Yeah, like a problematic cycle could mean it
could be a readout of current status, but it also could tell you about people’s
makeup, I guess, you know, genetic or early life. Mm -hmm. And one of the things
that I feel like that you touched on in the study was the potential for treatment
in a different way. And there was a comparison of the typical approach,
which would be different psychiatric medications versus potential hormone replacement
options. Did you want to talk a little bit about that as well? Because again, I
think then from my perspective, which I think is a bit different, would be like if
there’s a hormonal potential solution, that would indicate there’s a hormonal
imbalance. And if we sorted out the imbalance, then maybe the symptoms wouldn’t be
so bad. And kind of getting back to the vital sign piece of it. But I thought
that was really interesting that you shared the… So talk a little bit about, I
guess, the comparison between the current kind of under psychiatric medications for
certain disorders versus the hormonal kind of approach that you talked about. – Yeah,
so I suppose if someone’s presenting with mood symptoms, anxiety symptoms, suicidal
thoughts, you, and you’re making a diagnosis of a depression or anxiety disorder,
then your kind of normal tools are lifestyle changes, talking therapy and medication.
And applications tend to be focused around neurotransmitters, particularly serotonin,
for the mood and anxiety into things. So that would be selective serotonin reuptake
inhibitors like phlox, tenor or prozac are often first line. But if you’re
identifying, there’s a link with menstrual cycle and I suggest that there may,
it could be a hormone imbalance, it could be an altered sensitivity to normal
hormonal changes. I don’t think we’ve got that one totally sorted out yet,
scientifically, but what the current guidelines in the UK that there were a College
of Obstetricians and Gynecologists have created advises that you can try to stabilize
the level of hormones. So mostly that’s done by suppressing ovulation and you’re
giving extrinsic hormones, or if it’s hormone replacement therapy, ovulation might
continue, but there’s kind of more stable background replacement level. That’s not
normally in a psychiatrist’s toolbox to even think about trying that. That is really
interesting. I mean, I think that my audience is familiar with the concept of like
women with severe PMDD symptoms for them to be medicated with hormonal birth control,
like you said, to suppress ovulation so that they’re no longer having the natural
change in influx of hormones. And so, I mean, that’s a whole conversation because
there’s certainly a camp of women who disagree with shutting down ovulation as the
solution because that has implications as well, right? But again, what’s interesting
is that then there’s different ways to look at it. One of the ways ways is just
to demonize hormones and be like kind of like the old school researchers who only
did research on male animals and males because they don’t have this hormonal
confusion to deal with. So kind of demonizing hormones altogether to shut them down
and then she’ll feel better, which has its own implications versus the concept of
like what you said, like doing some sort of stabilization, which would imply that
there’s some sort of imbalance. And if did, the woman could feel much better or
potentially have a reduction in symptoms. Yeah. Yeah. The shutting down hormones, you
may be thinking about it had a truth in releasing hormone analogues,
which induced like a medical menopause. And that is also an option for really severe
PMDD. But try not to use that unless you have to. It’s always a risk benefit
scenario because PMDD can be absolutely terrible and for some people it’s
transformational, but yeah, where possible being, you know, the gentlest intervention
possible is definitely preferable. Well, and I feel like when you were talking about
the medication, now I didn’t read it this morning, I did read it a few weeks ago,
but what I remember was that there were these implications that in some cases,
going the hormonal route was as effective in some cases as some of the other
medications, which again, I mean, could you talk a little bit about like what the
potential benefits of that is? It’s not my field. So I don’t know what all of the
side effects associated with SSRIs. But I’m not up to date with all of the
potential side effects and downsides of these types of medications, could there be a
benefit for treating women for whom there is this cyclical component with hormonal
therapies versus doing the full -on typical psychiatric drugs? Yeah,
well, I think for some women, SSRIs work well in the region of two thirds,
but they don’t work for everyone. The same is probably true with the hormonal
treatments. So it’s a little bit of a trial and error approach,
unfortunately. It would be really great to be able to say to people, “Hi, this is
your subtype and this is what you need, but we’re not there yet.” So there’s that.
There’s just the fact that some people don’t want to take SSRIs. They don’t like
the idea of influencing their brain chemistry directly that way, although changing
hormones does indirectly influence brain chemistry too, so does talking, you know,
it’s all a spectrum. And then, yes, for some people, the side effects of SSRIs are
too much. Majority people tolerate them okay, but some people just don’t, some people
are just more sensitive, headaches, nausea, slight feeling of agitation,
It’s something that particularly concerns people as loss of sexual function,
particularly the ability to have orgasm. And yes, some people report that doesn’t
seem to come back after a successful that that isn’t what the product literature
says.
I mean, that’s a pretty significant side effect. I don’t think I was aware of that
one. So it’s interesting then, because it sounds like the implication is that it
could be an additional tool in the toolbox of the doctor, the psychiatrist,
where it could give them more options and potentially address certain concerns that
some patients might have. If a specific patient has concerns about the SSRI class of
drugs, then it does give another alternative or if someone isn’t responding to those,
either way, it still provides an alternative. And I have another question along these
lines, which is, because I’m finding this all very interesting, because if there’s a
hormonal row for some women that can kind of reduce some of these symptoms, does
that mean that the cyclical component for them is enough that it’s,
so I’m trying to think of how to ask this question, because are there women who
are mostly okay, but it’s like in that time period is when they have their big
problem and outside of that leading up to the cycle, they’re basically okay. Again,
try to phrase the question, but with psychiatric disorders, you would assume the
person has the psychiatric disorder all the time. But if there’s a potential for the
hormonal treatment to work in certain cases, then that would mean that they’re kind
of okay a lot of the time. But then when they go into this phase, they’re really
kicked into, like, really dangerous territory. Hmm. Yeah. So I think, I think what
you’re trying to get at is if the hormones could be corrected, would that be
enough? You would they not need to have other psychotropic medications? That’s a much
better way of asking it. Yeah. Yeah. No, no, it’s okay. I think I might disappoint
in my answer, which is probably we’re not sure, like, It’s hard to put a proportion
as to how many people with a severe mental illness that would be the case for.
I suppose looking at the other way, studies that have tried to look at the
association of menstrual cycle stage and psychiatric admission has found that all
cause psychiatric admission in women who menstruate is about 20 % higher and for
psychosis is about 50 % higher, so that’s a pretty big increase.
So if we could stabilise the cycle in people with psychotic illness,
would that reduce admissions by 50 % or a third? Potentially.
I think the next step for psychiatry is probably to be thinking about using hormonal
treatments alongside established treatments for most people, things like antipsychotic
treatment for schizophrenia, for example, and maybe that might allow the doses of the
other treatments to be a bit lower, which is always a win in terms of reducing
side effects.
That is just so, – It’s just so interesting. What’s interesting about it obviously is
that there is this potential for just the improvement, I suppose, of quality of
life, the reduction of the need for, whether it’s the need for certain medications
at all or whether it’s just reducing the amount or whether it’s just related to
stabilizing their condition so that there’s fewer severe incidents where they have to
be hospitalized. I mean, there’s huge implications of that. And if you, like what
you said, there’s this possibility, of course, you’d have to kind of implement it
and see what, how it turns out. But there’s this possibility that in some cases, it
could reduce those admissions by up to 50%. Like that’s, that’s pretty wild. Yeah.
Yeah. And I mean, if there was a magical drug that could do that, it would
probably already be on the market, right? Yeah, Exactly. Yeah, I think,
you know, it’s definitely a case for looking into this more. And the other thing I
was going to say is we’ve talked quite a lot about medication, but I think it’s
also important to think just about the role of understanding what’s going on from
the persons and their supporting teams perspective. If it was the case,
but things are always worse around the time of periods, then you can have that in
people’s wellness recovery action plans and listed as a trigger and the person or
the friends and family can say, okay, we know, we know what’s good on here. Let’s,
let’s not do this other stressful thing at this time or something that people in
clinic have said to me is that they, like they know that this will pass. And it’s
not that we always want people just to tough it out, but, but knowing that it
probably won’t still be like this in three days time, I think that does help some
people to get to get fruited or feeling. – I love that you said that because,
and I mean, my questions around the medication were certainly based on that kind of
curiosity and thinking about some of the things that you said. But as general port
of call, my first strategy for anyone isn’t necessarily like, let’s go straight to
the medication. So I’m really glad that you brought that up because there is a lot
of value just for, I know there’s been a lot of value in my life over the years,
tracking my cycles and understanding how my moods can shift a little bit, my energy
levels can shift a little bit so that I can then organize my work life, my family
life in such a way that there aren’t as heavy demands on me during those days
leading up to my period or during the times that I’m actively bleeding. And a lot
of women find that by simply shifting their routines, their schedule. And if they
know, so I’ve certainly worked with some clients with some really severe, let’s say
endometriosis symptoms, where they just until they get that stabilized, they’re having
a couple of really rough days every cycle. If they know that and they can chart
their cycles, they can kind of track when they anticipate their period is coming,
even just having that information, scheduling a load or kind of scheduling a couple
of days where you can rest that in and of itself, even if the symptoms aren’t
totally gone, has certainly been a game changer for many clients. I feel like that’s
a really powerful message, what you said about having action plans based on that,
and letting friends and family know and having the patient themselves know that this
is related to the cycle and it’s not going to just, especially if it relates
suicidal thoughts or like all these other things that are going on horrible to deal
with. But knowing that there’s a light at the end of the tunnel is, I think for
some people enough to have them actually be able to get through it. Yeah. It has
the potential to be empowering for people. So I feel like we’ve already like got
through this, but I still have to ask because I like to put that like all the
nails in the coffin. Like So why, in your opinion, are these doctors not asking?
Like, why did it not occur to them? Like, yeah, is it to do with the training,
you think? – Well, I mean, I can’t answer for everybody, but it is something I
bring up and try to understand. And I think there’s probably a few reasons. The
default male assumption, which pervades so many aspects of life, definitely extends to
medicine and psychiatry where we just don’t really think much about female specific
factors, including menstrual cycles. I think also there has,
it’s interesting actually, if you go back to 19th century psychiatry, the menstrual
cycle, menopause were thought about and talked about a lot more as associations with
mental health symptoms. And I think we perhaps have gone a little bit too far the
other way in trying to not stigmatize women and sort of play to this centuries old
concept of the fragile, hormonal female, if it’s unreliable, vulnerable.
The way it’s been framed in the past, I think it’s been quite negative towards
women. And of course, you can frame it a different way about this incredible
process, this complex orchestra of hormonal and other changes that make women
optimized for what’s needed or what potential they have at each stage of her cycle.
Can be an amazing thing, but it’s historically been used against women. And I think
perhaps that may have made at least some patients feel that it’s a bit kind of
invalidating or reductionist to have it suggested, but it’s over hormones. Whereas We
know that lots of other things vary between men and women, which may increase
women’s risk of mental health problems.
Structural inequalities, violence against women, sexual violence. There’s a lot of bad
stuff that goes on, but it isn’t hormones. We don’t want to just say that that’s
all it is, because it kind of takes pressure off of our important areas. So that’s
kind of two big reasons. And I think probably another Everyone has just not really
been sure what to do with the answer. If someone says, “Yeah, I think it’s really
related to my periods,” I’m like, “Oh, God, well, what do we do by that? Who do
we ask?” It makes you probably make us feel a bit exposed when that kind of comes
back to the training bit. You get stuck in a bit of a vicious cycle, I guess.
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Those are really good answers. I mean, obviously you’ve contemplated this a lot.
It’s a part of your work. Yeah, it makes me think as well because it makes a lot
of sense. And the historical aspect of it is also really interesting to consider,
because yes, we do come from this history of, oh, she’s hysterical. Let’s just cut
out the uterus. Like, because that’s like all that kind of stuff. And, but you’re
right when you say that we’ve gone too far in the other direction because while we
don’t want to be stigmatized in that way because we have a cycle, we do have a
cycle. So the solution to not stigmatizing us isn’t to pretend that we don’t have
one. It’s to sort it out and to actually start researching females,
women with menstrual cycles, so that we can stop putting it under the rug. I think
a lot of people are really surprised by that. I mentioned that in an interview that
I did. It was this in -person interview that I did for Primarily Pure, their
podcast. They flew me out to California and I was interviewed by one of the hosts
of the show, who’s a woman, but the whole crew was male. So the cameraman, the
sound guy, the lighting guy, all these men are in the room. And it was like the
men that are like, “What do you mean that they’ve only studied most researches done
on male animals? What do you mean?” So I think most people don’t know that that’s
the history. Most people don’t know that even drugs, Most drugs, historically, were
not even tested on women. Hopefully, this is changing. Obviously, huge implications
for the field of psychology or psychiatry, I should say, and psychology. But so
another question along those lines then, in terms, well, sorry, and then I really
was thinking about what you said about like, “Well, then what do we do about it?”
If I ask it, I don’t know what to say. I thought it was really really funny too.
But so what’s the solution? If you could wave a magic wand and shift the whole
psychiatry field, how could it be different? What do you think would need to happen
in order for the average psychiatrist to have this piece as part of their working
practice with all their female patients? That’s a really good question. Yeah. It’s
just sharpening up my magic wand here. I mean, I think it’s got to start in
medical school, actually. We’re talking about a systemic change. It’s massive. And
it’s not just psychiatry, lots of medical specialties, you know, diabetes, asthma,
migraine, epilepsy, these also changes with the menstrual cycle as well. So it just
seems to be built in. We get taught something at medical school called a systemic
inquiry. I don’t know if you have it in the States as well, but the idea is that
you’ve heard what the patient has to say and you kind of run down a whole list of
stuff at the end and you recover all the different systems, you’re a logical but
not menstrual cycle. So I think it just used to get slotted in there so we just
routinely inquire. So for people who are already psychiatrists that’s going to mean
like more access to education opportunities through your continuing professional
development, for example. I think it’s going to need communication across specialties
as well, as a psychiatrist who’s learned how to do things like prescribe hormonal
contraception and hormonal replacement therapy is quite bamboozling to start with.
There’s a lot of long names, so it sounds ridiculous, but getting it all clear in
heads, it takes an effort. And it may well be that not all psychiatrists end up
being all fair with that, but we need to have colleagues in gynecology with kind of
well established lines of communication, you could help us or in primary care, if
it’s if it’s something that we would expect a GP to be able to handle, ask our
colleagues for help there. Yeah, as I speak, I’m thinking that GPs are very
overburdened in the NHS at the moment. But I do think this is something that could
potentially save resource and money down the line, as well as make women feel
better, which is kind of the point really.
Well, you know, Dr. Katie, I would love to give you that magic wand, because I
feel like all of your recommendations and suggestions were very sound. And if those
things happened, it would be different for women. We would suffer less and have more
answers because I think for a lot of women, they’re suffering cyclically. A lot of
women are suffering cyclically. I think one of the things that your paper really
touches on is that there are millions of women that are struggling already with
psychiatric illnesses who don’t even know that it’s worsening around their period in
a cyclical way. They might just feel like it’s out of control because they’re
already compromised a bit because they’re not, they’re already struggling with an
illness. When you’re struggling with an illness, you’re not exactly top of mental
clarity to be able to sort all the stuff out. Like, that’s why we need help.
That’s why we need our practitioners to be able to support us and all of that good
stuff. So, so there’s a huge implication here and a huge opportunity as well.
And I hope that your paper is the start of a broader conversation that it’s hard
though, is the research tells us that it takes 20 years for new research to end up
in the offices of our professionals. And I think when I first heard that stat many
years ago, it kind of sounds nuts. But when you think about what has to happen,
really it has to trickle down into the schools. And then the next generation of
professionals have to go through the schooling and be working in practice. Because as
you said, the psychiatrist that’s been practicing already for 30 years. Is he
changing his or are they changing the way they practice? I mean, maybe some of
them, but I would imagine that that’s not really where we’re going to get the
change.
Well, oh, no, go ahead. Sorry. I’m always don’t worry. Whatever I prefer and thought
I was going to have his flown away. Well, my apologies for that. Well,
all I was going to say was that we have covered so much ground. We have had such
a, I’m just, this has been a fascinating conversation. And I can just imagine how
much my listeners are going to enjoy this, particularly my listeners who have
struggled with mental health challenges or they have patients, clients, family,
friends who struggled. It’s just so eye -opening. And a lot of things related to the
menstrual cycle, I feel like in retrospect, it’s like, well, obviously. So after you
get, after you kind of hear this concept after that, every, I’m sure for you as
well, it’s like, well, obviously that’s why she had this exacerbation at that time.
And but for the person who’s never heard it before, it’s just, you know what I
mean? Like so many things come into play all of a sudden, it makes sense. Like,
wow. So with So with all that in mind, for the listener, whether she has personally
dealt with mental health issues or whether she’s a clinician working with patients
who have dealt with these issues, what, if anything, would you want them to know
and take away from our conversation? I would just ask, do you think there’s any
link between your mental cycle and your mental health? And then just go from there.
But it might be that you just note it, understand it. It might be that you try to
treat it or seek advice on how to change things. But I think if we don’t start
asking, then we can’t change anything. Well, I feel like those are wonderful words
to end on. Such a simple message. But if everybody did that, what a difference it
would make in the field of psychiatry? Yeah, well, I mean, it’s just, there’s a
part of me that’s like, come on, psychiatrists, let’s go, let’s do this.
Katie outlined what you need to do. This is not that complicated, but obviously it
is complicated. Well, so share with us a little bit about yourself, about where you
are in the world, you know, what you do, if you have your website information if
anyone wants to connect with you and anything exciting that you have coming up on
the horizon. Well, I’m a psychiatrist and researcher working in Edinburgh,
Scotland. I’m on LinkedIn. That’s my foray into social media. My main focus is
trying to get funding to do more research, but also to with policy makers and my
clinical colleagues to try to make some changes already because there’s various,
it’s always useful to find out more things, but some things are obvious that we can
start doing already. So I guess I’m really interested in hearing from Lyft experience
accounts. That’s really informed the directions that my research has gone in,
particularly people order. Yeah, I’m not, I’m not able to offer medical advice.
I’m afraid without coming through my clinic, but always interested to hear people’s
stories if they want to. Okay, well, I will be sure to link your LinkedIn and any
other resources. I’ll link the paper that started this whole conversation. So our
listeners can go have a read again the paper that started my Just my interest in
this topic is called the menstrual cycle and overlooked vital sign in psychiatry. And
I just want to thank you so much for being here today. This was such a great
conversation and I’m really excited to share it. Yeah, well, thanks for the invite.
It’s been good to toss ideas around. Thank you for listening. If you enjoyed today’s
episode and you’re wanting to share it with a friend or you’re wanting to grab any
of the links that we talked about, head over to fertilityfriday .com /588.
Well, I hope that you enjoyed today’s episode with Dr. Marwick. I mean, what a
fascinating topic. And I feel like after you hear this conversation, it’s similar to
how women discover charting and it’s like after they start charting, it’s like, “This
is just so basic. Why should we not be doing this?” Right? So I feel like after
hearing a conversation like this, it’s like, “Well, duh, of course we should be
doing this. How are we not doing this? How is this not happening, right? Especially
with these significant links to the menstrual cycle with all these other conditions
that you wouldn’t necessarily think. I mean, this is what happens when we have a
system that’s based on the male body, right? Like, let’s call it like it is. All
of our systems, conventional approaches are based on the male as a standard model,
and the woman is basically a mini man. And so we don’t really look at some of the
specific complexities or nuances that would apply to women that really need to be
looked at and studied specifically. So I would say, of course, like that is a big
problem. And even if you think about the conversation that we had today, I mean,
this is the missing piece. We’re just not looking at women. We’re not thinking about
women of reproductive age. And we’re certainly not thinking about menstruation as the
cyclical thing that is going to affect their conditions, even seemingly unrelated
conditions, even though it’s right there in the data. So that absolutely stood out
to me in today’s conversation. I think the other thing, I mean, there’s a lot of
things that stood out to me. One of the other things is how powerful it is, not
even to have all the answers, but just to start asking the question, how powerful
is it just to start asking the question of, are these symptoms at all related to
your cycle? Have you ever track to see if your symptoms are somewhat cyclical.
And even just knowing that the symptoms are related to the cycle as a first step
can help you to move through them. And one of the examples that stands out was
just when she was saying that for some of her patients it’s just knowing that this
is related to the cycle means that it’s not going to be like this forever. Whereas
before, you’re experiencing all of these emotional changes and it feels very intense,
but you don’t have the frame of reference to know that this is a cyclical thing.
So you kind of feel like, well, this is going to last forever. And it makes the
downward spiral even worse. Just knowing that when I’m in my this time of my cycle,
I tend to have worse symptoms, just gives you a little bit more control and to
know that this is something that happens. And the more that you experience it. So
for many women who are cycling, you can think of your own experience if you’ve been
cycling and paying attention to your cycles, or if you’ve been working with clients
who’ve been paying attention to their cycles, even just knowing that you have certain
changes in shifts in energy and mood and things like that. And when you track your
cycle, you know it’s coming. You are able to strategize around it, so that’s the
first step. And of course, in our programs, we teach our practitioners to take it
to the next step, which is now that we know, let’s look at what’s happening in the
cycle, let’s look at what’s happening hormonally and let’s find out how we can
support and stabilize that situation because often when you support hormone production
to get the cycle to a more healthy place where you can actually see she has a
sufficiently long luteal phase, you can see that the temperatures are where they
should be, you can see the signs of hormone normalization on the chart. That tends
to correspond with an improvement of certain symptoms. It doesn’t solve the whole
problem, obviously, but how much better would that experience be for women who are
having such detrimental psychiatric responses? How much better would it be for them
to actually be able to stabilize those hormones a bit when you’re tracking?
You can see very specifically, you can start rating your symptoms, you can see
tangible changes if you’re moving in the right direction. And even if you’re able to
improve the symptom situation by like 20%, that’s huge, right?
And most of us would want that. So something to think about, I just really enjoyed
this conversation. And again, one of the things that stood out to me was just how
powerful it would be in the field of psychiatry if the professionals were trained
just to ask their female patients about their cycle to see if there was any
connection. Like it would like shift things so much for such a huge percentage of
women. So I really hope that we get there at some point. So with that said,
if this episode resonated with you and if you can think of someone who you think
really needs to hear it, the share link is fertilityfriday com /588.
And with that said, I hope you have a wonderful week weekend whenever you’re tuning
into the show. And of course, as always, until next time, be well and happy
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