The Menstrual Cycle as an Overlooked Vital Sign in Psychiatry (Episode 588)

Full Transcript: Episode 588

Lisa Hendrickson-Jack:

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: An 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 depression 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 premenstrual phase. So even conditions that are not traditionally thought of as related to the menstrual cycle, like 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 going to 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, 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 isn’t 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.

Lisa: And I’m excited to be here today with Dr. Katie Marwick. Thank you so much for joining us today.

Dr. Katie Marwick: Thank you for having me. I’m excited to be here.

Lisa: Well, I’m excited to have you. As I was sharing in the kind of pre-chat before we started recording, I typically release 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: An 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.

Dr. Marwick: 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. 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. And I’d like to help things change going forward.

Lisa: 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?

Dr. Marwick: 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.

Lisa: That was something that really struck me when I read your paper because 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?

Dr. Marwick: 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.

Lisa: 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 one; 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 of this? It’s kind of like, to me, it’s like this obvious thing — obviously, if it’s worsening around this time, we should be looking at it. But obviously not obvious to your typical practitioner.

Dr. Marwick: Yeah. So you’re right. There’s kind of two main ways that menstrual cycle and mental health 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 with the cycle. And that seems to show a slightly different pattern where it gets worse before a period is due. It can 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 it 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 — although that may show a slightly different pattern of some people experiencing symptoms around ovulation as well.

Lisa: 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? Because there’s a lot — 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, what made this come to the forefront in your work?

Dr. Marwick: 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 in perimenopause and also the perimenstrual phase, and started looking into it from a trying-to-get-a-mechanistic-understanding as to why these reproductive transitions are times of risk in severe mental illness.

Lisa: 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 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 what was interesting about the paper was it was kind of intermixed with a narrative of personal experience of these changes related to the cycle. So although you 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 are really happening?

Dr. Marwick: Yeah. Well, 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 prospective as in going forward over time and recording symptoms alongside menstrual cycle. And the authors of that study gathered 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 that 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 mention to people that I’m even interested in this area, it just comes spilling out. People are so fascinated and really notice it. It’s 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.

Lisa: It definitely — I would imagine that to have this conversation with highly trained professionals, having that story within the research makes it more memorable and also helps to drive the point home and potentially helps 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 always feel like when I find a qualitative study, 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.

Dr. Marwick: Yeah. And a couple of things — I guess my own assumptions got mixed up by talking to people with lived experience. 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 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 very down to earth. She’s like, you know, you ask me if I’m suicidal, and 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 playing into the fans of stigma by not asking.

Lisa: Oh my goodness. I love that so much. And it’s so interesting 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 — 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 was your last period” 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 for years of their life 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 — 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. And I think a lot of women — their cycles aren’t great, so they are also just trying to get through it in survival mode. 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.

Dr. Marwick: Yeah. I guess we do say to people, “What makes it better, what makes it worse?” We ask these very broad questions, but then we have a bit of a mental checklist we might run through — like relationship problems or money problems or physical health problems — but tend not to explicitly ask, “How about your periods?” And I just feel like we should add it to our checklist.

Lisa: 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. One of the concepts I want to ask you about is that every woman who has a menstrual cycle doesn’t necessarily have severe PMS symptoms. 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 it’s impacting her daily life, she can’t function — that tells us that there’s something wrong with her cycle. 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 is like, well, the cycle is just so bad and everyone with this psychiatric disorder, it’s going to 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.

Dr. Marwick: Yeah. Interesting. I suppose another possibility is potentially people have some sort of genetic vulnerability or early life exposures which make them predisposed to having 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 be a readout of current status. But it also could tell you about people’s makeup — genetic or early life.

Lisa: And one of the things that I feel like 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 hormonal approaches. Did you want to talk a little bit about that as well? Because again, from my perspective, 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. Talk a little bit about the comparison between the current standard psychiatric medications for certain disorders versus the hormonal kind of approach that you talked about.

Dr. Marwick: Yeah. So I suppose if someone’s presenting with mood symptoms, anxiety symptoms, suicidal thoughts, 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 medications tend to be focused around neurotransmitters, particularly serotonin for the mood and anxiety end of things. So that would be selective serotonin reuptake inhibitors like paroxetine or Prozac — often first line. But if you’re identifying there’s a link with the menstrual cycle, and that suggests there may be a hormone imbalance or 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 from the Royal College of Obstetricians and Gynaecologists advise is that you can try to stabilize the level of hormones. So mostly that’s done by suppressing ovulation and giving extrinsic hormones, or if it’s hormone replacement therapy, ovulation might continue but there’s a more stable background replacement level. That’s not normally in a psychiatrist’s toolbox to even think about trying.

Lisa: That is really interesting. I mean, I think that my audience is familiar with the concept of women with severe PMDD symptoms being medicated with hormonal birth control to suppress ovulation so that they’re no longer having the natural change in influx of hormones. And so 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. But what’s interesting is that there are different ways to look at it. One of the ways is just to demonize hormones altogether — kind of like the old school researchers who only did research on male animals because they don’t have this hormonal complexity to deal with — and shut them down, and then she’ll feel better, which has its own implications. Versus the concept of doing some sort of stabilization, which would imply that there’s some sort of imbalance, and if that was corrected, the woman could feel much better or potentially have a reduction in symptoms.

Dr. Marwick: Yeah. The shutting down hormones — you may be thinking about gonadotropin-releasing hormone analogues, which induce like a medical menopause. And that is also an option for really severe PMDD. But we try not to use that unless we have to. It’s always a risk-benefit scenario because PMDD can be absolutely terrible and for some people it’s transformational. But where possible, being, you know, as gentle as possible with intervention is definitely preferable.

Lisa: Well, what I remember was that there were these implications that in some cases going the hormonal route was as effective as some of the other medications. Could you talk a little bit about what the potential benefits of that are? Could there be a benefit for treating women for whom there’s this cyclical component with hormonal therapies versus doing the full-on typical psychiatric drugs?

Dr. Marwick: 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, “Aha, this is your subtype and this is what you need,” but we’re not there yet. There’s also 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. It’s all a spectrum. And then yes, for some people the side effects of SSRIs are too much. The majority of people tolerate them okay, but some people just don’t. Some people are just more sensitive — headaches, nausea, slight feeling of agitation. And something that particularly concerns people is loss of sexual function, particularly the ability to have orgasm. And yes, some people report that that doesn’t seem to come back after SSRIs — that isn’t what the product literature says.

Lisa: 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 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 — if there’s a hormonal route for some women that can kind of reduce some of these symptoms, does that mean that the cyclical component for them is enough that they’re kind of okay a lot of the time, but then when they go into this phase, they’re really kicked into really dangerous territory?

Dr. Marwick: Yeah. So I think what you’re trying to get at is: if the hormones could be corrected, would that be enough? Would they not need to have other psychotropic medication? I think I might disappoint in my answer, which is probably we’re not sure. 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 it 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 stabilize 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.

Lisa: That is just so interesting. What’s interesting about it obviously is that there is this potential for the improvement of quality of life, the reduction of 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 are fewer severe incidents where they have to be hospitalized. I mean, there are huge implications of that. And if what you said is the case — there’s this possibility that in some cases it could reduce those admissions by up to 50%. That’s pretty wild.

Dr. Marwick: Yeah. And I mean, if there was a magical drug that could do that, it would probably already be on the market, right?

Lisa: Yeah. Exactly.

Dr. Marwick: I think 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 person and their supporting team’s perspective. If it was the case that 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 what’s going on here. Let’s not do this other stressful thing at this time.” Or something that people in clinic have said to me is that they know that this will pass. And it’s not that we always want people just to tough it out, but knowing that it probably won’t still be like this in three days’ time — I think that does help some people to get through how they’re feeling.

Lisa: I love that you said that. And I mean, my questions around the medication were certainly based on that kind of curiosity. But as a 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 in — 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. A lot of women find that by simply shifting their routines, their schedule — and if they know, I’ve certainly worked with some clients with some really severe 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 lighter 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 last. Especially if it relates to suicidal thoughts or 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.

Dr. Marwick: Yeah. It has the potential to be empowering for people.

Lisa: So I feel like we’ve already gotten through this, but I still have to ask because I like to put all the nails in the coffin. So why, in your opinion, are these doctors not asking? Like, why did it not occur to them? Is it to do with the training, you think?

Dr. Marwick: 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 and 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 — who’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. It 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 invalidating or reductionist to have it suggested that it’s all her 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 that isn’t hormones. We don’t want to just say that that’s all it is, because it kind of takes the pressure off other important areas. So that’s kind of two big reasons. And I think probably another is just not really being sure what to do with the answer. If someone says, “Yeah, I think it’s really related to my periods,” you think, “Oh God, what do we do with that? Who do we ask?” It makes you feel a bit exposed. Which kind of comes back to the training bit — you get stuck in a bit of a vicious cycle, I guess.

Lisa: Those are really good answers. 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” and all that kind of stuff. 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. Most people don’t know that most research has been done on male animals. Most people don’t know that most drugs historically were not even tested on women. So another question along those lines — if you could wave a magic wand and shift the whole psychiatry field, 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?

Dr. Marwick: That’s a really good question. 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 change with the menstrual cycle as well. So it just needs 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 cover all the different systems. Urological, but not menstrual. So I think it just needs to get slotted in there so we just routinely inquire. For people who are already psychiatrists, that’s going to mean more access to education opportunities through continuing professional development, for example. I think it’s going to need communication across specialties as well — a psychiatrist who’s learned how to prescribe hormonal contraception and hormonal replacement therapy has quite a lot to get their head around to start with. And it may well be that not all psychiatrists end up being au fait with that, but we need to have colleagues in gynecology with well-established lines of communication who could help us, or in primary care if it’s something that we would expect a GP to be able to handle. 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.

Lisa: Well, 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 — they’re already struggling with an illness. When you’re struggling with an illness, you’re not exactly at the top of mental clarity to be able to sort all the stuff out. That’s why we need help. That’s why we need our practitioners to be able to support us. 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. It’s hard, though, because the research tells us that it takes 20 years for new research to end up in the offices of our professionals.

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?

Dr. Marwick: I would just ask: do you think there’s any link between your menstrual 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.

Lisa: 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. Well, so share with us a little bit about yourself, about where you are in the world, 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.

Dr. Marwick: 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 work with policy makers and my clinical colleagues to try to make some changes already, because some things are obvious that we can start doing already. I’m really interested in hearing from lived experience accounts. That’s really informed the directions that my research has gone in, particularly people with bipolar disorder. Yeah, 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.

Lisa: Okay. Well, I will be sure to link your LinkedIn and any other resources. I’ll link the paper that started this whole conversation. Again, the paper is called “The Menstrual Cycle: An 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.

Dr. Marwick: Yeah. Well, thanks for the invite. It’s been good to toss ideas around.

Lisa: 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. 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?” 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 that is a big problem. And even if you think about the conversation that we had today, 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.

I think the other thing — 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 tracked 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. 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 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 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?

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 charting.