PMDD and the Menstrual Cycle as a Vital Sign in Psychiatry (Episode 574)

Full Transcript: Episode 574

Lisa Hendrickson-Jack: This is the Fertility Friday Podcast, episode number 574.

A recent paper came out entitled “The Menstrual Cycle: An Overlooked Vital Sign in Psychiatry.” And in today’s episode, we are going to talk about it. We are going to talk about how the menstrual cycle impacts not only the physical body but also our emotions and even some specific psychiatric disorders and what the implications are for finally acknowledging this link for women. So without further ado, let’s go ahead and jump in.

So this is a fairly new paper. It came out just a few months ago. If you’re listening in real time, it came out in early 2025. And essentially, this question is being asked: should we be looking at the menstrual cycle as a vital sign in psychiatry? Now, of course, I find this to be very interesting. I think that it, of course, it’s timely, but the way it feels, I think, in the broader population is like, this is so cutting edge and this is new information and we should be looking at this. And I feel like if people just listened to women to begin with, this could have been resolved a long time ago. It is incredible to me that you could be treating women and giving them very highly powerful psychiatric medications and never even ask if their symptoms are at any point correlated to what’s happening in their menstrual cycle.

So although this paper does address a variety of different psychiatric concerns and it kind of brings up a few different things, I think the biggest psychiatric issue that is looked at, of course, is PMDD — premenstrual dysphoric disorder. And this topic I always find to be particularly interesting and I would say somewhat frustrating. I’ve always found it to be somewhat frustrating because I would characterize PMDD as PMS’s really angry older cousin or something like that — because ultimately when you look at the research on PMS, premenstrual syndrome, when you look at the research on PMDD, what characterizes it as such is the cyclical nature of the condition itself. So it’s well known that women are really suffering with these symptoms during the week before their period specifically. And the symptoms can just — in the case of PMS, the symptoms can be moderate to severe. You may experience depression, anxiety. You may experience, you know, carbohydrate cravings, sleeplessness. You may experience just like heightened emotions and changing emotions, teariness, and, you know, anger, rage. There’s lots of jokes and memes about it. But with PMS, although it’s troubling and obviously it’s not a good situation, the difference between PMS and PMDD is typically that PMDD is when it crosses into new territory — it begins to impair your ability to do basic things like go to work and just live your normal day-to-day life. So the big kind of mark in the sand that differentiates PMS and PMDD is certainly the severity of it. And PMDD is typically defined when it starts to interfere with your ability to just live your normal life and to do your day-to-day activities.

When you look at the research around PMS and PMDD, though, you see that women who suffer from this condition do experience significant dips in progesterone and have significant hormone imbalance, especially when we’re looking at that second half of the cycle. So these women are characterized by having just not enough progesterone relative to estrogen for one reason or another. And this imbalance of hormones is highly correlated to the negative experiences that they’re having and all of the different symptoms that they’re experiencing. And what’s really interesting about this specific issue is that once the period comes, the issue is largely resolved. If there was ever a clue that there’s a hormonal issue — that this issue is hormonal in nature — it would be that it happens the week before your period and then basically kind of either goes away or significantly improves only to return again at that same time of the cycle.

So from our perspective, in our FAM program when we’re teaching practitioners, we have significant protocols and strategies for supporting optimal hormone production. And by doing that, many women experience a significant reduction or even a total elimination of these types of symptoms. Because if it’s being caused by a hormonal imbalance, we can look at the whole person and see: well, what’s happening here? Where are the gaps? What are you doing to potentially contribute to this hormone imbalance? And is there anything you can do to improve that? There’s a variety of dietary, lifestyle, and supplement strategies that can significantly mitigate it. And even for women who may still require psychiatric medications, if you improve the hormonal balance overall, then they may need significantly less or they may have a different approach that they can discuss with their healthcare practitioner.

So as I talk through this, and I’ve kind of laid the groundwork here at least for the condition of PMDD, you have a sense that this is a hormonal issue. And especially if you’re a longer time listener to the podcast, you know that it’s not — this isn’t just new information. It just makes logical sense. As soon as you learn how the menstrual cycle works, as soon as you get into cycle charting and you understand the different phases of the cycle and how estrogen primarily is what we have dominant in the first half of the cycle, and then the second half of the cycle we have progesterone, and it’s important for these hormones to be optimal and balanced and all that — it kind of just makes sense. Of course, if a person’s hormones are imbalanced, it could contribute to this issue.

But what’s interesting about it is that what this paper is saying — the reason that they’re asking the question “should the menstrual cycle be looked at as a vital sign in psychiatry?” — is because many of these women are seeking support for psychiatric issues and their practitioners are never even asking them about their cycles. And what they talk about, which is just really unnerving, is that not only is the menstrual cycle linked to a variety of specific psychiatric issues like what we talked about — PMS and PMDD — they’re also linked to a variety of other issues. Not only is PMDD specifically linked to the menstrual cycle, but there’s a variety of other conditions such as epilepsy, migraine, and asthma that have all been shown to worsen during this phase of the menstrual cycle. And they shared an interesting data point in the study. They say meta-analyses have found that the perimenstrual phase has an increased risk of psychiatric admission for all diagnoses, particularly psychosis, and menstruation is associated with an increased rate of suicide attempts and completed suicide.

So in this paper they’re highlighting that not only is it linked to the condition that we know is characterized by cyclical variation, but they’re also saying that all of the conditions seem to have some sort of — they seem to be affected by the menstrual cycle, because they’ve noticed an increase in outbreaks and outbursts and certain issues with a variety of conditions based on the menstrual cycle. And even knowing that there’s an increased rate of suicide attempts and completed suicide in line with the menstrual cycle is terrifying. And so, of course, if you’re working in the psychiatric field, it would just make perfect sense for you to have a deeper understanding of the menstrual cycle. You shouldn’t really be working with female patients and not even talking about the menstrual cycle, not even asking any questions about it. Because if that menstrual cycle is severely off — they’re not having periods, or there’s issues with their cycles, or whatever the case is — or if you take it a step deeper and you have them charting their cycles and you can see a profound low progesterone issue, a super short luteal phase, all kinds of issues that would indicate there’s a progesterone issue, then you may find a significant improvement in your client’s mental condition if they clean up some of those diet and lifestyle factors to improve hormone balance, especially if this is hormone related. And then you still can address the outstanding psychiatric concerns — but in this way, you’d be addressing the whole person.

So to me, I feel like when I see a headline like this — should psychiatry consider the menstrual cycle as a vital sign? — I’m like, well, it would have been great if you were doing this for the last 30 years. But if we’re just showing up now to the party, yes, you definitely should. And it’s like malpractice that you haven’t been, to this day, even asking about it.

So in this paper, what’s interesting as well is they’re just asking this question. They’re trying to shed light on this. They’re trying to get some attention to this question. I think that’s why they released this paper — to really get the community talking and to show that there is a missed opportunity here for those working in the psychiatric field who are not making this a part of even just their intake and how they’re analyzing their patients. And one of the ways that they do this is by sharing a personal story. So one of the authors shares some of her reflections on this. And I’m going to read something directly quoted from the paper. The researcher’s initials were SA. She says: “I think I always had negative emotional changes before my periods, though I didn’t realize it as it was my normal. When I was diagnosed with psychosis and then schizophrenia, this continued. I’m pretty sure the three times I was hospitalized were before a period started. I know my period is coming as I get early morning wakings. This lack of sleep is then associated with what might be called basic symptoms, where I can see lines in the pavement move and the world seems a little brighter and louder. I also get irritable around this time and can get more stuck on thinking patterns. I feel my brain is connected in a different way with more ‘aha’ moments when I see connections which in retrospect are not there.”

So this is really interesting because, again, for me this is not groundbreaking information. I’ve spoken to so many women — this is my whole job, this is my whole career. I’ve been working with women for decades here and this is the kind of stuff that they talk about. If you ask about the menstrual cycle, if you’re dealing with a woman and she’s dealing with some challenges — it’s not to say 100% of the time, but a significant portion of the time, if she’s dealing with certain struggles and you just talk to her and you just find out: is there a cyclical nature to this? Is there a time of the cycle when this tends to happen? Have you been tracking your cycle? Do you notice any changes as your period approaches? A lot of women do notice, but because we’re not necessarily tracking — unless we’re like down the rabbit hole like we are — they don’t really pay attention. But as soon as you start tracking, as soon as you start noting it down, whether you have your charting app or a notebook or whatever you’re doing, then all of a sudden everything starts to make sense.

So as she was reflecting, she said that she was hospitalized multiple times, but only when she looked at it did she realize that it was always around the time her period was coming. This is really important information, and it certainly means that her experience and her emotions are linked to that. And so we should be looking deeper at that. And if we look at the menstrual cycle as a vital sign, then we can try to also remove the stigma — because of course there’s a stigma around the menstrual cycle, like “oh, women are crazy around their periods” — and we have to be able to distinguish between the normal fluctuation. So yes, healthy normal women are still going to experience some degree of fluctuation and changes in mood as they go through the different stages of their menstrual cycle. And we have to be able to define what is normal and what is abnormal. In The Fifth Vital Sign, I talked about an old medical term called menstrual molimina. And that’s the term for the normal fluctuation and changes that happen when you’re in different phases of the menstrual cycle. It is not affecting your ability to work. You’re not turning into a crazy rage monster or whatever. You’re just going through a variety of different changes. And the more you cycle and the more that you pay attention, you start to see: okay, this is what tends to happen for me. And if I’m on top of my routines, if I make sure to get enough sleep and I’m making sure to not skip meals or whatever the case is for you, then you can generally mitigate that and just live your normal life with some normal fluctuations.

So if we define what’s normal and we look at the menstrual cycle as a vital sign, then when you see a woman struggling — slipping into deep depression, having significant anxiety, really exacerbating other potential psychiatric conditions during that time — that is a sign. That’s another way that your body is telling you something’s out of whack. And yes, she may need psychiatric care, but I would argue that if we assessed her overall health at that time and looked at her hormone balance, there would also be something there. You can’t have a woman having such severe mood changes around her period and expect that everything is hormonally fine.

So interestingly, in this paper, what the suggestion is is ultimately to kind of look at dosing hormones. So for psychiatric professionals, they are looking at a variety of different psychiatric medications, and there are studies showing that maybe if we supplement with estrogen or progesterone or something like that, it could mitigate some of these factors. And while that certainly is an option that should be looked into, and it likely could be a lot less detrimental in some cases than some of the psychiatric medications, I think there’s more to the story. And I think that there certainly is a value in looking at this from a functional perspective and looking at the whole woman.

And so at the end of the day, I’m thrilled to see this type of paper coming out. I’m thrilled to see the attention that is being put on this topic, and I hope to see more of it. One of the issues that stands out to me when reading this paper is that a lot of women are struggling, particularly during these different phases of their cycle — over and over again, cyclically — and basically none of their healthcare providers are even asking about their periods or even identifying that there could be a link there. And that’s a huge area for opportunity. It’s a huge gap. And obviously it means that these women are being underserved, when really they could have a much better understanding of what’s going on — even if it was just identified that there was this link between their psychiatric issues and their cycle.

So like many papers like this one — giving an overview of what’s going on and shedding light on certain issues — she is calling for more research in the area. She’s identifying that most of the research has been done on men. We’re not studying women specifically. Historically in the research, when women are considered, we’re considered to be too complicated because we have this cycle and it gets in the way and it confounds the results. But ultimately that is what needs to be studied. Because until we can look at research specifically on women that includes our menstrual cycle in this conversation, we’re not really going to have treatments tailored to us that are actually geared for our hormone cycle so that we can actually feel better. We can’t just take the cycle out of the equation when that’s a significant part of the lives of women of reproductive age.

I hope that you enjoyed today’s episode. If you’re wanting to learn more about this topic and also find the paper that I’m talking about, you can head over to fertilityfriday.com/574. And with that said, I hope you have a wonderful weekend, whenever you’re tuning into the show. And of course, as always, until next time — be well and happy charting.