Monthly moods - when hormones dictate how you feel

The cyclical mood swings experienced by many women can be due to hormonal imbalances, though GPs may not see the full picture, says Helen O’Callaghan.

EVERY month it’s the same. Your period arrives and you’re wiped out for three days. On day four, you wake up feeling ‘there’s life in me yet’. For the next week or so, your mood is up, your work mode’s efficient, physically you feel good. Around ovulation, things get even better— for about two days, your brain is clicking along at a great rate, you’re bright, chilled and on good terms with everyone.

Then things start to ebb a little, not too much at first— instead of feeling great, you feel just about ok. But by that last week before your period, you’re really on a downward spiral until — in the final days of your cycle – all you want to do is crawl into a corner and be left alone.

For many women, their bright and bleak moods wax and wane according to the different stages of their menstrual cycle. In a single cycle, a woman can shift from being a peak performer to being out of sync. It’s an emotional and a physical fact — and statistics prove it.

Between 20% and 30% of women say their asthma is less controlled in the second half of their cycle, up to 60% link their migraine attacks to the pre-menstrual phase and a particular type of epilepsy, catamenial, sees seizures clustered around menstruation time.

It’s why pharmaceutical companies very often request fit healthy men when they’re looking for participants for clinical trials – and not fit, healthy women. “The companies acknowledge that because women have a cycle they’re subject to a lot of variables and changes that could impact a study,” says Dr Shirley McQuade, director of Dublin Well Woman Centre.

Physicians see a lot more women than men, says Dr Patrick Magovern, a GP with a special interest in patients with unexplained symptoms. And it’s not only because they tend to be more proactive about their health. “Women’s bodies tend to go wrong easier. They tend to be more subtle.”

But for lots of women, the big issue is that their moods go so off kilter, depending on where they are in their cycle. According to consultant gynaecologist Prof John Studd of the London PMS and Menopause Centre, depression is twice as common in women as in men and 70% of all prescriptions for anti-depressants are for women. The WHO estimates that women are three to four times more likely than men to suffer depression.

Dr Marion Gluck, a holistic medical doctor specialising in women’s health and in hormonal-balancing therapy, as well as author of It Must Be My Hormones, says hormones matter hugely for women’s mood.

“Just think of PMS, of postnatal depression, of how well a woman feels in pregnancy, how unwell during her period.”

Dr McQuade says about 90% of women are aware of their cycle and that things change during it. “It doesn’t mean they’re discomfited by it, but 20-30% of women have definite uncomfortable symptoms.”

Between 3 and 5% of women suffer severe PMS — a type called PMDD or Premenstrual Dysphoric Disorder — for at least some of their reproductive life.

Prof Studd sees as many as five new patients a day with depression that has resisted all medications offered by psychiatrists. He finds it tragic that “many of these women have prolonged severe depression related to periods” and that this hormonal connection is often missed by their GPs.

“The depression is cyclical so it’s often misdiagnosed as bipolar disorder — patients are given the wrong treatment in the form of mood-stabilising drugs and anti-depressants.”

He says women suffer all sorts of ineffective psychiatric treatments for a condition that’s essentially endocrine in nature (he calls it reproductive depression) and easily treatable by appropriate hormones.

At his Dublin clinic, Dr Magovern sees patients who’ve had hormonally-linked depression treated with anti-depressants or endometriosis-type drugs to close down hormonal activity. “Hysterectomy may have been suggested as a way to shut down their hormones.”

Often GPs brush aside a hormonal basis for depression. “A regular cycle can be confused with hormonal balance,” says Dr Magovern. But if a woman’s mood correlates closely each month with significant phases of her cycle, it’s makes sense that her depression is hormonally related. “It stands up to simple logic.”

Dr Magovern describes a typical pattern of mood and physical symptoms in a 28-day cycle: “The woman’s wiped out during menstruation. She feels quite good from day five to after ovulation. She’ll often say ‘I only have one good week a month’. Oestrogen peaks at ovulation — for about two days she feels great, her brain clicking along, she’s chatting to her husband, great with the kids. On day 21, when oestrogen begins to decline for that last week, she’s slowed intellectually and just wants to go into a corner.”

Recalling a “bright, 30-something-year-old patient” who begged him to “get rid of her terrible twin” because her mood became so bleak for several days before her period, Dr Magovern says there are two types of Premenstrual Tension (PMT): The fading lily in the corner, who will talk to no-one; and the very aggressive woman who’s thinking a-mile-a-minute and is losing her temper with everybody around her. The first suggests low oestrogen, the second oestrogen dominance, says Dr Magovern.

Dr Gluck describes oestrogen as the vitality hormone that makes you feel “very female and alive, it makes you feel like a woman”. Dr Magovern says oestrogen has a huge effect on “blue sky thinking; it’s an activating hormone, the hormone of the multi-tasking female brain. You get a lot of brain fog with oestrogen deficiency.”

A woman also needs enough oestrogen in her system to make testosterone work.

Progesterone — the pro-gestation hormone of pregnancy—– is the calming, relaxing, happy hormone. “A big drop in progesterone can contribute to irritability,” says Dr Magovern.

Dr Jan Toledano, a doctor specialising in bio-identical hormones [these have a chemical structure identical to body’s naturally-occurring hormones] and a colleague of Dr Gluck’s at the London-based Marion Gluck Clinic, calls progesterone “the body’s natural anti-depressant”.

For Dr Gluck, hormones are like an orchestra. “They need to be fine-tuned to function well.” She sees PMS as an imbalance between oestrogen and progesterone. And even when doctors do get it right — that it’s a problem needing treatment with hormones — they make another error. “The big problem within the medical fraternity is they think PMS is an oestrogen issue and they often try to treat it with oestrogen, making the problem worse. Whereas PMS is usually due to insufficient progesterone in relation to the amount of oestrogen the woman’s making — what’s required is topping up with progesterone.”

Dr Gluck estimates about 80% of women feel fantastic (“the best in their lives”) during pregnancy. But most women experience some degree of emotional distress after childbirth, with 10 to 15% suffering from PND. Both pregnancy euphoria and PND are down to hormones, she says.

“A woman should be unbelievably happy after childbirth; pregnancy is over, the birth was okay and she’s bonding with baby. The big drop in progesterone after the birth causes the postnatal blues. This sometimes progresses to PND, which is often treated with anti-depressants but shouldn’t be — they don’t work. What’s needed are replacement hormones for a short while until the woman’s own hormones kick in again.”

If a woman feels depressed, it’s worth asking: Why do I feel like this now? What’s happening in my body? Dr Magovern urges women who suspect their depression is hormone-linked to get their blood hormone levels measured. In a 28-day cycle, this should be done on day one to three and again on day 18 to 21. Dr McQuade recommends women keep a diary of their moods.

Hormone-based contraception can also disturb a woman’s mood. Alice Roberts, professor of Public Engagement in Science at the University of Birmingham, wrote recently in the Observer newspaper that going back on the combined contraceptive pill after a period of breastfeeding her new baby plunged her into ‘depths of despair, turning me into an irascible harpy in the days before my period’. She stopped taking the pill and the mood swings became ‘infinitely more containable and benign’. Her GP put her on a progesterone-only ‘mini-pill’ and Roberts reported that ‘family life has remained much more harmonious’ as a result.

Dr Gluck points out that the contraceptive pill contains a synthetic progestogen — a progesterone substitute — essentially a non-hormonal molecule that has some activity on some progesterone receptors but that isn’t metabolised well by the body. “It’s this synthetic progestogen that most women don’t tolerate. It causes depression and low libido — a lot of young girls just can’t be bothered [with sex]. Many women learn to tolerate [the pill] but they don’t feel ‘right’ on it.”

Dr McQuade says fewer than 10% of women come back to her clinic complaining that the pill is causing low mood. But for these women, it’s a definite feature. “It’s quite clear the pill has changed their mood. I use a wide variety of pills and they all seem to do it. Sometimes I see women who’ve been on the pill for 18 months and they come off it to try for a baby and they say ‘I didn’t realise the pill was causing my low mood’.”

Sometimes changing to a different contraceptive pill, from among the 14 different types she prescribes, can do the trick. “Some people are quite happy on one type of synthetic progestogen but have mood swings on another,” says Dr McQuade.

“I also get a lot of GP referrals, where the GP realises the woman has a problem with the pill affecting mood.” For such women, the solution may be to opt for a low hormone contraceptive (vaginal NuvaRing) or a hormone-free one like the copper coil.

Initially, Dr Gluck wanted to make the title of her book Hormones Are a Girl’s Best Friend. You can understand why. Hormones are a girl’s best friend — but only so long as they’re in optimum balance.