Premenstrual mood changes… What’s normal?

20 May 2020.

Here is our myth-busting guide to help you know the difference between ‘normal’ and problematic mood changes. Trigger warning– mention of suicidal thinking


What mood changes are normal?

Let’s start with the type of mood we are talking about in relation to the menstrual cycle. There are five main ones to watch out for [1]:

  1. Joyful– feeling happy, positive, energetic, productive, creative, and content.
  2. Sensitive– feeling moved by beautiful music, a soppy TV show or advert, increased empathy for others and/or more easily frustrated or upset. This is often expressed as tearfulness regardless of the reason!
  3. Irritable– feeling annoyed, frustrated, angry, typically directed at other people and is often combined with increased sensitivity to things like sound, smell, light, and being touched.
  4. Anxious- feeling worried, nervous,  unsettled, like something bad might happen, or overwhelmed. Often accompanied by increased heart rate, shallow breathing, and muscle tension or digestive changes.
  5. Low– feeling sad, upset, negative, low energy, typically internalised – self blame, low self-esteem, self-loathing.

I’m guessing that most of you were surprised to see ‘joyful’ in there? Well, society has done a great job of positioning the menstrual cycle as an entirely negative experience (despite its crucial role in the continuation of our species and reproductive health). We hardly ever hear accounts of people experiencing cyclical joy because it simply doesn’t fit into this story, even though it is a common menstrual cycle-related experience [2].

Pure joy! Try listening to music you love next time you’re feeling emotionally sensitive. Photo: Andrea Piacquadio

Likewise, the tearfulness that some people experience just before menstruation is generally equated with a low or irritable mood- the fact that tearfulness is also caused by beautiful, joyful, or plain old empathetic (feeling moved by the experiences of others) triggers is nearly always overlooked [1].

So long as these mood changes are mild-moderate and do not significantly disrupt your life in any way, they are perfectly normal experiences. As they are for every single human on the planet, regardless of sex or whether or not that person menstruates.

Contrary to popular opinion, people who menstruate are not more likely to experience significant negative mood changes during the premenstrual (luteal) phase of the menstrual cycle (unless suffering from Premenstrual Dysphoric Disorder (PMDD)- a condition outlined below) [3]. As previously discussed, a high quality systematic review of all of the existing prospective research (up to 2012) conducted on negative mood changes and the menstrual cycle, found no evidence of a specific ‘premenstrual mood pattern’ in the general menstruating population [3]. Indeed, in the studies that included male participants as a control population, day of the week was more likely to cause negative mood changes in both male and female groups (usually Sundays & Mondays!), than any particular phase of the menstrual cycle – and this is obviously due to an external social factor (the working week) rather than any biological cause [3].

Now then. This does not mean that the menstrual cycle does not affect mood in any way. It just means that the vast majority of menstruating people do not experience moderate-severe cyclical mood changes, and in the vast majority of people who menstruate, mood changes are not restricted to the premenstrual phase only. As we have mentioned before, the review makes no comment on the experiences of people with PMDD, except to imply that what they experience is not merely a ‘more severe’ version of typical menstrual cycle-related mood changes i.e. that there is something fundamentally ‘different’ happening in this condition [4].

As we will discuss below, there are lots of reasons why the menstrual cycle can and does trigger mood changes- but the sexist stereotype of the irrationally angry ‘premenstrual’ woman is not backed by scientific evidence. This is important to know, especially since this argument continues to be used against women in leadership positions e.g. Hilary Clinton in the ‘political’ cartoon above (Note– she had already been through menopause at the time) [5]!

What is not normal?

In short, any mood symptoms that are regular and severe enough to prevent or disrupt daily activities, impact on interpersonal relationships, or threaten your wellbeing.

This even includes ‘joyful’ moods, if they are so extreme as to perhaps indicate the ‘mania’ associated with bi-polar disorder.

For people who menstruate, ‘negative’ mood changes most commonly involve irritability, followed by anxiety, then low mood- and it is not uncommon to experience two, or all three, negative moods together [6].

If you menstruate and are experiencing debilitating mood changes, it is CRUCIAL that you track your symptoms on an app or calendar. Where in the cycle you experience such changes can indicate different conditions (listed in order of prevalence, from most common to least likely);

  1. Chronic mental health disorders e.g. depression, anxiety, bi-polar disorder, or borderline personality disorder– (if moderate- severe mood symptoms occur throughout the cycle)
  2. Cyclical worsening of a chronic mental health issue (if symptoms are only a problem during certain parts of the cycle but occur at a mild level throughout)
  3. PMDD– Premenstrual Dysphoric Disorder (if severe mood symptoms only occur in the luteal phase of the cycle)
screaming woman with head in hands
Despair is not normal. Please seek help. Photo: David Garrison @Pexels

A diagnosis of PMDD currently involves the presence of at least five out of eleven symptom types with at least one of the main symptoms being; severe irritabilitydepressed mood, or anxiety. These symptoms should only occur in the two weeks before menstruation and stop completely between menstruation and ovulation. In order to meet the criteria for diagnosis, the symptoms should be tracked for at least two consecutive cycles in order to confirm the cyclical nature of symptoms [7].

Note– If you feel suicidal at any point, please seek professional support immediately. Suicidal thinking is NOT a typical menstrual cycle-related experience.

Getting help in the UK:

If you are feeling suicidal, there are people you can talk to, who want to help:

  • speak to a friend, family member or someone you trust as they may be able to help you calm down and find some breathing space
  • call the Samaritans 24-hour support service on 116 123
  • go to your nearest accident and emergency (A&E) department and tell the staff how you are feeling (even during lock-down!)
  • contact NHS 111
  • make an urgent appointment to see your GP

Read more about getting help if you’re feeling suicidal.


What causes negative mood changes?

1. The same things that cause them in all humans! 

Yes, the menstrual cycle can influence mood changes, but these experiences are not something unique to humans who menstruate. What makes a baby cry, or a grown man grumpy? Well let’s see… Hunger, thirst, pain, tiredness, sensory overload, a traumatic experience, stress, poor mental health, low self-esteem and other people being mean or annoying? Ha! Snap! It’s exactly the same for all humans. Just because you have a menstrual cycle does not mean that you should attribute any and all negative mood changes to ‘hormones’ or ‘biology’ alone [8].

Rage or joy? Depends who tidied up… Photo: Gustavo Fring @ Pexels

By framing negative moods as ‘hormonal’ or ‘PMS‘, people may internalise issues in their lives that need to be resolved [8]. For example, you find yourself shouting at the kids or your partner for not listening to you, or not doing enough around the house. Attributing this (righteous!) anger to your hormones is never going to make you feel better, reduce your workload, get your family to pull their weight, or prevent the same thing happening again and again. Make a note of what made you angry/ feel upset/ anxious and when you are feeling better have a chat with your family to explain how their behaviour affects your health and most importantly, sign them up to some chores!

Research suggests that household or workplace (gender) inequalities, or financial or interpersonal problems, are the underlying cause of distress in the vast majority of people who experience moderate-severe ‘PMS‘ [9]. While cyclical changes in the reproductive system may heighten such experiences (i.e. emotional sensitivity!), this could be re-framed as an opportunity to bring problems to light (in order to then take action to resolve them) rather than a distressing embodied experience, over which you have no control.

2. Something else.

This is where things get a little complicated. Various ‘biopsychosocial’ (biological, psychological and social) factors are known to influence the severity of cyclical mood changes;

Biological– Contrary to popular opinion, female sex hormones (e.g. oestrogen or progesterone) DO NOT directly ’cause’ mood changes [10]. In fact, research shows that there is no underlying sex hormone imbalance, reproductive illness, or gynaecological abnormality in people who experience severe PMS or PMDD [10].

However, the normal and healthy menstrual cycle can trigger certain physiological changes that are known to affect mood. For example, cyclical changes in blood sugar levels can result in food cravings and low or irritable mood [11]; disrupted sleep patterns can result in fatigue, leading to low mood and irritability [12]; water retention can lead to changes in the digestive system (bloating/ constipation), dehydration, and blood pressure changes, which can result in irritability or anxiety [13]; cycle-related conditions such as pelvic inflammation or iron deficiency anaemia are also known to increase irritability and other mood changes [14]. Smoking and alcohol consumption are also linked with cyclical negative mood, so try not to manage your emotions with these things [15]!

Relationships are not easy. Speak up about the things that irritate or worry you rather than self-silencing. Photo: Pixabay

In the case of people with underlying stress or mental health issues, it is likely that one or more of these physiological changes somehow trigger or worsen symptoms at certain times in the menstrual cycle, but the exact cause(s) remain unknown (largely due to a lack of research in this area) [16].

In the case of people with PMDD, the above physiological changes probably play a role, but research suggests that there may be additional genetic and/ or biochemical differences, too [17]. As yet, the exact mechanism behind PMDD remains unclear but most researchers describe it as an individual ‘sensitivity’ to the normal neurochemical changes occurring during the menstrual cycle [17].

Psychological– Research shows that a person’s attitude towards menstruation has a real effect on the experience of cyclical mood changes- a more negative perception is associated with more severe negative mood changes [18]. Also, people who tend to be anxious in general [19] and those who tend to self-silence (internalise) stress, anger and frustration rather than express it to others are more likely to experience moderate-severe changes [20].

Sociological– Anyone noticed how their premenstrual changes seem to have got worse during COVID 19 lock-down? Guess what? Your menstrual cycle and sex hormones are still doing the same thing as usual, what has changed is your underlying stress level. Lock-down is an inherently stressful situation, even if you do not consciously realise this, your body ‘knows’ (i.e. will respond to your subconscious thoughts and anxieties).

Also, as mentioned above, social inequalities and gender norms play a role in people’s experiences of cyclical mood changes. Having an unequally large share of unpaid care work, being paid less, and perhaps other daily reminders of being positioned as a lower status human, understandably results in distress. This is compounded by the way in which women are ‘supposed’ to behave, as is well summarised by Chrisler & Gorman [8] “the feminine gender role emphasises self-discipline; good women, especially good mothers, are assumed to be soft-spoken, receptive, nurturing, kind, and patient. Any woman who is turned inward [doing her own thing] or seen as inapproachable because she is irritable, angry, or exhausted is thought to be ill or ‘not herself'”. In this way, attributing negative mood changes to ‘hormones’ absolves the individual of any lapses in their performance of this idealised feminine gender role, even if it isn’t the whole truth or likely to resolve the issue in the long term [8].


How to manage cyclical mood changes

1. Track your moods for 2- 3 cycles (positive and negative). Note the trigger of each change, too e.g. “I shouted at Donald after he wrote something stupid, embarrassing and potentially dangerous on Twitter”.

2. Identify any pattern in mood changes. For example, if you feel low or irritable only during or after your period, you may have anaemia. If you experience moderate- severe symptoms most of the time, or across different phases of the cycle, you may have depression or anxiety. If you only experience severe mood changes just before your period, you may have PMDD.

3. Take action! If you are frequently experiencing severe mood changes, especially if you feel suicidal, please seek professional medical advice immediately. Contrary to popular opinion, there are treatments available (medications, therapy, lifestyle changes) that can successfully resolve or significantly alleviate these symptoms in most cases.

For everyone else, you may want to consider voting for community/ political leaders who endorse equal human rights and therefore have a specific policy to address gender inequalities, especially in relation to unpaid care work. Or, even better, consider running for such leadership positions yourself?!

In the meantime, have a chat with your partner, children, wider family, friends, boss, colleagues or clients about what they could do to help you. Could they cook more often, clean up after themselves, share in childcare, take equal responsibility for household tasks, reduce your unpaid working hours, allow you more time to yourself, pay you more, help you to draw up a debt-management plan, treat you with greater respect? [Please make sure you schedule these chats for times when you’re feeling more diplomatic!]

Only after you have identified and addressed (as much as possible) the external factors affecting your mood should you take a good look at the things you can do for yourself. Learn more about specific symptoms on our management pages – irritability, anxiety, depression, or PMDD. And remember the tried and tested ‘4 steps to improved menstrual health and wellbeing‘- through improved diet, exercise, self-esteem and relaxation!


Citation:

If you are using my work and ideas in a publication, professional or educational setting, please cite as:

King, S (2020) ‘Premenstrual mood changes… What’s normal?’ Menstrual Matters https://www.menstrual-matters.com/blog/mood-changes/ retrieved on [insert date accessed]


References:

[1] This is my shortlist of cyclical mood changes based on as yet unpublished data/ work. If referencing this specific list, please cite this blog in the meantime. Previous research has identified joyful mood changes (see reference below) but the part about tearfulness as being an indication of emotional sensitivity to both positive and negative mood changes is original work (as far as I know!). Feel free to contact me directly for more information info@menstrual-matters.com

[2] Chrisler, J. C., Johnston, I. K., Champagne, N. M., & Preston, K.E. (1994) ‘Menstrual joy: The Construct and Its Consequences’, Psychology of Women Quarterly, 18(3), pp. 375–387. doi: 10.1111/j.1471-6402.1994.tb00461.x.

[3] Romans, S, R Clarkson, G Einstein, M Petrovic, and D Stewart. (2012) “Mood and the Menstrual Cycle: A Review of Prospective Data Studies.” GENM 9:361–84. https://doi.org/10.1016/j.genm.2012.07.003

[4] I previously wrote about the above review paper and explained in more detail about how it makes no claims about PMDD here – https://www.menstrual-matters.com/blog/not-all-women/

[5] This 100% sexist cartoon drawn by Pat Oliphant (https://en.wikipedia.org/wiki/Pat_Oliphant) was published in the lead up to the 2008 US election, when Hilary Clinton was running for president alongside fellow Democrat candidate, Barack Obama. She was 59 years old and no longer had a menstrual cycle. Facts never seem to get in the way of a good gender myth! Check out this interesting blog on the topic- https://www.dailykos.com/stories/2008/1/11/434904/-

[6] Pearlstein T, Yonkers KA, Fayyad R, & Gillespie JA (2005). Pretreatment pattern of symptom expression in premenstrual dysphoric disorderJournal of Affective Disorders85(3), 275–282. 10.1016/j.jad.2004.10.004

[7] For more information on the specific diagnostic criteria for PMDD see https://www.menstrual-matters.com/tips-and-tricks/pmdd/

[8] There’s a great overview of the many and varied evidence-based reasons why we shouldn’t attribute mood changes to ‘biology’ alone in Chrisler, J. & Gorman, J (2015) ‘The Medicalization of Women’s Moods’ p77-98 in McHugh MC, Chrisler JC. (Eds). The wrong prescription for women: how medicine and media create a “need” for treatments, drugs, and surgery. Santa Barbara: Praeger ISBN: 978-1-4408-3176-8

[9] See: Beck, L. E., Gevirtz, R., & Mortola, J. F. (1990). The predictive role of psychosocial stress on symptom severity in premenstrual syndrome. Psychosomatic Medicine.

Kuczmierczyk, A. R., Labrum, A. H., & Johnson, C. C. (1992). Perception of family and work environments in women with premenstrual syndrome. Journal of Psychosomatic Research36(8), 787-795.

Ussher, J. M., & Perz, J. (2013). PMS as a process of negotiation: Women’s experience and management of premenstrual distress. Psychology & health28(8), 909-927.

Ussher, JM, Perz, J & Mooney-Somers, J (2007) ‘The Experience and Positioning of Affect in the Context of Intersubjectivity: The Case of Premenstrual Syndrome’. International Journal of Critical Psychology (now Subjectivity), 21: 144-165

Warner, P., & Bancroft, J. (1990). Factors related to self-reporting of the pre-menstrual syndrome. The British Journal of Psychiatry157(2), 249-260.

[10] See: Schmidt PJ, Purdy RH, Moore PH, Paul SM, & Rubinow DR (1994). Circulating levels of anxiolytic steroids in the luteal phase in women with premenstrual syndrome and in control subjectsJournal of Clinical Endocrinology & Metabolism79(5), 1256–1260

Nguyen, T. V., Reuter, J. M., Gaikwad, N. W., Rotroff, D. M., Kucera, H. R., Motsinger-Reif, A., Smith, C. P., Nieman, L. K., Rubinow, D. R., Kaddurah-Daouk, R., & Schmidt, P. J. (2017). The steroid metabolome in women with premenstrual dysphoric disorder during GnRH agonist-induced ovarian suppression: effects of estradiol and progesterone addback. Translational psychiatry7(8), e1193. https://doi.org/10.1038/tp.2017.146

[11] Benton, D. (2002). Carbohydrate ingestion, blood glucose and mood. Neuroscience & Biobehavioral Reviews26(3), 293-308.

[12] Armitage, R. (2007). Sleep and circadian rhythms in mood disorders. Acta Psychiatrica Scandinavica115, 104-115.

[13] See: Mykletun, A., Jacka, F., Williams, L., Pasco, J., Henry, M., Nicholson, G. C., … & Berk, M. (2010). Prevalence of mood and anxiety disorder in self reported irritable bowel syndrome (IBS). An epidemiological population based study of women. BMC gastroenterology10(1), 88.

Belsey, J., Greenfield, S., Candy, D., & Geraint, M. (2010). Systematic review: impact of constipation on quality of life in adults and children. Alimentary pharmacology & therapeutics31(9), 938-949.

Perlmuter, L. C., Sarda, G., Casavant, V., O’Hara, K., Hindes, M., Knott, P. T., & Mosnaim, A. D. (2012). A review of orthostatic blood pressure regulation and its association with mood and cognition. Clinical Autonomic Research22(2), 99-107.

Amare, A. T., Schubert, K. O., Klingler-Hoffmann, M., Cohen-Woods, S., & Baune, B. T. (2017). The genetic overlap between mood disorders and cardiometabolic diseases: a systematic review of genome wide and candidate gene studies. Translational psychiatry7(1), e1007-e1007.

[14] See: Shen, C. C., Yang, A. C., Hung, J. H., Hu, L. Y., Chiang, Y. Y., & Tsai, S. J. (2016). Risk of psychiatric disorders following pelvic inflammatory disease: a nationwide population-based retrospective cohort study. Journal of Psychosomatic Obstetrics & Gynecology37(1), 6-11.

Graziottin, A., Skaper, S. D., & Fusco, M. (2014). Mast cells in chronic inflammation, pelvic pain and depression in women. Gynecological Endocrinology30(7), 472-477.

Percy, L., Mansour, D., & Fraser, I. (2017). Iron deficiency and iron deficiency anaemia in women. Best Practice & Research Clinical Obstetrics & Gynaecology, 40, 55–67. doi:10.1016/j.bpobgyn.2016.09.007 and Taymor ML, Sturgis SH, Yahia C. (1964) The etiological role of chronic iron deficiency in production of menorrhagia. JAMA 187:323–27.

[15] See: Elizabeth R. Bertone-Johnson, Susan E. Hankinson, Susan R. Johnson, JoAnn E. Manson, Cigarette Smoking and the Development of Premenstrual Syndrome, American Journal of Epidemiology, Volume 168, Issue 8, 15 October 2008, Pages 938–945, https://doi.org/10.1093/aje/kwn194

del Mar Fernández, M., Saulyte, J., Inskip, H. M., & Takkouche, B. (2018). Premenstrual syndrome and alcohol consumption: a systematic review and meta-analysis. BMJ open8(3), e019490.

[16] This is a major research gap in the literature, with far reaching implications for the diagnoses of PMS/ PMDD and various mental health conditions. For example, a recent Taiwanese study found that 86% of 129 patients who thought they were experiencing PMS actually qualified for a diagnosis of an underlying mental health disorder. Hsiao, M. C., Liu, C. Y., Chen, K. C., & Hsieh, T. S. T. A. (2002). Characteristics of women seeking treatment for premenstrual syndrome in Taiwan. Acta Psychiatrica Scandinavica106(2), 150-155.

[17] Eisenlohr-Moul T. (2019). Premenstrual Disorders: A Primer and Research Agenda for Psychologists. The Clinical psychologist72(1), 5–17.

[18] See: Marván, M. L. and Escobedo, C. (1999) ‘Premenstrual symptomatology: Role of prior knowledge about premenstrual syndrome’, Psychosomatic Medicine, 61(2), pp. 163–167. doi: 10.1097/00006842-199903000-00007

Marvan, M. L., & Trujillo, P. (2009). Menstrual socialization, beliefs, and attitudes concerning menstruation in rural and urban Mexican women. Health care for women international31(1), 53-67.

Chrisler, J. C., Gorman, J. A., Marván, M. L., & Johnston-Robledo, I. (2014). Ambivalent sexism and attitudes toward women in different stages of reproductive life: A semantic, cross-cultural approach. Health care for women international35(6), 634-657.

[19] See: Giannini, A. J., Price, W. A., Loiselle, R. H., & Giannini, M. C. (1985). Pseudocholinesterase and trait anxiety in premenstrual tension syndrome. The Journal of clinical psychiatry46(4), 139-140.

Picone, L., & Kirkby, R. J. (1990). Relationship between anxiety and premenstrual syndrome. Psychological reports67(1), 43-48.

[20] See:Chrisler, J. C., Gorman, J. A., & Streckfuss, L. (2014). Self-silencing, perfectionism, dualistic discourse, loss of control, and the experience of premenstrual syndrome. Women’s Reproductive Health1(2), 138-152.

Ussher, J. M., & Perz, J. (2010). Disruption of the silenced-self: The case of pre-menstrual syndrome. Silencing the self across cultures: depression and gender in the social world435, 458.

Ussher, J. M., & Perz, J. (2013). PMS as a process of negotiation: Women’s experience and management of premenstrual distress. Psychology & health28(8), 909-927.

Brown, M. A., & Ornitz, A. W. (1993). Family coping and premenstrual symptomatology. Journal of Obstetric, Gynecologic, & Neonatal Nursing22(1), 49-55.


Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.