Female cycles and Mental Health

Miranda West, CSW

As a therapist (and as a woman in general), it’s important to understand how mental health can look differently in men vs women. Men have a 24 hour cycle, and women have a 28 day cycle (menstrual, follicular, luteal, premenstrual). This difference can be massive regarding how hormones affect men vs women and how mental health can be impacted

Understanding the menstrual cycle can help women feel more in-tune with their body and be more patient when energy levels and/or hormones differ throughout the month. Throughout the menstrual cycle, there are two main hormones that fluctuate: progesterone and estrogen. Let’s dive into each phase, the hormone changes therein, and how that can affect mental health. But before we go into specific phases, it will be important to understand the two hormones that fluctuate throughout our cycles: progesterone and estrogen.

Progesterone

The main purpose of progesterone in our bodies is to prepare the lining of the uterus for a fertilized egg, and dropping it if none is provided. Regarding mental health, progesterone is essentially only present in the luteal phase (and during pregnancy). When levels are high, the brain receives a larger amount of the calming chemical allopregnanolone. While this sounds like it should be generally more relaxing, it largely depends on the individual and their situation. Allopregnanolone acts on GABA receptors (calm switches) in the brain which help reduce anxiety, promote relaxation and improve mood. As progesterone levels are high, many people experience these calming effects while many can experience the opposite effect. Instead of feeling calm, they might experience heightened anxiety, mood swings, or irritability. This paradoxical response could be due to sensitivity in the GABA system or fluctuations in how the brain processes progesterone and its byproducts.

In summary, whether progesterone makes you feel more stressed or calm during the luteal phase largely depends on how your brain reacts to the hormone and it’s effects. This is one reason why some women feel great during the luteal phase, while others struggle with symptoms of premenstrual syndrome (PMS) or premenstrual dysphoric disorder (PMDD); which we’ll cover below.

Estrogen

In general, women are more susceptible to depressive, anxiety, and eating disorders and this study suggests that biological factors may play a strong role in- specifically estrogen. Estrogen acts as our brain’s natural mood stabilizer through its signaling mechanisms and interactions of serotonin, dopamine, and glutamate; which all have heavy involvement in cognition and mood. 

Estrogen helps boost serotonin (the happiness and connection hormone) by increasing the production of serotonin and improving the sensitivity of receptors so our brain uses serotonin more effectively. In summary, higher estrogen levels can help stabilize emotion, promote happiness, and reduce depressive feelings.

Similar to serotonin production, estrogen increases dopamine (another happiness hormone) production as well as improves dopamine receptor sensitivity which leads to the brain responding more strongly to the available dopamine. Additionally, estrogen acts as a neuroprotectant for dopamine-producing neurons which helps maintain dopamine balance and prevents depletion.
Glutamate is the neurotransmitter that helps with learning, memory and overall cognitive performance and is also significantly affected by estrogen. Like with the neurotransmitters mentioned above, estrogen helps enhance the production of glutamate in the hippocampus and prefrontal cortex, which are vital for memory, learning and emotional regulation. Additionally, it can support glutamate receptor sensitivity. These all contribute to better memory, quicker thinking, and emotional stability. 

Phases

Regarding phases, the woman’s cycle is split into 2 distinct phases: the follicular and luteal phases. The follicular phase consists of the first part of the cycle lasting from menstruation to ovulation and typically lasts ~12-14 days. The luteal phase follows ovulation and lasts ~14 days as well, while the days immediately prior to menstruation can be termed as the premenstrual phase.

Menstruation

During Menstruation, estrogen and progesterone levels are low as the uterine lining sheds. This can manifest in emotional well being as fatigue, irritability, mood swings, and emotional sensitivity. With the drop of estrogen also comes the drop of serotonin and dopamine which can result in mood swings, emotional sensitivity, depressive moods, and lower social motivation. 

Follicular

With the rising of estrogen and progesterone, during the follicular phase we experience an increase in mood, motivation and cognitive function. With the increased support of estrogen, higher levels of serotonin result in more stable emotions, better focus, and improved social interactions. With an increase in dopamine, we may feel a greater sense of overall happiness and energy. During this phase, many feel their most confident and productive. 

Ovulation

Leading up to ovulation, estrogen levels rise sharply, peaking just before the release of an egg. This surge has been linked to heightened sexual desire, increased energy, and a greater sense of wellbeing. Additionally, high estrogen levels can enhance  dopamine and serotonin activity, which increase pleasure and mood stability. While many women experience a mood boost, others may feel increased anxiety and emotional sensitivity due to hormonal changes. 

Luteal

In early luteal phase, as our progesterone levels are higher, this can cause us to feel more relaxed or drowsy. Later in the luteal phase, both our estrogen and progesterone levels drop which can lead to mood swings, anxiety, irritability and depressive symptoms. During the late luteal phase (or premenstrual phase (PMS)), some individuals experience heightened symptoms which can be identified as PMDD. 

What is PMDD?

PMDD occurs solely in the luteal phase of the menstrual cycle. It is characterized by significant emotional, physical, and behavioral distress; specifically mood swings, irritability, depressed mood, anxiety, loss of interest, fatigue, and feeling emotionally overwhelmed. PMDD was added to the DSM-5 in 2013 as giving women a dedicated diagnosis would encourage proper treatment and better understanding of symptoms. 

What causes PMDD?

Exact causes of PMDD are unknown, but there are hypothesis that it is an abnormal reaction to hormonal changes in the menstrual cycle which can cause serotonin deficiencies. 

Additionally, it has been studied that women with PMDD reported feeling more stressed and having stronger negative emotions in response to stress, especially during the days before their period. When they felt stressed, they also experienced fewer positive emotions and were more likely to ruminate compared to women without PMDD, regardless of where they were in their menstrual cycle. In summary: Women with PMDD experience more intense stress, stronger negative emotions, and less positive emotion during stress, especially before their period, along with altered cortisol patterns. These findings are also linked to the research that women with PMDD use less helpful coping mechanisms such as overthinking and increase self- depreciation in response to stress. As stress levels rise as well as difficulties with emotional regulation, levels in irritation and emotional liability (mood swings) increase.

The menstrual cycle and mental disorders

This study from the National Library of Medicine provides specifics regarding how hormone changes within the menstrual cycle can affect certain psychiatric disorders. Here, I will define the most common seen in a therapeutic setting but please refer to the study for a more comprehensive guide.

Suicidality

Research consistently shows that rates of suicidality and self-harming are significantly elevated during the premenstrual and menstrual phases. Studies indiciate that 25% to 54% of suicidal ideation or attempts occur during menstruation, while attempts range from 26% to 67% in the premenstrual and menstrual phases (CRAZY). 

Depression

Depression is a disorder that affects about twice as many women as men. While some research suggests that hormonal fluctuations during the menstrual cycle may play a part, especially during the premenstrual phase, some studies do not find direct correlation between hormonal changes and depression. 

Anxiety

Anxiety symptoms often worsen during the premenstrual phase, particularly in women with high baseline anxiety or preexisting anxiety disorders. While some studies found no significant menstrual cycle effects, others linked luteal-phase progesterone fluctuations to increased anxiety and stress responses. Women with social anxiety disorder report higher social avoidance premenstrually, and those with generalized anxiety disorder (GAD) + PMS experience greater symptom worsening. Naturally cycling women tend to show more cycle-related anxiety patterns, while those on oral contraceptives experience more stable symptoms.

PTSD

PTSD symptoms may change throughout the menstrual cycle, with more frequent and intense intrusive memories during the luteal phase, when estrogen levels are lower. Women who experienced trauma or were assessed in this phase reported more flashbacks. Estrogen might help protect against distressing memories, while problems with progesterone processing could make fear responses worse. Some PTSD symptoms, like phobic anxiety, change with the cycle, while others, like general anxiety sensitivity, stay the same. High-quality studies confirm that intrusive memories are more common in the luteal phase, but more research is needed to understand why.