Motivation and emotion/Book/2015/Menstrual cycle and emotion

Menstrual cycle and emotion:
How and why do emotions vary during the menstrual cycle?

Overview

“Women complain about premenstrual syndrome, but I think of it as the only time of the month that I can be myself.”
― Roseanne Barr)

The menstrual cycle is something that the majority of people have experienced either directly or indirectly. Whilst men do not have a menstrual cycle, it is highly likely that they have been bystanders whilst a significant female (e.g., girlfriend, sister or wife) have dealt with the associated variables and consequences. The changes in emotion and mood associated with the menstrual cycle have frequently been stereotyped in Westernised society.

A common reoccurring perception of the emotions, paints women to be: crazy, irrational and emotional throughout their menstrual cycle. A quick google search of "girls on their period" provides a multitude of results, ranging from: memes which aim to make light of the subject, YouTube videos demonstrating how "girls act" during the menstrual cycle (click here to view an example), informative articles explaining what is occurring during the menstrual cycle and some inaccurate articles. An analysis of research conducted by Romans, Clarkson, Einstein, Petrovic & Stewart (2012) looked at a variety of research and concluded that there is no consistent information to support or discredit the existence, cause and prevalence of emotion and mood based changes during the menstrual cycle.

Chapter goals

Explain the menstrual cycle process
Explain "How" and "Why" emotions vary during the menstrual cycle
Discuss theory and research relating to emotion and mood
Suggest treatments for emotion/mood flactuation

Menstrual cycle

Emotions

Figure 2. Examples of emotions

Emotions are a difficult construct to define; however, it is considered that the best definition is a blend of mental and behavioural aspects which include: appraisal, action tendency, subjective experience, physiological reactions, facial and vocal expression elements (Reisenzai, 2007).

Affect, feelings, and mood are often used in the same context without a clear distinction between the various terms (Shouse, 2005).

Affect is an abstract idea that can be described as: “ a non-conscious experience of intensity; it is a moment of unformed and unstructured potential” (Shouse, 2005).
Mood can be defined as: “A continued emotional state that affects one’s outlook on life.” (Sikora, 2011).
Feelings can be defined as: experiences that are references against our past experiences and are categorised based on previous knowledge (Shouse, 2005).

Fact

The affective phenomenon relates to the combined study of emotions, moods and affect. Historically these terms have been used interchangeably and efforts to distinguish between the various terms have only occurred in the recent years (Ekkakkis, 2012).

Theory and research

The "how" and "why" of emotional change throughout the menstrual cycle is not clear. Research and theory is inconclusive as to the cause of the changes as well as the reasons for the change in emotion.

Menstrual cycle disorders

Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) are two mood disorders that appear to be linked to the hormonal changes that occur throughout the menstrual cycle (Freeman, 2007). However, research is inconclusive in terms of the overall relationship between the menstrual cycle and associated mood disorders (Romans et al. 2012).

PMS is the disorder that is utilised to explain the symptoms that women experience during the week prior to the menstrual phase of their menstrual cycle (Reilly & Kremer, 2001). PMS has a range of physical and psychological symptoms which may include the following (MayoClinic, 2015):

tension
anxiety
depressed mood
crying spells
fatigue
acne

The cause of PMS is undetermined, hormones may play a role and chemical changes in the brain may also be an influencing factor. (MayoClinic, 2015).

PMDD is a more severe form of PMS, that is also defined in The Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM IV - TR defines the symptoms of PMDD as: a significant depressed mood, high levels of anxiety and marked affective lability. PMDD differs from PMS in that the changes in mood are extreme (Gallenberg, 2012).

According to the DSM IV - TR the diagnosis for PMDD requires that the above-mentioned symptoms be present during the final week of the luteal phase (for a minimum of one year); the symptoms ease during the initial week of menses; and the symptoms are non-existent in the following week. The other criteria for the diagnosis include a range of symptoms (see table 1), of which the individual has to display a minimum of five, for a majority of the luteal phase.

Table 1.DSM IV - TR diagnostic criteria for PMDD

Psychological feeling	Physiological
sad, hopeless or depreciating	change in appetite
tense, anxious or 'on edge'	hyper insomnia or insomnia
marked lability of mood	tearfulness
irritability, anger or increased conflict	cramps, breast tenderness
difficulty concentrating	bloating and/or weight gain.
fatigued or lethargic	joint or muscle pain

Biological and physiological explanations

Biorhythm theory

The idea of emotions being related to a 28 day cycle was initially proposed in the form of Fliess’ Biorhythm Theory (Shermer, 2002). The theory was based on the premise that humans have three cycles that occur monthly: a physical cycle lasting 23 days; an emotional cycle lasting 28 days; and an intellectual cycle lasting 33 days. It is thought that the 28 day emotional cycle idea was related to the menstrual cycle (Shermer, 2002. & Hines 1998). The Biorhythms were developed to assist with predicting why humans experience highs and lows depending on the particular day (Cavendish, 2010). A review of the research for the Biorhythm Theory has been unsuccessful in verifying its validity[factual?]. Consequently the Biorhythm Theory is often referred to as a pseudo-theory without any scientific proof (Hines, 1998).

Hormones and the menstrual cycle

Figure 3. Diagram of the endocrine system

The menstrual cycle is a repetitive process which is dictated by the changes of the levels of various hormones in the body. The specific hormones are produced and controlled by the: hypothalamus, pituitary glands and the ovaries. The three areas form a part of the endocrine system (Popat, Prodanov, Kalis & Nelson, 2008). The three areas of the endocrine system produce and control the specific hormones that are necessary for menstruation to occur (Babycentre, 2015 & Brzyski & Knudston, 2015).These hormones are also associated with a range of emotionally and mood based aspects as shown in Table 2.

Table 2.
Menstrual cycle hormone function

Hormone	Location	Function	Association to emotion and/or mood
Gonadotrophin-releasing hormone (GnRh)	Brain (Hypothalamus)	Stimulation of body to release Follicle-stimulating hormone and Luteinizing hormone	Use of GnRh agonists is limited (due to high cost) however the available research has found that PMS symptoms ease with the use of GnRh agonists. With further research suggesting that GnRh agonists are a potential solution to easing disorders caused by oestrogen. (Kumar & Sharma 2014 ; Warnock, Burden & Morris 1998).
Follicle-stimulating hormone (FSH)	Pituitary Gland (in the brain)	Responsible for the ripening of ovum	Low FSH levels are associated with various menstrual cycle disorders including infertility and ovarian failure. These issues may present in the form of mood swings and depression (Serge, 2014).
Luteinising Hormone (LH)	Pituitary Gland (in the brain)	Stimulates ovaries for the release of ovum	It is suggested that a decrease in oestrogen levels combined with an increase in LH, may be associated with mood disorder occurrences in perimenopausal and menopausal women (Steiner, Dunn, Born, 2003).
Oestrogen	Ovaries	Stimulates and prepares body for potential conception	Oestrogen is related to mood in terms of it's capacity to increase serotonin in the body. However, high levels of oestrogen may lead to anxiety and irritability and low levels may lead to depression (Integrative Psychiatry, 2015).
Progesterone	Ovaries	Stimulates and prepares body for potential conception	Progesterone is said to ease anxiety and depression as well as assist with the increase of serotonin (Integrative Psychiatry, 2015; NatureOne, 2015). However, an excessive amount of Progesterone is said to be associated with the increase of cortisol in the body (Scott, 2012).

The changes of hormones throughout the menstrual cycle are said to be directly related to the changes in mood (Schwartz, Romanis, Meiyappan, Souzal & Einstein, 2012). Various studies have looked at the effects of hormonal changes throughout the menstrual cycle and the implications for mood and emotional change and the results are inconclusive:

"Yes" menstrual cycle hormones do affect emotion and mood:

Payne (2003) - Conducted a literarture review in relation to the effects of estrogen on mood. The results concluded that whilst not all women demonstrate hormonally stimulated depressive symptoms, there is a group of women that have mood changes directly related to the changes of hormones.
Ossewarde, Hermans, Wingen, Kooijman, Johannson, Backstrom & Fernandez (2010) - Utilised a crossover study design to investigate the changes during the luteal and follicular stages. Their results concluded that: changes during the menstrual cycle play a role in the emotional regulatory circuit and are additionally influenced by stress. Their results also concluded that the luteal phase was related to negative emotions and that heart rate was higher during stress induced situations.

"No" menstrual cycle hormones do not affect mood or emotion

Van Goozen, Wiegant, Endert, Helmond & Van de Poll. (1997) — Investigated mood changes in relation to hormonal changes throughout the menstrual cycle for a group of participants. The study utilised a combination of blood tests to test hormone levels and self-report assessments to measure mood. The researchers found a pattern for the change in the levels of oestrogen, progesterone and androgenic hormones. However, they did not find any pattern in the changes in relation to mood - depression, tension, anger or fatigue. Consequently the results of this study do not support the ideology that hormonal variations throughout the menstrual cycle are casual, or in this case even correlated to mood alteration.
Schwartz, Romanis, Meiyappan, Souzal & Einstein (2012) — Looked at ovarian hormone levels by measuring them directly and comparing the hormone changes to mood change. Their results concluded that hormone levels were not correlated to moods. The study established that the individual’s interpretation of their stress levels and overall physical health were proven to be a more reliable predictor of mood than the hormone levels.

Time for a break

Click here to watch a
Ted Talk by Robyn Stein De Luca
on the good news about PMS

Psychological explanations

[Provide more detail]

Social Learning Theory (SLT)

Figure 4. Reciprocal determinism presented in context of the Social Learning Theory

The social learning theory focuses on behaviour in terms of learning and is dictated by the outcomes of the behaviour. Bandura (1971) explained that: people learn by observing the behaviour of others and we perform actions that achieve a desired outcome. We are also likely to continue a behaviour if we receive reinforcement that is beneficial to us (Bandura, 1971).

It is suspected that the SLT may play a crucial role in the development of Premenstrual Syndrome (PMS). Scalise (2007) suggested that women develop a negative attitude in regard to their menstrual cycle and as a consequence they develop coping mechanisms such as overeating and mood swings. A study conducted by Woods, Mitchell and Lentz (1995), looked at the effect of social influence in terms of how an individual responds to their menstrual cycle. The researchers looked at three classes of symptoms: low severity (LS); premenstrual syndrome (PMS); and premenstrual magnification (PMM). Their results were consistent with the social learning theory, such that women who anticipated negative symptoms and reported being socially primed to expect negative symptoms throughout the menstrual cycle were more likely to report these negative symptoms. The researchers concluded that stressful experiences and social priming of negative menstrual symptoms might enforce the negative connotation relating to their menstruation (Woods, Mitchell & Lentz, 1995).

Example

According to the SLT, emotional changes during the menstrual cycle occur because of the social expectation that they will. For example if Anna's mum displayed severe mood swings throughout the month, which she attributed to the menstrual cycle, then Anna is likely to copy her mum's behaviour and behave in a similar manner. Moreover, if the behaviour led to a reward such as chocolate then Anna may perform the specific behaviour in the hope that she will also receive chocolate.

Cognitive theory

Cognitive attribution is important in the aetiology of PMS. According to cognitive theory, both physical symptoms and the meaning of these symptoms induce distressing emotions (Blake, Salkovskis, Gath, Day & Garrod, 1998). Therefore, when a woman feels sad, irritable or angry she may find these emotions more distressing if she attributes them to bodily functions out of her control (i.e. menstruation). In taking this view, distorted thinking is an important component of PMS, generating psychological and physiological upset (Blake et al., 1998). Blake et al. (1998) found cognitive therapy (CT) significantly improved PMS and depressive symptoms in women previously diagnosed with PMS.

Likewise, meta-analysis by Kleinstäuber, Witthöft and Hiller (2012) revealed small to medium effects for efficacy of CBT as treatment for PMS. Symptom-reduction was maintained for longer following psychotherapy compared to pharmacotherapy, possibly due to side effects associated with the latter (Kleinstäuber et al., 2012). Whilst cognitions appear to play a role in women’s experience of PMS, associated mood fluctuations cannot be explained by biological or psychological theory alone. Rather, an integrated approach best accounts for observed emotional variations.

Interpreting emotions during the menstrual cycle

Derntl et al. (2008) conducted a study looking at emotion recognition in females during both the follicular phase (FPG) and the luteal phase. The study utilised a series of images that depicted various emotions. The participants were then asked to pick from two options in order to correctly identify the emotion that was presented to them. They measured the activation of the amygdala throughout the experiment, utilising echo-planar imaging (EPI). Derntl and colleagues (2008) concluded that amygdala activation occurred in both the FPG and luteal phase groups, with the FPG demonstrating a higher amygdala stimulation. Moreover, the results of the study concluded that women in the FPG phase demonstrated a better capacity in recognising emotions in comparison to the luteal phase group.

Further research conducted by Derntl, Exner, Fernbach, Moser & Habel (2008) also concluded that the correct identification of emotions was the most reliable during the follicular phase. The researchers also found that lower progesterone levels were related to higher accuracy when identifying emotions. Moreover, females in the luteal phase were more likely to misinterpret emotions that were negative as being angry. The correlation between levels of estradiol and progesterone were significant in relation to the identification of anger, with females in the luteal phase showing higher inaccuracies when interpreting emotions (Derntl, Exner, Fernbach, Moser & Habel, 2008).

Treatment options

Crocus Sativus (Saffron)

Figure 6. Picture of Golden Saffron

A randomised trial that utilised a placebo and experimental sample was conducted by Hosseini, Kashani, Aleyaseen, Ghoreishi, Rahmanpour, Zarrinara & Akhondzaden (2007) to assess the efficacy of saffron as a treatment for PMS. The participants in the experimental group were given two tablets per day (30mg total), which were made from saffron petals. The results were tracked over a period of two menstrual cycles for both the experimental and control group. The premise of the study was based on previous research that had concluded that saffron acts as an anti-depressant by the means of the serotonergic system (Hosseini et al. 2007). This study provided further support for the use of Saffron in the treatment for PMS, with the experimental group displaying statistically significant positive changes in their depressive mood (Hosseini et al. 2007).

Drug treatments

Figure 7. Oral contraceptive

A study conducted on a sample of 1600 women, found that the treatment group that utilised a drospirenone and estradiol contraceptive pill showed reduced signs of PMS when compared to the placebo group after three months of use (Lopez, Kpatein, Helmerhorst, 2009). Further research conducted by Zervoudis, Vladareanu, Galazios, Liberis, Tsikouras and Veduta (2008) concluded that the use of an oral contraceptive was 67.9% more effective at treating PMS when compared to a baseline group.

Hypnosis and CBT

Typical medication treatments have been compared with alternative treatment methods such as cognitive behavioural therapy (CBT) and hypnosis. Rasht and Sari (2015) found that over a 8 week period implementation of CBT and combination of CBT and hypnosis - patients demonstrated a reduction in reported pain (p < 0.001). Further research found a decrease in anxiety prior to expected menstruation period. Group therapy was also found to reduce fear emotions prior to menstruation periods (Glover, Jovanovic, & Norrholm, 2015). Post-traumatic stress disorder (PTSD) treatment demonstrated efficacy in separating fear response with the increased presence of oestrogen in a female’s system.

Conclusion

References

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