Cases That Test Your Skills

Increased anxiety and depression after menstruation

Current Psychiatry. 2023 March;22(3):42-45 | doi: 10.12788/cp.0338

Ms. C, age 29, has bipolar disorder and generalized anxiety disorder. Her anxiety and depressive symptoms worsen each month after menstruating. How can you best help her?

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References

1. Epperson CN, Steiner M, Hartlage SA, et al. Premenstrual dysphoric disorder: evidence for a new category for DSM-5. Am J Psychiatry. 2012;169(5):465-475.

2. Raffi ER, Freeman MP. The etiology of premenstrual dysphoric disorder: 5 interwoven pieces. Current Psychiatry. 2017;16(9):20-28.

3. Timby E, Bäckström T, Nyberg S, et al. Women with premenstrual dysphoric disorder have altered sensitivity to allopregnanolone over the menstrual cycle compared to controls--a pilot study. Psychopharmacology (Berl). 2016;233(11):2109-2117.

4. Yen JY, Lin HC, Lin PC, et al. Early- and late-luteal-phase estrogen and progesterone levels of women with premenstrual dysphoric disorder. Int J Environ Res Public Health. 2019;16(22):4352.

5. Huang Y, Zhou R, Wu M, et al. Premenstrual syndrome is associated with blunted cortisol reactivity to the TSST. Stress. 2015;18(2):160-168.

6. Hantsoo L, Epperson CN. Premenstrual dysphoric disorder: epidemiology and treatment. Curr Psychiatry Rep. 2015;17(11):87.

7. Tiranini L, Nappi RE. Recent advances in understanding/management of premenstrual dysphoric disorder/premenstrual syndrome. Faculty Rev. 2022:11:(11). doi:10.12703/r/11-11

8. Raffi ER. Premenstrual dysphoric disorder. Current Psychiatry. 2017;16(9). Accessed January 30, 2023. https://www.mdedge.com/psychiatry/article/145089/somatic-disorders/premenstrual-dysphoric-disorder

9. Kiesner J. One woman’s low is another woman’s high: paradoxical effects of the menstrual cycle. Psychoneuroendocrinology. 2011;36(1):68-76.

10. Alnuweiri T. Feel low after your period? Postmenstrual syndrome could be the reason. Accessed January 30, 2023. https://www.wellandgood.com/pms-after-period/

11. Sharkey L. Everything you need to know about post-menstrual syndrome. Healthline. Published April 28, 2020. Accessed January 30, 2023. https://www.healthline.com/health/post-menstrual-syndrome

12. Santoru F, Berretti R, Locci A, et al. Decreased allopregnanolone induced by hormonal contraceptives is associated with a reduction in social behavior and sexual motivation in female rats. Psychopharmacology (Berl). 2014;231(17):3351-3364.

13. Sepede G, Brunetti M, Di Giannantonio M. Comorbid premenstrual dysphoric disorder in women with bipolar disorder: management challenges. Neuropsychiatr Dis Treatment. 2020;16:415-426.

14. Rapkin AJ, Korotkaya Y, Taylor KC. Contraception counseling for women with premenstrual dysphoric disorder (PMDD): current perspectives. Open Access J Contraception. 2019;10:27-39. doi:10.2147/OAJC.S183193

15. Roe AH, Bartz DA, Douglas PS. Combined estrogen-progestin contraception: side effects and health concerns. UpToDate. Accessed February 1, 2023. https://www.uptodate.com/contents/combined-estrogen-progestin-contraception-side-effects-and-health-concerns

16. Ford O, Lethaby A, Roberts H, et al. Progesterone for premenstrual syndrome. Cochrane Database Sys Rev. 2012;3:CD003415. doi:10.1002/14651858.CD003415.pub4

17. Kaunitz AM. Contraception: progestin-only pills (POPs). UpToDate. Accessed February 1, 2023. https://www.uptodate.com/contents/contraception-progestin-only-pills-pops

CASE Increased anxiety and depression

Ms. C, age 29, has bipolar II disorder (BD II) and generalized anxiety disorder. She presents to her outpatient psychiatrist seeking relief from chronic and significant dips in her mood from Day 5 to Day 15 of her menstrual cycle. During this time, she says she experiences increased anxiety, insomnia, frequent tearfulness, and intermittent suicidal ideation.

Ms. C meticulously charts her menstrual cycle using a smartphone app and reports having a regular 28-day cycle. She says she has experienced this worsening of symptoms since the onset of menarche, but her mood generally stabilizes after Day 14 of her cycle–around the time of ovulation–and remains euthymic throughout the premenstrual period.

HISTORY Depression and a change in medication

Ms. C has a history of major depressive episodes and has experienced hypomanic episodes that lasted 1 to 2 weeks and were associated with an elevated mood, high energy, rapid speech, and increased self-confidence. Ms. C says she has chronically high anxiety associated with trouble sleeping, difficulty focusing, restlessness, and muscle tension. When she was receiving care from previous psychiatrists, treatment with lithium, quetiapine, lamotrigine, sertraline, and fluoxetine was not successful, and Ms. C said she had severe anxiety when she tried sertraline and fluoxetine. After several months of substantial mood instability and high anxiety, Ms. C responded well to pregabalin 100 mg 3 times a day, lurasidone 60 mg/d at bedtime, and gabapentin 500 mg/d at bedtime. Over the last 4 months, she reports that her overall mood has been even, and she has been coping well with her anxiety.

Ms. C is married with no children. She uses condoms for birth control. She previously tried taking a combined estrogen/progestin oral contraceptive, but stopped because she said it made her feel very depressed. Ms. C reports no history of substance use. She is employed, says she has many positive relationships, and does not have a social history suggestive of a personality disorder.

The author’s observations

Many women report worsening of mood during the premenstrual period (luteal phase). Premenstrual dysphoric disorder (PMDD) involves symptoms that develop during the luteal phase and end shortly after menstruation; this condition impacts ≤5% of women.¹ The etiology of PMDD appears to involve contributions from genetics, hormones such as estrogen and progesterone, allopregnanolone (a progesterone metabolite), brain-derived neurotrophic factor, brain structural and functional differences, and hypothalamic pathways.²

Researchers have postulated that the precipitous decline in the levels of progesterone and allopregnanolone in the luteal phase may contribute to the mood symptoms of PMDD.² Allopregnanolone is a modulator of gamma-aminobutyric acid type A (GABA-A) receptors and may exert anxiolytic and sedative effects. Women who experience PMDD may be less sensitive to the effects of allopregnanolone.³ Additionally, early luteal phase levels of estrogen may predict late luteal phase symptoms of PMDD.⁴ The mechanism involved may be estrogen’s effect on the serotonin system. The HPA axis may also be involved in the etiology of PMDD because patients with this condition appear to have a blunted cortisol response in reaction to stress.⁵ Research also has implicated immune activation and inflammation in the etiology of PMDD.⁶

A PMDD diagnosis should be distinguished from a premenstrual exacerbation of an underlying psychiatric condition, which occurs when a patient has an untreated primary mood or anxiety disorder that worsens during the premenstrual period. PMDD is differentiated from premenstrual syndrome by the severity of symptoms.² The recommended first-line treatment of PMDD is an SSRI, but if an SSRI does not work, is not tolerated, or is not preferred for any other reason, recommended alternatives include combined hormone oral contraceptive pills, dutasteride, gabapentin, or various supplements.^7,8 PMDD has been widely studied and is treated by both psychiatrists and gynecologists. In addition, some women report experiencing mood instability around ovulation. Kiesner⁹ found that 13% of women studied showed an increased negative mood state midcycle, rather than during the premenstrual period.

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