Session 1: Women’s Mental Health Across the Lifespan

Session 1: Women’s Mental Health Across the Lifespan

Throughout their lifetimes, women will experience changes in their moods as a consequence of aging. From puberty to post-menopause, these physical, emotional, and physical changes can be confusing and concerning. In Session 1, Liisa Hantsoo, a clinical psychologist and assistant professor, addresses changes in mood related to menstrual cycles. This lecture will focus on a range of mood symptoms that may occur across the monthly cycle, ranging from mild irritability to severe premenstrual dysphoric disorder (PMDD). Visit www.jhu.edu/hopkinsathome to learn more.

[Music] so um again i'm lisa hanso i'm a psychologist in the women's mood disorder center and i'm going to be talking to you tonight about mood and the menstrual cycle so um the this is part one of this three-part mini course and again it's a group of um us who are both researchers and clinicians in the women's mood disorder center and our main goal here is to help increase awareness about women's mental health across the lifespan so around the menstrual cycle perinatally and around menopause so tonight for part one i'm going to be focusing on mood and the menstrual cycle so i'll talk about premenstrual symptoms i'll talk about how we evaluate and diagnose mood symptoms around the menstrual cycle i'll talk about some treatment options and then we'll get a little bit into the biology so i like to start things off with interesting facts and so this fact is the average woman has 450 periods in her lifetime so if you're someone who experiences premenstrual symptoms that's a lot of occasions in which you might experience these symptoms 450 periods and so before we jump too much into the details i'm going to take us back to sixth grade health class for a minute and just do a quick review of the menstrual cycle so we're all on the same page um the menstrual cycle is roughly 28 days and so the cycle refers to this you know entire length from the time that bleeding starts up until the day before the next period starts so we have this full cycle that's 28 days within that we have the menstrual period which is the time when the person is bleeding and then we have this premenstrual phase over here which is the week or so before the next period starts and we go back to the beginning and you can roughly break the menstrual cycle into two halves so you have the follicular phase and then you have the ludial phase and they're divided in half by ovulation which is when the egg is released so some of the basic terminology out of the way so i want to start off with this idea that premenstrual symptoms are common so premenstrual symptoms affect up to 75 of women with regular menstrual cycles and this um was shown in a large study of over 40 000 women in the netherlands and it's been found in other similar studies as well so that means if you have a room full of 10 women at least seven of them will have experienced some type of premenstrual symptom at some point i also want to make a note that i'm using the term women this is because most of the research that i'll present tonight has been done on women so just a note on terminology there so premenstrual symptoms are common um they can be physical or mood-based and so in terms of the physical symptoms um we can see things like headaches fatigue difficulty sleeping trouble concentrating we can see things like acne or oily skin you can see breast tenderness or swelling you can just have gi issues like constipation or diarrhea you can also have things like food cravings for things like salty or sweet stuff sometimes there's abdominal bloating you can also have menstrual cramps some women have a change in libido and so those are some of the main physical symptoms that we tend to see we also see mood symptoms and so these are things like mood swings low mood increased anxiety or what we call um affective ability which can look like crying really easily and so when we think about these symptoms what are what are the most common ones and it turns out that on abdominal pain or cramps are usually the most common um followed by mood symptoms so again this is a study that i mentioned before in the netherlands that was over 40 000 women they asked them about their premenstrual symptoms and so abdominal cramps were the most common one by over 80 of women and then mood symptoms were the second most common so over 70 of women were reporting having mood symptoms premenstrually and this number is pretty consistent across other studies as well so premenstrual mood symptoms um occur on a spectrum and so you know there are often people who experience you know some irritability before their period or a little bit of anxiety and you know that's pretty pretty typical um again you know over 70 percent of women will say you know yeah i have a little irritability before my period but there's a subset of women who have clinically significant mood symptoms premenstrually and so these are things like premenstrual syndrome or pms or premenstrual dysphoric disorder or pmdd and so i'm going to dive a little bit into each one of these so pms occurs in around 20 of women so two out of ten women um pms is not considered a mood disorder um this is because pms can actually include only physical symptoms so this could be someone who has really significant cramping really bad headaches that kind of thing the american college of obstetrics and gynecology defines pms as having at least one symptom um and this again can be any one of those symptoms that i mentioned earlier it's present in the five days before menses starts and then it remits it goes away within four days of the menstrual period starting it has to cause some kind of interference so maybe it makes it harder to get things done at work or at school and it has to happen for at least three menstrual cycles in a row so that's pms the more severe end of the spectrum is pmdd and so pmdd only occurs in around three to eight percent of women so you know relatively small percentage it's uh considered a mood disorder and that's because it has to include her diagnosis and mood symptoms um in some women it's only mood symptoms they don't even have any of the physical symptoms but it can include physical symptoms as well pmdd can be quite impairing um and so if you think you know the average woman has 450 periods over the course of her life um if you add all of those times up and you know she's having symptoms for five to seven days before her period that adds up to a lot of time um so that can be up to four to eight years cumulatively if you kind of compress everything um over the lifespan and that's similar to um the impairment that it would be experienced by people who have major depression or dysthymic disorder for instance so the prevalence of pmdd is similar to other mental health diagnoses like post-traumatic stress disorder ptsd or panic disorder and you can see here in this chart pmdd is kind of sandwiched there right between ptsd and panic disorder which are both you know disorders that we hear about fairly commonly and i want to emphasize too that pmdd is a severe mood disorder so this really affects women's functioning um it's not just major depression kind of tied to the menstrual cycle it's unique from that and it's often characterized by irritability anger anxiety these are some quotes that i pulled from a paper that came out recently that focused on women's qualitative experience of having pmdd and the women say things like um i feel like it's an alter ego i'm a completely different person in that premenstrual phase um i feel very low hopeless tearful but also getting angry um feeling depressed feeling anxious um and so these are these are some of the experiences that women report when they have pmdd so i'm going to talk a little bit about how we evaluate premenstrual mood issues and so i'm this slide is pretty busy but i'm going to kind of jump into the details and then zoom back out a little bit so i wanted to start with pmdd since that's at the most severe end of the spectrum and it's the most complicated to diagnose um so for pmdd again you need to have those core mood symptoms and so you need to have at least one of these four mood symptoms these are affective mobility which um sort of refers to mood swings so um being more tearful than usual being more sensitive to rejection so if someone says something to you might feel more kind of hurt by it than normal um irritability this can look like anger or interpersonal conflict um low mood so that can look like hopelessness feeling just kind of down um a lot of women will report on really self-deprecating thoughts um and then anxiety so feeling tense feeling on edge worrying a lot so you have to have at least one of those and then you have to have at least one of these additional symptoms so these are decreased interests so feeling less interested in things that you normally care about trouble concentrating low energy changes in appetite or food cravings and so again women with pmdd often crave things like sugary or salty snacks um sleep disturbance this can be either sleeping too much or not getting enough sleep insomnia feeling overwhelmed or out of control and then also physical symptoms so this is where we see those things like headaches breast tenderness that kind of thing so out of all of these symptoms you have to have at least five total they have to occur in that premenstrual week but then disappear once menses starts and they have to have happened in the majority of cycles in the past year um with pmdd again it's a rather involved diagnosis to make and so um in addition to the normal clinical interview that you would do with your healthcare provider um you also will need to do uh daily symptom readings for at least two menstrual cycles um and so this is called prospective daily reading meaning instead of thinking back and thinking oh yeah i think i might have had irritability before my period um you know it can be hard to kind of think back and necessarily remember and so providers um you know for the gold standard of diagnosis they ask people to start tracking um and then you know we can really get a sense in real time what the symptoms are looking like in terms of the menstrual cycle so pmdd diagnosis can be challenging a lot of patients come in and say that they've had trouble getting an accurate diagnosis and again here are some quotes from that paper that i referred to earlier so women with pmdd are saying i felt like the healthcare providers thought that i was making this up my mental health care team was saying we don't believe in this kind of thing or i've never heard of it or another says that her um her primary care provider is um just saying you know oh you're just depressed it's just depression and so in terms of pmdd diagnosis um you know one of the challenges um is kind of finding the right provider to get the accurate diagnosis and so there was a study done in 2018 by the international association of premenstrual mood disorders iapmd um it was a global survey and they asked over 2500 women or patients who were seeking care for pmdd what their experiences were in trying to get a diagnosis and we found that you know patients sought care from a number of different types of providers so this ranged from primary care doctors to gynecologists to psychiatrists to psychologists this paper just came out and we definitely found differences in terms of how the different providers were able to address premenstrual symptoms and so kind of different strengths and different weaknesses of different types of providers another challenge for diagnosing premenstrual mood symptoms is that the symptoms can fit some different patterns and so um here you can see patient a this is someone who has what we would think of as pretty classic you know pms or pmdd where they're having symptoms in the few days before menses um and then the symptoms go away but you can also have people like patient b who have a little spike in symptoms around ovulation and then they continue to have some symptoms um kind of throughout the luteal phase um patients c and d are also having a pretty extended length of time of their of their symptoms another challenge that women can face when they're experiencing premenstrual mood symptoms is that it gets mistaken for other cyclic disorders um so these can be things like bipolar disorder or cyclothymic disorder which are cyclic mood disorders and so often you know women will come in and they'll say you know yeah i was misdiagnosed with bipolar disorder and so basically what happened was the provider noticed that there was a cyclicity to the moods that the moods were getting worse and then getting better and then getting worse but they didn't take that extra step and tie it to the menstrual cycle you also want to make sure that it's not premenstrual exacerbation of an existing mood disorder so major depression for instance it turns out that around 60 of women who have major depression will experience pre-menstrual worsening of their depressive symptoms so this is another important thing to watch out for all right let's go ahead and move into treatment so i broke this down um kind of by level so we'll talk about you know what if i'm having mild premenstrual symptoms and we'll talk about if you're having more significant pms symptoms or if you're having that most severe um pmdd so what if i'm having just mild premenstrual symptoms um so this is you know not super exciting advice but this is what the research says so it's really important to do some good self-care and really checking in about just some of those really basic things so getting enough sleep making sure that you have good sleep hygiene um making sure your diet is you know pretty balanced and nutritious you're getting lots of fruits and veggies things like that physical activity so this can be something pretty basic like walking yoga something to get you moving um managing stress which you know sometimes is easier said than done but really taking taking a look at how you experience and manage stress in your life and also you know using things like social support to help buffer some of that stress so reaching out to friends and you know kind of being involved with with friends or family members for support okay what if i'm experiencing pms so i'm having maybe some kind of significant irritability or anxiety before my menstrual cycle first step is you want to make sure that all of your self-care is in place another thing that there's been a decent amount of research on is calcium carbonate which is also known as tums and so there have been several studies that show that women with sort of mild pms symptoms if they take 500 to 1000 milligrams of tums every day during that ludial phase that can help alleviate some of the symptoms um cognitive behavioral therapy or cvt is another good option um but it's important to talk with your health care provider so the treatment really depends on you know whether you're having physical symptoms mood symptoms and what those particular symptoms are being a psychologist i have to give a little plug for cvt um and so cbt is a type of psychotherapy where you're meeting with a psychologist and talking about ways to kind of notice negative thought patterns be able to modify some of those negative thought patterns and work on coping strategies so you know how do i cope with stress that kind of thing [Music] all right and then what if i'm at the most severe end of the spectrum and i'm having pmdd so um there are a number of treatment options for pmdd um and i'm gonna run through three of the most common which are cbt which we already talked about um selective serotonin reuptake inhibitors and oral contraceptives there are other options like generate medications and rooferectomy but those are not as commonly used so we're going to focus on the the more common treatments tonight so um ssri selective serotonin reuptake inhibitors and you might have heard of these before they are um this is a first-line treatment for um things like depression and anxiety and so they're also used to treat pmdd um they actually have a pretty rapid effect in pmdd so with major depression it can take several weeks for the ssri to kick in in pmdd you often see an improvement in symptoms within 24 to 48 hours um they can also be given at a relatively low dosage compared to the doses that are used for major depression and for pmdd you can take them continuously as you would for major depression which is you know when you take them every day but they can also be taken intermittently which means they're just taken during the ludial phase or the premenstrual phase oral contraceptives are another treatment option for pmdd um there's really mixed evidence for the efficacy of oral contraceptives for pmdd um and i think in part this is because there's such a wide variety of oral contraceptives each with a different formulation of hormones so the one oral contraceptive that is fda approved to treat pmdd specifically is called yaz it's a monophasic contraceptive which means that it's a constant hormone level um so you're not having any fluctuations in the level of hormone you take the same level every day and then um you take the active pill for 24 days and then you have four sugar pills or inactive pills and so there have been a number of studies on yaz that have shown that it helps reduce pmdd symptoms um there was a meta-analysis of this that came out about a decade ago that showed that it had pretty good results all right so we're gonna go ahead and jump into some of the biology um and so you know one of the sort of obvious questions that we get often is you know what about hormones right because you know with premenstrual symptoms we see this ebb and flow in the symptoms with the menstrual cycle and we also see hormones fluctuating across the menstrual cycle and so you kind of put two and two together and think okay well hormones must be involved somehow with these premenstrual mood symptoms and so that is true um so hormones can have really powerful effects on the brain and on behavior um and so you know the main female hormones um estradiol and progesterone are produced in the ovaries um but you know they can travel through the bloodstream and actually act on the brain as well um and so one of the um hormones that we're really interested in um in terms of pmdd in particular is um it's related to progesterone so progesterone again is one of those main female hormones um it gets metabolized or converted into something called aloe pregnant alone or aloe and aloe is what we call a neuroactive steroid hormone um so neuroactive just means that it affects the brain it affects the central nervous system and so aloe um it actually acts on the same receptors that things like alcohol or benzodiazepines would work on and so benzodiazepines are things like xanax and so because of that it has these anti-anxiety and sedative effects so we think that what is going on with aloe is that it may be interacting with those receptors um in a slightly dysfunctional way um and we know that it's not just the level of hormones so if you measure hormone levels in the blood of a person who has pmdd versus a person that does not have pmdd their hormone levels look the same um so it's it's not the hormones themselves um it's what we call the hormone sensitivity hypothesis which is the idea that this is actually an altered brain sensitivity to normal hormonal fluctuations and so we i bring you back to this image of the menstrual cycle and you can see over here in the ludial phase you know this is this premenstrual week over here you can see that um there's this really rapid rise in progesterone and then a really rapid decrease in progesterone and so we think that women with pmdd for instance their brains are a little bit more sensitive to these major fluctuations than women who don't have pmdd and so that's an active area of research where we're trying to figure out you know what is it about women with pmdd or pms who are responding to these changes in hormones in a little bit different way than women who don't have these mood symptoms all right so that was a really quick whirlwind tour of uh premenstrual mood symptoms so in conclusion um i just want to emphasize that many and in fact i would say most women experience premonstral symptoms of some type whether it's mood or physical in terms of the mood symptoms these occur on a spectrum of severity so it can again range from mild irritability for a day or two before your period up to you know full-blown pmdd um the good news is there's a range of treatment options available and there are also a lot of good resources available um so i've included two one is the international association for premenstrual disorders iapmd.org and then women's health.gov is another good place to get basic information and with that i would like to thank everyone for attending and listening i want to also thank my team so my really fantastic colleagues at the hopkins women's mood disorder center as well as people who participate in research both in my research and in research in general um so you know the data that i showed you tonight from all these different studies this was made possible by people who decided to volunteer to go be in a research study and so research is you know really important if you're interested in research it's a really great way to kind of get involved in supporting women's women's health i also want to recognize my funding sources so i actually didn't talk about any of my funded research tonight but those are my funding sources in case you're interested and then my contact information is at the bottom

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