Mood swings, depression, tiredness, fatigue, irritability, anxiety, reduced cognitive ability, aggression, anger, sleep disorders and food cravings. One of the fun things about having a womb is that the aforementioned are simply considered par for the course. That's your lot. Sorry gals, but if you've got the temerity to be biological, then you're also going to have to suffer the psychological.
The relationship between female hormones and mental health is a razor-sharp, gravel-scattered line to walk for a woman like me. Because, on the one hand, of course we should take the time to consider this shit. As Gloria Steinem argued in If Men Could Menstruate, were the bleeding tables tipped to the other gender, "Doctors would research little about heart attacks, from which men would be hormonally protected, but everything about cramps."
We're not a second sex and this stuff is worth the investment of our time and attention, not to mention money. But on the other hand, as a woman who cries, cuts all her hair off and then realises two days later as her gusset fills with blood that it was that pesky progesterone all along, I am extremely wary of painting women as somehow weaker as a result of our hormones. The last thing in the world I want to do is add fuel to the fire of dickhead Mark who sits by toilets in the Finance department and makes lazy, humourless jokes about how one of his female colleagues "must be on the blob again!" because he just saw her giving someone their tax sheet.
No. Women are not biologically inferior because hormones affect our mental health. But Jesus Christ, it would be nice to have that mental health taken seriously once in a while.
I knew a man who, after several months of depression, weight gain, crying and an inability to concentrate on his job finally went to an endocrinologist to be told that, due to an excess of testosterone, his body had started to convert testosterone to oestrogen. "Oestrogen?" He asked. "Like the stuff in the pill? This is what that feels like?" This is what that feels like. He is the only man I will probably ever meet who knows what it's like to be swayed by the waves of female hormones and he swore sombrely that if the contraceptive pill was designed to increase female suicide, he wouldn't be the least surprised.
Talking of death, when another friend went to her doctor, telling him that her PMS made her feel like a psychopath, all he did was "calmly look at me with half-closed Garfield eyes and say, 'Most of the murders committed by women are when they've had PMS'." He then discharged her. That, as far as he was concerned, was that.
The first question, of course, is how. How do hormones affect our mental health? What is the ebbing tide that flows between womb and brain?
The answer is: we don't really know. "The precise aetiology of PMS remains unknown," writes Nick Panay, the Chairman of the National Association for Premenstrual Syndrome. "But cyclical ovarian activity and the effect of estradiol and progesterone on the neurotransmitters serotonin and gamma-aminobutyric acid (GABA) appear to be key factors." In short, the monthly cycle of those all-important reproductive hormones, released at different stages into the baby-making system, seem to affect the way signals pass through our brains.
They change the functioning of neurotransmitters, i.e. can actually change the chemistry and engineering of that big wet cauliflower responsible for our thinking. Or so we suspect because, as Panay puts it, "Rapidly changing estradiol levels, not only premenstrually but also postnatally and perimenopausally, lead to this triad of hormone-dependent depressive disorders often in the same predisposed individual." And, of course, some of us are more predisposed than others.
As a working definition, Parney characterises PMS as "a condition which manifests with distressing physical, behavioural and psychological symptoms that are not due to organic or underlying psychiatric disease". Of course, some women with PMS suffer from an underlying psychological condition. But then again, many of us don't. The definition also adds that these symptoms occur regularly during the luteal phase of each menstrual cycle but then "disappear or significantly regress by the end of menstruation". For some women, that's only the half of it; for them, the symptoms of PMS tip over into a rarer, even less understood condition: PMDD.
The DSM-IV defines PMDD as a "depressive disorder not otherwise specified". Which is pretty fucking helpful. The symptoms include depression, decreased interest in usual activities, lethargy and either hypersomnia or insomnia. In other words, a shit show that can all-too-easily be diagnosed as depression, bipolar disorder or all manner of other mental illnesses. The only difference, according to psychologists such as Jean Endicott of Clinical Psychology in the Department of Psychiatry at Columbia University, is that the symptoms of PMDD are cyclical, tied to your menstruation and subside once you actually start bleeding.
The monthly cycle of those all-important reproductive hormones, released at different stages into the baby-making system, seem to affect the way signals pass through our brains
"The most bizarre part is that as soon as I start bleeding it goes away," the artist and PMDD sufferer Charley Feltham tells me over email from Cornwall. "Literally 30 minutes or an hour later and I feel totally normal again. Like I've been in a fog for a week and then I just step out." For the week or ten days before her period, however, Charley loses herself entirely. "Smells are stronger, sounds are louder, things that don't bother me normally become a major issue, I'm clumsy and accident prone, totally exhausted and emotional. As I get closer to my period all of that intensifies and gets coupled with an extreme self-loathing, sometimes even suicidal thoughts. I look in the mirror and my whole face looks different, distorted and not myself. It sounds bonkers; it feels bonkers."
But it is a flavour of "bonkers" that is all too familiar to about 5 percent of menstruating women. In fact, the rate may be even higher than that – the National Association for Premenstrual Syndrome quote 5-8 percent with the caveat that it's likely to be under reported, especially by women from ethnic minorities. And if you think that the reason we know so little about PMDD is because relatively few people have it, remember that only four percent of the adult population in Sweden suffers from diabetes. And we've all heard about that.
Luckily, Charley's doctor was knowledgeable enough to diagnose PMDD and prescribed the contraceptive pill Yasmin for three months at a time with minimal breaks. "Within six weeks all my symptoms subsided and I felt like a totally different person," she says. "I still had bad anxiety, which is just exacerbated by hormones, so I ended up taking an SSRI too which helped a lot, for a while. It was kind of bizarre and also amazing, like I had confirmation that it was hormones and not just me being a massive arsehole."
Sadly, we are fleshy monkeys living in a social world and sometimes mental health issues arise from the confluence of external and biological triggers
In his treatment guidelines for PMS, Nick Panay writes that, "When treating women with PMS, newer contraceptive pill types may represent effective treatment for PMS and should be considered as one of the first-line pharmaceutical interventions." If the combined pill is a first step in the fight against PMS and PMDD, then it is not the only possibility. There is increasing evidence that serotonin may play a key role in PMS and PMDD, and so a number of SSRIs (a type of antidepressants that increase the level of the neurotransmitter, serotonin) have been used in its treatment, with better results than a comparative placebo.
The other option – the elephant in the womb, as it were – is a hysterectomy. But while for some women that is a serious consideration, many others would prefer to run the gamut of lifestyle changes, cognitive behavioural therapy, progesterone treatments and antidepressants first. Because, as is so often the case, good diet, exercise, reducing stress, not bingeing on carbohydrates, caffeine or alcohol can all help to reduce the effects of PMS and PMDD.
Of course, treating the mental health impact of our swirling, pumping, changing hormones is far from simple. It's not just a case of cutting out bread and drinking less tea. In the 2011 study Hormone-Specific Psychiatric Disorders: Do They Exist? Margaret Altemus wrote, "There are several challenges to identifying hormone-related syndromes. First, in naturalistic reproductive hormone fluxes, such as puberty, the menstrual cycle, pregnancy, lactation and menopause, multiple hormonal changes occur simultaneously." Amen to that.
"There is an unfortunate tendency to attribute psychiatric symptoms to fluctuations in oestrogen, rather than considering a more complete set of hormonal changes," she continues. We cannot easily isolate one hormone, one neurotransmitter, one organ or one area of the brain and blame that entirely. Oh, that we could. Sadly, we are fleshy monkeys living in a social world and sometimes mental health issues arise from the confluence of external and biological triggers. Who can say whether postpartum depression is caused by a change in hormones, lack of sleep, poor diet, stress, significant life changes or chronic pain when it is likely that you will be suffering all six? How can we say whether the young menstruating woman suffering from self-hatred and anxiety is the victim of changing hormones, social conditioning, poor relationships or financial insecurity when she is likely to be experiencing all four at once?
How can we tease apart the causes from the symptoms, when all too often our doctors, partners, friends and colleagues dismiss both as just "women's problems"?
As Dr Venkatraman Chandra Mouli of the World Health Organisation said to me in an interview earlier this year, "Menstrual problems don't kill. So nobody really gives a damn, except the women who suffer." Except, of course, they can kill. And women do suffer. Not just in low- and middle-income countries, as a physical result of using bark, sand, rags and newspaper instead of tampons and towels. Menstrual problems kill women because of the damage they reap on our minds. As Parnay writes, "PMS continues to be poorly understood and in many cases inadequately managed. It can be the cause of considerable morbidity and at time even mortality."
So, if you suspect that the fury and the despair, the frustration and self-loathing, the misery, misanthropy, mania and misadventure that flows through the moon-like waters of your body is more than you can cope with then – at the risk of sounding like Judy Blume – keep a diary. Try to note down when you're feeling what, for a couple of months, and then when you go to the doctor (and you really must go to the doctor) you'll have something concrete to show them. Get your thyroid tested. Ask about the contraception you're using. Do exercise, eat healthily and get plenty of sleep. Don't let anyone dismiss your hormones as "just hormones" and don't ever be afraid to ask for help.
Your body and your mind are wonderful things. Even if they act like bleeding cunts sometimes.
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