I am a woman diagnosed with bipolar II disorder and I suspect that I am also hormonally vulnerable. I wrote this blog because I wanted to share some of my newly gained understanding of women and hormones, and the influence of hormones on mood.
Hormones are produced in the endocrine glands and released into the blood stream. They have many functions such as the regulation of the sleep and wake cycle, metabolism, energy, mood, response to stress, the structure of the bones, the menstrual cycle and reproduction. In this blog-post I will focus on the regulation of the menstrual cycle and it’s influence on mood. Hormones affect both – mind and body and they are intimately connected to feelings.
In the first week of the cycle, the uterus sheds it’s lining and menstruation occurs. Low estrogen 
levels recover and rise throughout the second week until their peak at ovulation. Ovulation happens in the middle of the menstrual cycle, between the second and the third week. The mature egg is released by the ovary into the pelvis. Testosterone levels also peak at ovulation and bring with it increased mental focus, better mood and energy and an increased sexual interest. High levels of estrogen and testosterone make the second week easy emotionally and physically for most women.
After ovulation, progesterone levels rise, and the estrogen levels drop. Progesterone reverses some of the positive effects of estrogen but it has also a stabilizing effect on the brain. By the end of week three, if there is no pregnancy, progesterone levels fall again and many women start feeling first signs of PMS (premenstrual syndrome) or PMDD (premenstrual dysphoric disorder).
Regarding PMS, week four is the most difficult week for most women. In the last few days of the cycle, progesterone levels collapse and estrogen levels are likewise low. This initiates the shedding of the uterus lining. In the last days before the menses, the calming effect of progesterone is withdrawn. During this time most women experience some symptoms of PMS such as mood swings, irritability, lack of joy, hopelessness, suicidal thinking, migraine, brain fog, lack of mental focus, fatigue and insomnia.
This is only a textbook description of the hormonal changes within the menstrual cycle. As often, things are more complicated. Hormone changes are not as smooth and predictable. Small but still significant estrogen fluctuations occur from day to day and even from hour to hour.
During the menstrual cycle estrogen rises and falls more than tenfold but estrogen production also rise and drop during a woman’s life such as in puberty and during menopause. These upwards and downwards surges in estrogen levels have positive and negative effects on the brain.
Estrogen improves blood flow in the brain and in the first two weeks of the cycle, the hippocampus (an important center in the brain for processing memory and learning) grows additional connections. Both is thought to have a positive effect on cognitive functioning. However, these additional connections are undone in the second half of the cycle when progesterone levels are high. Therefore, brain performance can change with the hormonal fluctuations during the cycle.
Another effect of ovarian estrogen is, that it stimulates the production of two ‘feel good brain chemicals’ – oxytocin and dopamine (which form the biological basis for a woman’s drive for intimacy) and it affects neurotransmitters that control mood and memory (such as serotonin, norepinephrine and acetylcholine). Consequently, estrogen may also negatively effect a woman’s sleep and wake cycle, and increases her vulnerability to depression.
The tricky thing is, that hormone levels can be within, what is considered, a normal range but the women still experience difficulties. This can be due to a woman’s vulnerability to hormone fluctuations. Often, it is not estrogen itself which is to blame. Symptoms can be due to an imbalance of estrogen/progesterone ratios or due to how sudden estrogen levels change. Hormonally vulnerable women find these fluctuations often less tolerable with age.
PMS and PMDD can technically just be diagnosed if the symptoms occur in the last two weeks before menstruation. But PMS-symptoms do not always appear this timely. Some women report them at other times of the cycle or they experience symptoms throughout the cycle. Such untimely PMS can easily be mistaken for bipolar affective disorder with rapid cycling. What sets PMDD from bipolar apart is that PMDD has some relation to the cycle, is often accompanied by somatic symptoms such as bloating, it becomes worse with age (before menopause) and symptoms disappear during pregnancy.
The subjective experience of women also differs. Some women report that they have the impression that PMS intensifies their bipolar symptoms while others perceive a qualitative difference between bipolar depression and PMS depression.
Many doctors seem not understand the effect of hormones on well being. Many assume that if the reproductive function of a women is unimpaired and her cycle is regular, estrogen and progesterone levels must be okay. But just because ovulation occurs in a timely manner does not mean that estrogen and progesterone levels are right for a woman’s sense of well being. In addition, it can be frustrating to have a psychiatrist who does not know much about hormones and to have an endocrinologist who does not know much about psychotropic medications and psychiatry.
The diagnosis of PMS and PMDD is entirely dependent of a woman’s subjective reports and there is much individual difference. Woman’s cycles can only be understood if doctors listen to women and the description of their symptoms.
Elisabeth Berger
References:
Brizendine, L. (2007) The Female Brain. London, UK.
Redmond, G. (2005) It’s Your Hormones. New York, USA.