Moving the Mood Dial on Hormonal Fluctuations

A natural occurrence for many women, menstruation, or more casually referred to as one’s “period,” developmentally occurs before pregnancy and menopause. Yet understanding and appreciating the menstrual cycle’s influence on women’s health—especially, mental wellness—has only just begun.

“Of those three major life phases, research focused on the menstrual cycle and mood is by far the smallest,” says Tory Eisenlohr-Moul, PhD, associate professor of psychiatry at UIC, licensed clinical psychologist, and a leading authority in premenstrual disorders. “And yet, menses affects the most people and for longer periods of time throughout their entire reproductive lifespan.”

The fluctuating hormone levels that occur before menstrual bleeding commonly lead to mood swings ranging from irritability to anxiety and/or depression. For six percent of individuals of reproductive age, however, their periods can result in intense emotions and feelings of hopelessness to the point of fostering suicidal thoughts. Known as premenstrual dysphoric disorder (PMDD), this relatively new diagnosis was first introduced into the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) in 2013. Treatment for PMDD can range from birth control pills to SSRIs.

“While we don’t know what exactly causes PMDD, there is a good amount of evidence that it is not due to a hormone imbalance,” says Eisenlohr-Moul. “In 1998, an important experimental study demonstrated that abnormal brain sensitivity to normal hormonal changes may really be what is at play.”

At the University of Illinois College of Medicine, Eisenlohr-Moul leads the Clarifying the Endocrinology of Acute Risk (CLEAR) Lab for emotional distress, interpersonal problems, substance abuse, and suicide attempts across the menstrual cycle in at-risk women. Her innovative work has furthered the understanding of PMDD with the aim of better predicting and preventing severe psychiatric outcomes. For example, in a large global study of 600 participants, Eisenlohr-Moul and her colleagues found that 34 percent of individuals with PMDD reported they had made a suicide attempt related to their menstrual cycle and 72 percent had experienced suicidal thoughts premenstrually over their lifetime. In an ongoing NIH-funded study following adolescent girls with suicidality across the menstrual cycles, the Eisenlohr-Moul team has discovered that the teens’ suicide risk goes up and down according to cyclical changes. Other CLEAR Lab projects involve clinical trials focused on a variety of hormone treatments, such as stabilizing estrogen levels to prevent suicidality in the PMDD patient population.

While validation of PMDD and acknowledgement of its impact on women’s mental health has slowly grown, the field remains complicated and a bit messy, according to Eisenlohr-Moul. “In 2019, the World Health Organization’s International Classification of Diseases added PMDD as a gynecological diagnosis. Because the signs and symptoms of PMDD fall somewhere between normal hormonal mood changes and a brain sensitivity disorder, diverse medical specialties own it in different ways, but no one fully owns it,” says Dr. Eisenlohr-Moul, whose advocacy work has been instrumental in closing gaps between different specialty providers. “Whether we are practicing in psychiatry, gynecology, or primary care, all of us should be able to help patients where they feel most comfortable seeking care,” she continues. “As a clinical psychologist, I help patients cope with their symptoms and work to connect them with the right specialists because many people still don’t know who to see and where to go.”