Unmasking the cycle: Premenstrual and menstrual exacerbation of psychiatric disorders and impact on female mental health

Abstract

Premenstrual and menstrual exacerbation of psychiatric disorders is a significant area of concern in female mental health. Many females experience a worsening of psychiatric symptoms in the premenstrual and menstrual phases of their menstrual cycle, including heightened anxiety, depression, irritability, and mood swings. These exacerbations are most commonly associated with premenstrual syndrome and premenstrual dysphoric disorder that are characterized by severe emotional and physical symptoms that interfere with daily functioning. The hormonal fluctuations during the menstrual cycle, particularly changes in estrogen and progesterone levels, are believed to play a pivotal role in these exacerbations. Psychiatric disorders such as depression, anxiety, bipolar disorder, and schizophrenia may be influenced by these hormonal changes, with many females reporting an increase in symptom severity during specific phases of the cycle. The mechanisms behind this phenomenon remain complex, with both biological and psychosocial factors contributing to the heightened vulnerability. Clinical management includes careful monitoring of symptom patterns in relation to the menstrual cycle, with treatment options ranging from lifestyle modifications and psychotherapy to pharmacological interventions such as antidepressants and hormonal therapies. Understanding the link between menstruation and psychiatric disorders is essential for improving diagnosis and tailoring effective treatment strategies for affected individuals.

Key Words: Menstrual cycle; Premenstrual syndrome; Premenstrual dysphoric disorder; Psychiatric disorders; Females

Core Tip: This article highlighted the significant impact of premenstrual and menstrual exacerbations on female mental health. Many females experience worsened anxiety, depression, and other psychiatric symptoms during their menstrual cycle. This review emphasized the importance of recognizing these cyclical patterns in clinical practice and considering appropriate treatment options, including lifestyle modifications, psychotherapy, and pharmacotherapy. Exploring the impact of menstrual cycle on psychiatric disorders and understanding the influence of hormonal fluctuations on the exacerbation of psychiatric symptoms in females can enhance diagnosis and treatment strategies, addressing both biological and psychosocial factors for improved mental health outcomes.

INTRODUCTION

The menstrual cycle significantly influences female mental health, with hormonal fluctuations potentially exacerbating existing psychiatric disorders. This phenomenon, known as premenstrual exacerbation (PME), involves the intensification of psychiatric symptoms during the luteal phase of the menstrual cycle. PME is distinct from premenstrual dysphoric disorder (PMDD), which is characterized by mood disturbances that emerge exclusively in the premenstrual period.

Research indicates that PME affects various psychiatric diseases, such as mood or anxiety disorders, and psychotic disorders. The premenstrual and menstrual phases of the menstrual cycle bring profound physiological and psychological changes, heavily influencing mental health (Figure 1). The menstrual cycle is imbued with symbolic meanings linked to femininity, creativity, loss, and renewal. The hormonal shifts accompanying menstruation, specifically the decline in estrogen and progesterone, are thought to interact with deep-seated unconscious conflicts, amplifying psychological distress[1].

Figure 1 Psychiatric symptom severity across the menstrual cycle. This timeline graph illustrates the correlation between different phases of the menstrual cycle (menstrual, follicular, ovulatory, luteal, and premenstrual) and the relative severity of psychiatric symptoms. It highlights how symptom severity tends to peak during the premenstrual and menstrual phases.

For instance a systematic review found mixed evidence for perimenstrual exacerbation across mental disorders, suggesting that menstrual hormonal imbalances may heighten psychiatric symptoms, particularly in hormone-sensitive subjects[2]. In mood disorders, particularly bipolar disorder (BD), studies have shown that a significant proportion of females reported menstrual cycle-related mood changes[3-5]. Anxiety disorders also demonstrate susceptibility to PME. The menstrual phase due to hormonal variability represents a unique period of vulnerability for the onset or exacerbation of psychiatric manifestations, with a direct impact on diagnosis, risk assessment, and treatment[6]. Psychotic disorders are not exempt from menstrual influences. There is evidence of an excess in admissions for psychotic disorders during the perimenstrual phase, aligning with the hypothesis that hormonal changes can exacerbate psychotic symptoms[7].

Despite these findings the exact mechanisms underlying PME remain unclear. It is hypothesized that hormonal fluctuations, particularly in estrogen and progesterone levels, may interact with neurotransmitter systems, thereby influencing mood and behavior (Table 1). Menarche is a phenomenon rooted in physiological processes, imbued with psychic, cultural, social, and historical meanings that have varied across different epochs and global regions. The social group’s evaluation of menstruation significantly influences how females themselves perceive it. Therefore, the menstrual cycle is not merely a bodily event but primarily a cyclical process involving emotions and the relationship with one’s body and self.

Table 1 Hormonal secretion and mood effects across the menstrual cycle.

Phase	Hormone	Hormone level	Secretory role	Impact on mood and mental health
Menstrual (days 1-5)	Estrogen	Low	Shedding of endometrial lining due to hormonal withdrawal	Low mood, irritability, fatigue, depressive symptoms in some individuals
	Progesterone	Low	Minimal activity	Can contribute to emotional instability due to hormonal drop
	LH	Low	No active secretion; LH levels declined after previous cycle	No direct mood effect at this stage
Follicular (days 1-13)	Estrogen	Rising	Stimulates endometrial proliferation; supports follicle maturation	Improves mood, energy, cognitive function; neuroprotective and antidepressant-like effects
	Progesterone	Low	Not significantly secreted yet	May be associated with increased energy and mental clarity
	LH	Low to moderate	Stimulates theca cells to produce androgens; preparing for ovulation	Indirect effects on mood via estrogen production
Ovulatory (day 14 ± 1)	Estrogen	Peak	Triggers LH surge via positive feedback	Often associated with elevated mood, increased libido, cognitive sharpness
	Progesterone	Begins to rise	Prepares for potential implantation	Generally stable mood; for some early signs of anxiety
	LH	Surge	Induces ovulation (release of mature oocyte)	LH surge itself has limited direct mood effects; mediated via estrogen/progesterone shifts
Luteal (days 15-28)	Estrogen	Moderate	Supports endometrial maintenance with progesterone	Mood may remain stable early; may worsen in late luteal phase
	Progesterone	High	Dominant hormone; supports endometrial differentiation and potential implantation	Can cause mood swings, irritability, anxiety, especially in PMS/PMDD; modulates GABA receptors
	LH	Returns to baseline	No further significant role post-ovulation	Minimal direct mood effects
Premenstrual (late luteal)	Estrogen and progesterone	Rapidly declining	Corpus luteum regresses if no implantation	Hormonal withdrawal may trigger low mood, anxiety, emotional sensitivity (notably in PMDD)

LH: Luteinizing hormone; PMS: Premenstrual syndrome; PMDD: Premenstrual dysphoric disorder; GABA: Gamma-aminobutyric acid.

Menarche is also considered a rite of passage, marking the transition of a girl into womanhood, characterized by fertility. It has acquired particular significance due to its implications for procreation and consequently the power females gain over life and death in relation to another being. Donmall[8] outlined three significant aspects linked to menstruation and female psychology: The mother’s role in welcoming and experiencing the first menstruation; the emotional and psychological difficulty associated with irregular cycles due to the fear of internal bodily malfunctions, leading to feelings of inadequacy; and the mental association between menstruation and uncleanliness and shame, which indicates how for many females this negative experience is also linked to sexuality.

In traditional Chinese medicine (TCM), the menstrual cycle is closely linked to the flow of Qi (the vital life force or energy that flows through the body and sustains all physiological and mental activities) and blood, particularly through the liver, spleen, and heart meridians. TCM posits that emotional disturbances such as anxiety and depression in females are often associated with imbalances in these systems, particularly liver Qi stagnation and Heart Blood deficiency. During menstruation the natural movement of blood can exacerbate preexisting imbalances, leading to heightened emotional symptoms. For example, liver Qi stagnation is frequently implicated in premenstrual irritability and anxiety, while Heart Blood deficiency may manifest as sadness, palpitations, and insomnia. These patterns are considered integral to diagnosing and treating mood disturbances in females within the TCM framework, especially when timed with the menstrual cycle[9].

PREMENSTRUAL SYNDROME

Throughout the menstrual cycle females commonly experience a spectrum of physical, psychological, and behavioral changes, particularly between ovulation and menstruation. An early account of these changes was provided by Horney in 1931[10]. Around the same era the pivotal work of Frank[11] was widely recognized as the initial modern clinical description of premenstrual symptom. Both Horney and Frank utilized the term premenstrual tension to describe these cyclical emotional disturbances occurring late in the menstrual cycle. However, in 1953 Greene and Dalton[12] proposed that this term was insufficient to encompass the entirety of symptoms, suggesting instead premenstrual syndrome (PMS). This evolution illustrates a significant paradigm shift in understanding the symptomatic experiences of menstruating females and highlights the emotional and psychological aspects of the disturbances occurring during the menstrual cycle. Subsequent research highlighted a broader array of physical, emotional, and behavioral changes in the luteal phase, leading to a more holistic recognition of the condition’s complexity.

The transition from premenstrual tension to PMS underscored not only an evolution in clinical understanding but also the need for continued exploration of these symptoms within contemporary health contexts. This broader recognition of premenstrual challenges is critical, moving beyond historical perspectives to support a more inclusive approach to female health[13].

PMS is a prevalent condition affecting a significant proportion of females of reproductive age and is characterized by a variety of physical, emotional, and behavioral symptoms that repeat during the luteal phase of the menstrual cycle and resolve with the onset of menstruation. The global prevalence of PMS varies widely, with estimates ranging from 5.0% to 47.8%, depending on the diagnostic criteria and population studied[14]. The etiology of PMS is multifactorial and not yet fully elucidated. Hormonal fluctuations, particularly in estrogen and progesterone levels during the menstrual cycle, are believed to play a pivotal role. These hormonal changes may influence neurotransmitter systems, notably serotonin and gamma-aminobutyric acid, leading to the manifestation of PMS symptoms.

Additionally, genetic predisposition, lifestyle factors, and psychosocial stressors have been implicated in the development and severity of PMS[15]. It has been outlined that suicidal ideation may be implicated in the complex relationship between childhood abuse and premenstrual symptoms[16], and it has been described as an exacerbation during the perimenstrual phase of psychiatric symptoms, suicidal ideation, and suicidal planning, with depressive manifestations (depressed mood, hopelessness, perceived burdensomeness, and anhedonia), thus interpreted as possible statistical mediators in predicting perimenstrual aggravation of suicidality[17].

Clinically, PMS encompasses a wide array of symptoms. More frequent physical symptoms include bloating, breast tenderness, headaches, and fatigue. Emotional and behavioral symptoms often involve mood swings, irritability, anxiety, depression, and changes in sleep patterns. The severity of these symptoms can range from mild to debilitating, significantly impairing daily functioning and quality of life, and in severe cases PMS can progress to PMDD[18]. It has been described as a complex interaction between PMS and stress, involving hormonal pathways. Stress dysfunction (abnormal stress coping styles and stress reactivity patterns), in particular, represents a crucial factor influencing female vulnerability to PMS. Stress reactivity systems and PMS share neuroendocrine metabolic circuits based on hormonal fluctuations. For this reason there is a frequent comorbidity between PMS and stress-related disorders, and PMS itself may act as a stressor, originating a negative feedback loop that contributes to enhancing symptoms[19].

The diagnostic approach to PMS requires the prospective documentation of symptoms over at least two menstrual cycles to establish the cyclical pattern and temporal relationship with menstruation. This method distinguishes PMS from other mood or anxiety disorders that may present with similar symptoms but lack the cyclical nature associated with the menstrual cycle[20]. Management strategies for PMS are diverse and should be tailored to the individual’s symptomatology and severity. Lifestyle modifications, including regular exercise, dietary adjustments, and stress management techniques, are often recommended as first-line interventions. Regular physical activity has been associated with reductions in both physical and psychological symptoms of PMS, such as pain, fatigue, and mood disturbances[21,22].

Pharmacological treatments may be considered for individuals with moderate to severe symptoms. Selective serotonin reuptake inhibitors (SSRIs) have demonstrated efficacy in alleviating emotional and psychological symptoms of PMS and are often regarded as the first-line pharmacotherapy. Hormonal therapies, such as combined oral contraceptives, can be beneficial by suppressing ovulation and stabilizing hormonal fluctuations. Additionally, certain nutritional supplements, including vitamin B6, calcium, and zinc, have shown positive effects on the psychological symptoms of PMS[23]. Cognitive-behavioral therapy (CBT) has also been effective in managing PMS, particularly in addressing the emotional and psychological components. CBT focuses on modifying negative thought patterns and behaviors, thereby reducing symptom severity and improving coping mechanisms[24]. In addition, biofeedback training used for stress disorders may be useful in the treatment of PMS[19].

Since PMS is a complex and multifaceted disorder with a substantial impact on female health and well-being, a comprehensive approach that includes accurate diagnosis, patient education, lifestyle modifications, and individualized treatment plans is essential for effective management[25]. Increased awareness and understanding of PMS among healthcare providers and the general public are crucial steps toward improving outcomes for women experiencing this syndrome.

Healthcare providers must take into account the psychological ramifications of PMS and their impact on quality of life. This includes recognizing when to refer patients to clinical psychology services for therapeutic support in managing the diagnosis and its psychological effects to help alleviate psychological distress. There is also a need for additional training for healthcare professionals to properly assess PMDs and direct patients to suitable services.

Enhanced comprehension of premenstrual dysregulations would be advantageous within medical care settings where individuals in acute distress may present (i.e. urgent care facilities, primary care physicians, and psychiatric teams). Following diagnosis, numerous individuals reported only receiving care for somatic manifestations[26]. Thus, premenstrual education for clinicians is essential to possess a contemporary acknowledgement of the expanding research into the spectrum of evidence-supported treatment modalities and understand the requirement for restorative interventions aimed at the emotionally debilitating manifestations[27].

PMDD

PMDD is a severe mood disorder characterized by cognitive-affective and physical symptoms occurring during the luteal phase of the menstrual cycle and remit with menstruation. Defined as a specific clinical entity in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, PMDD affects approximately 5% of menstruating females, leading to significant impairment in daily functioning and quality of life[28]. The etiology of PMDD is complex and multifactorial, involving interactions between hormonal fluctuations and neurotransmitter systems[29,30]. While the precise mechanisms remain under investigation, it is hypothesized that neurosteroids, particularly those modulating the gamma-aminobutyric acid system, play a pivotal role in the pathophysiology of PMDD[31-33]. A recent study described a link between progesterone and the exacerbation of PMDD symptoms during the late-luteal phase and outlined that females with PMDD have relatively high cortisol levels during the late-luteal phase[34].

Disruptions in the homeostatic balance of ovarian steroids have been largely dismissed. Instead, contemporary investigations suggest that individuals experiencing premenstrual symptomatology, encompassing both PMS and PMDD, may exhibit aberrant responsiveness to typical hormonal variations[35,36]. A prospective analysis delineated three distinct phenomenological profiles of PMDD, characterized by pronounced symptomatology during the entire luteal phase, intense symptomatology during the premenstrual interval with delayed resolution, and moderate symptomatology during the premenstrual interval[37]. These findings underscored the importance of further examining the temporal dynamics and synergistic interactions of biological, psychological, and sociocultural determinants in elucidating the pathogenesis of PMDD.

Core body temperature (Tc) generally follows a clear circadian pattern with a daytime maximum and nighttime minimum[38]. In females with PMDD it has been described as an increased nocturnal Tc[39,40] and 24-h Tc[41] across the duration of the menstrual cycle not only during the symptomatic luteal phase. This suggests that elevated Tc may be a characteristic feature of the disorder. In studies of thermoregulation throughout the menstrual cycle, Tc is influenced by reproductive hormones, with estrogen lowering the thermoregulatory set point and progesterone increasing it[42]. Research on body Tc in mood disorders is limited although it has been found that patients with major depressive disorder (MDD) have elevated body Tc[43], possibly attributed to the inflammation hypothesis of MDD[44]. It has also been hypothesized that females with premenstrual syndrome/menstrual disorders may have a stronger inflammatory response[45], with higher C-reactive protein levels associated with worsened mood symptoms[46] although evidence is limited and not directly linked to an increase in Tc. Notably, a subset of investigations involving melatonin and somatic Tc failed to detect significant disparities between individuals with PMDD and control subjects[47].

Disrupted sleep-wake rhythms are often observed in individuals with PMDD. These disruptions can significantly impact overall health and well-being. Nexha et al[47] described a consistent pattern of diminished perceived sleep quality among individuals experiencing PMS or PMDD despite the absence of clear corroboration from objective sleep metrics. Among investigations employing objective sleep measures, the most recurrent findings were an augmentation of slow-wave sleep (SWS)[48] and a reduction in stage 1 sleep[49,50] in individuals with PMDD, suggesting a greater allocation of time to restorative deep sleep, as characterized by SWS, and a diminished presence of light sleep. Baker et al[50] reported an increase in SWS, a decrease in stage 1 sleep, and a decrease in the frequency of nocturnal awakenings. However, individuals with PMDD subjectively reported a higher incidence of perceived awakenings and a diminished sense of refreshment and alertness upon awakening.

Sleep-related complaints are prevalent among individuals, particularly during the premenstrual phase, and are frequently accompanied by algia, affective alterations, and somatic symptoms. Compromised sleep quality subsequently exerts deleterious effects on affect, defining a reciprocal relationship between sleep and mood[49]. It is conceivable that the effects of gonadal steroid fluctuations on melatonin and core Tc may modulate the subjective experience of sleep without altering sleep architecture[51].

Such disparities between objective and subjective sleep metrics are frequently observed in affective disorders[52,53] and in asymptomatic cohorts[54,55], suggesting that the perception of sleep is heterogeneous across patient potentially due to extraneous lifestyle factors unrelated to sleep architecture. The inconsistency between objective and subjective sleep reports may be attributed to a multitude of variables, including the imprecise terminology employed in assessments of subjective sleep quality[56]. These sleep parameters would benefit from longitudinal evaluations, potentially via actigraphy, enabling the mapping of sleep pattern trajectories in the course the menstrual cycle.

Cortisol serves as a critical regulator of the sleep-wake cycle and exhibits an inverse relationship to melatonin release. Cortisol levels peak during diurnal hours and reach nadir levels during nocturnal hours, facilitating the role of melatonin in signaling sleep onset. Flattened cortisol rhythms during the day, indicating a reduction or absence of the morning peak, have been linked to exacerbated depressive symptomatology[57,58].

Both pituitary hormones, prolactin and thyroid-stimulating hormone, are hypothesized to act synergistically in modulating female physiology[59]. Elevated prolactin levels and both elevated and diminished thyroid-stimulating hormone levels are frequently associated with depressive manifestations[60,61]. Compared with other affective disorders, PMS and PMDD remain understudied. There is a high lifetime comorbidity of PMS with other psychiatric disorders, especially with MDD, BD, and anxiety disorders[62], with multiple depressive disorders being the most common psychiatric disorders in the lifetime of people with PMDD[63].

Biorhythmic disorders are associated with the onset and persistence of affective episodes in patients with MDD and BD[64,65], and these diseases have also been linked to altered sleep and activity variables measured via actigraphy[66]. In addition, perturbation of biological rhythms has been recognized to independently predict functional impairment in subjects with affective disorders[67]. Since PMDD is classified as a depressive disorder and is frequently comorbid with other affective disorders, there may be shared mechanisms of biological rhythm disruption in affective symptoms, analogous to those observed in MDD and BD.

Clinically, PMDD presents with a range of affective, cognitive, and somatic symptoms. Affective symptoms include marked mood swings, irritability, depression, and anxiety. Cognitive symptoms often involve difficulty concentrating and feelings of being overwhelmed. Somatic symptoms may encompass breast tenderness, bloating, headaches, and joint or muscle pain. These symptoms are cyclical, emerging in the luteal phase and resolving shortly after the onset of menstruation[68,69].

The diagnosis of PMDD requires the prospective documentation of symptoms over at least two menstrual cycles to confirm their cyclical nature and to differentiate PMDD from other mood disorders. This approach ensures that the symptoms are not attributable to underlying psychiatric conditions and that they cause significant distress or impairment in social, occupational, or other important areas of functioning[70].

Neuroimaging studies have provided insights into the structural and functional brain correlates of PMDD. Research indicates alterations in grey matter volume and cortical thickness in regions associated with emotional regulation, such as the prefrontal cortex and amygdala. These findings suggest that PMDD may be associated with neurobiological changes that affect affective processing and regulation[71].

Management of PMDD is multifaceted, encompassing lifestyle modifications, pharmacotherapy, and psychotherapy. Lifestyle interventions, including regular physical activity, dietary adjustments, and stress management techniques, can alleviate symptoms. Pharmacological treatments often involve SSRIs, which have demonstrated efficacy in reducing both affective and somatic symptoms of PMDD. Hormonal therapies, such as oral contraceptives, may also be considered to stabilize hormonal fluctuations. CBT has been effective in addressing the psychological aspects of PMDD, aiding individuals in developing coping strategies to manage symptoms[24,72].

Significant challenges are encountered in the identification and treatment of PMDD within the healthcare system. Research indicates that patients with PMDD frequently experience delays in diagnosis and treatment within the healthcare infrastructure[73]. Further studies on diagnostic approaches for PMDD and the perspectives of healthcare professionals regarding its diagnosis are recommended.

PME OF PSYCHIATRIC DISORDERS

PME is defined as the worsening of symptoms of an existing psychiatric disorder during the premenstrual phase of the menstrual cycle. Unlike PMDD, which involves mood disturbances arising specifically in the luteal phase, PME involves the intensification of preexisting conditions such as MDD or generalized anxiety disorder during this period[74].

The phenomenon of PME of psychiatric disorders has garnered increasing attention due to its significant impact on female mental health and quality of life. It is a prevalent yet underrecognized condition, and its cyclical nature seriously impairs patients’ daily functioning. Studies indicate that a substantial proportion of females with mood disorders (including MDD and BD) experience premenstrual worsening of their symptoms.

Recent studies have identified premenstrual disorders as a risk factor for maternal antenatal depression and postpartum depression, suggesting that a screening for a history of PMS or PMDD during the early antepartum interview may contribute to preventing perinatal depression during the first stages of pregnancy[75]. Females with MDD may report intensified depressive symptoms, increased anxiety, and irritability and decreased functional capacity during the perimenstrual phase. Older females often have symptoms worsen. Premenopausal women with MDD often endorse PME and experience a worsening of depressive symptoms with a longer duration of a depressive episode[76]. PME of depressive disorders is associated with deteriorated functioning that is added to that already experienced by females with depression. It has also been outlined that patients may be susceptible due to the severity of depression, number of episodes, or remission status[77].

In BD the luteal phase may be associated with mood destabilization, leading to depressive or hypomanic episodes. It has been retrospectively observed that 64%-68% of females with BD reported menstrual cycle-related mood changes, while in prospective studies 44%-65% reported menstrual cycle-related mood changes[4]. Anxiety symptoms, including generalized anxiety and panic attacks, have been observed to worsen during the luteal phase of the menstrual cycle. The hormonal changes preceding menstruation can heighten anxiety levels, contributing to increased distress and impairment. Women with anxiety disorders (obsessive-compulsive disorder, generalized anxiety disorder, panic disorder) and psychotic disorders can experience premenstrual worsening of symptoms[7,78,79].

Psychotic disorders, such as schizophrenia, can also exhibit symptom exacerbation in relation to the menstrual cycle. Fluctuations in estrogen levels are believed to influence dopamine pathways, potentially worsening psychotic symptoms during the perimenstrual phase. Clinical observations have noted increased hospital admissions and symptom severity in females with schizophrenia during the premenstrual phase. Exacerbations of psychotic manifestations in females with schizophrenia can be distinguished from a rare condition called periodic or menstrual psychosis. There is still debate about whether periods of the month characterized by low estrogen production lead to an increase in schizophrenia symptoms among females of reproductive age or whether some females suffer from both schizophrenia and PMDD[8,80].

Individuals with borderline personality disorder may experience heightened emotional dysregulation during the perimenstrual and follicular phases. Studies suggest that depressive symptoms in borderline personality disorder peak during these phases, indicating a cyclical pattern of symptom exacerbation linked to hormonal changes[81]. Substance use behaviors have been found to fluctuate across the menstrual cycle, with certain phases associated with increased vulnerability. For instance alcohol use has been reported to rise during the premenstrual phase, potentially as a maladaptive coping mechanism for heightened emotional distress[81].

Early attachment experiences significantly influence how individuals navigate hormonal fluctuations. Females with insecure attachment styles may experience heightened vulnerability to menstrual-related distress due to unresolved dependency needs or fears of abandonment. The premenstrual phase may evoke these early relational patterns, contributing to exacerbations of psychiatric symptoms. It has been suggested that childhood trauma significantly increases the risk of mood disorders in phases of intense hormonal fluctuation such as perimenstrual period, pregnancy, postpartum, and perimenopause. Early traumas can be the origin of neurobiological changes influencing emotion regulation, which in turn represents a key predisposing, exacerbating, and perpetuating factor to hormonal sensitivity and subsequent psychiatric symptoms[82].

The exact mechanisms driving the premenstrual and menstrual exacerbation of psychiatric symptoms are complex and multifaceted. Hormonal fluctuations, particularly the cyclical changes in estrogen and progesterone, play a significant role. These hormones interact with neurotransmitter systems, such as serotonin and dopamine, influencing mood regulation and emotional stability. Additionally, individual differences in hormonal sensitivity may predispose certain females to more pronounced symptom exacerbation during specific menstrual phases[6].

Diagnosing PME requires careful assessment to distinguish it from PMDD and to identify the exacerbation of underlying psychiatric conditions. Prospective daily monitoring of symptoms over at least two menstrual cycles is recommended to establish a temporal relationship between symptom exacerbation and the menstrual cycle. This approach aids in confirming the cyclical pattern of symptom worsening and differentiating PME from other mood disorders. Additionally, clinicians should conduct a comprehensive psychiatric evaluation to assess the baseline psychiatric condition and its course. The management of PME involves a multimodal approach tailored to the individual’s baseline psychiatric condition and the severity of premenstrual symptom exacerbation. Pharmacological interventions may include the use of SSRIs, which have demonstrated efficacy in alleviating premenstrual mood symptoms. SSRIs can be administered continuously or intermittently during the luteal phase, depending on the patient’s symptom pattern and preference. Hormonal therapies, such as combined oral contraceptives, may also be considered to stabilize hormonal fluctuations and mitigate symptom exacerbation.

Psychotherapy and psychoeducation may help patients recognize and understand the cyclical nature of their symptoms to empower them to anticipate and manage exacerbations more effectively. Many females internalize societal taboos about menstruation that can exacerbate feelings of shame or inadequacy. Integrating psychological perspectives can provide a broader sociocultural context for understanding menstrual-related distress, emphasizing the role of gender norms and expectations in shaping female experiences[83,84].

Other non-pharmacological interventions, including lifestyle modifications and stress management techniques, play a crucial role in the comprehensive management of PME. Regular exercise, adequate sleep, and dietary adjustments have been shown to positively impact mood and reduce premenstrual symptom severity[13]. There is evidence for the potential of portable sensor technologies to refine the assessment of physiological parameters, including cardiac rhythm variability, sleep architecture, and motor activity, thereby facilitating advancements in this domain. Future remote electronic surveillance platforms may enable individuals and healthcare providers to track premenstrual symptomology in real-time. It could be possible to help individuals to recognize and mitigate premenstrual symptoms before they impede daily functioning, precipitate self-injurious or suicidal behaviors, or disrupt interpersonal dynamics.

The determinants contributing to menstrual cycle-related dysfunctions are receiving increasing attention. The influence of traumatic experiences on PME remains less elucidated. Individuals experiencing PME exhibit a greater frequency and intensity of childhood traumatic exposures compared with asymptomatic cohorts, with a direct relationship observed between early life trauma and the magnitude of premenstrual symptom expression.

Despite the persistent underdiagnosis and limited understanding of menstrual cycle-related dysfunctions, progress in the investigation of premenstrual psychological manifestations is anticipated[69]. It is crucial to consider psychological aspects in the management of these disorders as mental health plays a significant role in the overall well-being of affected individuals.

The onset of menses constitutes a pivotal juncture in female maturation, and menarche and menstruation remain intricate cognitive processes harboring potential conflict. Menstruation is an essential component of female existence, meriting investigation both intrinsically and for its potential to elucidate other domains of female lived experience. Menarche is a critical period for both identification with and differentiation from the mother, a process potentially complicated or facilitated by the mother’s personal menstrual experiences and/or sentiments regarding her own femininity. Furthermore, irregular menstrual cycles may engender heightened distress due to apprehensions of internal physiological dysfunctions. Psychologically, this fear originates from internalized guilt associated with aggression directed towards the mother during adolescence or from the notion that menstrual irregularity impedes the capacity of the psyche for integration. Menstruation may be linked to notions of impurity, defilement, and embarrassment, potentially reflective of attitudes towards sexuality[9].

CONCLUSION

Central to gestation, alongside the embryo, is the female capable of procreation. A pivotal moment within both social and individual consciousness marks the transition of a girl to womanhood: The onset of menarche. Different fantasies and expectations have been culturally and socially constructed around this event. During the menstrual cycle, the body signals a need for self-care, pause, rest, and enhanced bodily connection. The menstrual cycle functions as a map for self-discovery. Supportive psychological interventions can facilitate acknowledgment and understanding of the menstrual cycle, aiding in the observation of subtle changes that may indicate underlying issues or pathologies. Aligning with menstrual rhythms throughout the month can reduce stress related to performance pressures and foster inner awareness.

Despite the availability of various treatment options, both PMS and PMDD remain underdiagnosed and undertreated. This under recognition may be attributed to the normalization of symptoms as an inherent aspect of the menstrual cycle or a lack of awareness among healthcare providers and patients. In addition recognizing the intricate relationships between childhood trauma, depressive symptoms (including suicidal ideation), and premenstrual symptoms can help clinicians to comprehensively address young female mental and reproductive well-being. Trauma-informed interventions, personalized care, and awareness of potential association between childhood maltreatment are essential in managing these tangled challenges[16].

Many females endure significant distress and impairment without seeking or receiving appropriate care[18]. PME is a significant clinical concern for individuals with preexisting mood disorders, leading to cyclical exacerbations of depressive symptoms that impair functioning and quality of life. Hormonal, psychological, and social factors interact to form an integrated vulnerability that contributes to clinical outcomes. A thorough understanding of manifold and varied mechanisms underlying PME is essential for developing effective treatment strategies. Increased awareness among healthcare providers and patients is essential to improve recognition and management of this condition. Prospective symptom tracking over multiple menstrual cycles can aid in accurate diagnosis and differentiation from other mood disorders (Figure 2).

Figure 2 Conceptual model of premenstrual exacerbation and premenstrual dysphoric disorder. This figure presents a layered conceptual model illustrating how hormonal, psychological, and social factors interact to form an integrated vulnerability that contributes to clinical outcomes such as premenstrual exacerbation and premenstrual dysphoric disorder. The model emphasizes the convergence of multiple biopsychosocial influences in shaping premenstrual psychiatric symptoms. PME: Premenstrual exacerbation; PMDD: Premenstrual dysphoric disorder; HPA: Hypothalamic-pituitary-adrenal axis.

Further research is necessary to elucidate these pathways and to develop effective interventions for those affected by PME. Understanding PME is crucial for the comprehensive treatment of females with psychiatric disorders. Clinicians should consider the impact of the menstrual cycle when diagnosing and developing treatment plans as addressing PME may improve overall psychiatric outcomes and quality of life for affected individuals.