I collect chronic illnesses. It’s not a hobby I’d have picked for myself, but it does give me great material to write about. While I’m grateful none of my illnesses are life-threatening, and my health is pretty good most of the time, the challenges of living with chronic illness are real and require some day-to-day management. I’ve found that in the one-and-a-half years since I got pregnant with my daughter that hormonal changes associated with fertility, such as the menstrual cycle, pregnancy, childbirth, and caring for an infant, have significantly impacted my chronic health issues.
If you are a woman who also experiences chronic illness, you may wonder how your chronic illness impacts your menstrual cycle, and vice versa. More importantly, if there is an impact, how can you mitigate it? This article explores the relationship between the hormonal fluctuations that accompany the menstrual cycle and some chronic physical and mental illnesses, and ends with some advice for menstruating women with chronic illness.
The menstrual cycle can impact symptoms of particular chronic physical illnesses
Our reproductive hormones impact many chronic physical illnesses, which makes sense since we know that hormones affect every part of the body. Each phase of your menstrual cycle may impact the symptoms of your chronic illness either positively or negatively based on which hormone or hormones are dominant or at low levels during that particular phase.
In one study, researchers reported that symptoms of chronic illnesses such as migraine, epilepsy, asthma, rheumatoid arthritis, and depression can have different degrees of severity depending on where a woman is in her menstrual cycle [1].
Epilepsy
Catamenial epilepsy is a form of epilepsy in which the frequency of seizures increases during certain phases of the cycle. Interestingly, which phase the seizures increase during can vary by woman. Anywhere from 10% to 70% of fertile women with epilepsy experience catamenial epilepsy, which occurs as a result of the changes in estrogen and progesterone levels during the cycle, according to research [2].
Skin conditions
Our hormones affect the skin, which means that dermatological conditions can also present differently depending on where a woman is in her cycle; according to one study, conditions including psoriasis, atopic eczema, and irritant dermatitis are exacerbated when progesterone is at its highest (in the luteal phase, before the period) [3].
Autoimmune disease
Hormones can also play a role in autoimmune disease symptoms. For example, estrogen can have an “anti-inflammatory and neuroprotective effect” in multiple sclerosis, but “opposite effects” with systemic lupus erythematosus (the most common type of lupus) per this study [4]. (Notably, use of hormonal contraception may be linked to the development of certain autoimmune diseases, including MS and Lupus.)
Fibromyalgia (FM)
When it comes to the effects of the menstrual cycle on fibromyalgia symptoms (which is a chronic illness much more common among women than men), research is mixed. A 2014 study, which found that “FM pain did not vary across the menstrual cycle,” also acknowledged that other studies have found a worsening of pain during the luteal phase [5].
Likewise, a 2018 study that measured women’s hormone levels every day for six weeks found no significant relationship between estradiol levels and pain, but did find that fibromyalgia pain was lowest during the middle of the luteal phase, when progesterone levels are at their highest [6]. Conversely, pain was highest during the menstrual phase, when all sex hormones are at their lowest. Low progesterone levels were particularly associated with high pain levels when cortisol, the stress hormone, was also high. Higher testosterone was also associated with lower pain levels.
Some chronic physical illnesses may prevent ovulation and periods
The relationship between the menstrual cycle and chronic disease symptoms can go both ways, with chronic illness affecting the menstrual cycle.
Some chronic illnesses may keep a woman from ovulating (known as anovulation) and therefore menstruating (amenorrhea) altogether. One clinical review article found that celiac disease, inflammatory bowel disease, chronic kidney disease, diabetes, and autoimmune diseases can cause amenorrhea, and another identified renal disease, liver disease, immunodeficiencies, inflammatory bowel disease, and uncontrolled diabetes as being associated with anovulation and amenorrhea [7][8]. The physical effects of eating disorders are also well known to be a cause of amenorrhea; as one article puts it, “the body goes into survival mode,” which shuts down the possibility of reproduction.
How do our reproductive hormones impact chronic mental illness?
Many of us have experienced the mood swings that can come with having a menstrual cycle, but women with mental illness may experience more extreme exacerbations of mental health during different phases of the cycle.
“The estrogen hypothesis”
Research suggests that a decrease in estrogen might be a factor in the depression and anxiety many women experience before their periods, when estrogen is low [9]. And, according to this research review, women with anxiety disorders, such as panic disorder, social anxiety disorder, and posttraumatic stress disorder (PTSD), often experience worse symptoms during the seven days before their period, while some women with generalized anxiety disorder have also reported worse symptoms during the middle of their luteal phase (the last phase of the cycle) [10].
In addition to exacerbating depressive and anxious symptoms, decreased estrogen levels during the premenstrual phase also appear to worsen psychosis symptoms, according to the authors of this meta-analysis (note that this study identifies “termination of pregnancy” as an “intervention,” an idea unsupported by the data on mental health outcomes of women who have abortions) [11]. Another meta-analysis suggests that “a large minority” of women with schizophrenia experience exacerbated symptoms during the premenstrual phase but concludes that this area is under-researched [12].
Similarly, researchers have found increased hospitalizations due to schizophrenia during the luteal phase (the last phase of the cycle, when progesterone is dominant) [13]. Because of the exacerbation of symptoms when estrogen is low, researchers describe the “estrogen hypothesis,” (also mentioned here) which suggests that estrogen has a protective effect for women with schizophrenia.
Mental illness and ovulation
In addition to the interplay between symptom severity and hormones, mental illness can also impact ovulation. We’ve discussed in other articles how stress can delay ovulation; according to one study, severe depression and stress can actually put the body into a state where ovulation and menstruation don’t happen [14]. As the authors of another study wrote, “FHA (functional hypothalamic amenorrhea) is precipitated by a combination of psychosocial stressors and metabolic challenge” [15].
Psychiatric medications and menstrual issues
And while hormonal fluctuations appear to worsen some mental illness symptoms, trouble can also go the other way, since some medications intended to treat mental illness may negatively impact women’s menstrual cycles and hormone levels. As an example, a small study of women with “chronic, treatment-resistant schizophrenia” found “a very high rate of menstrual dysfunction” associated with taking either typical or atypical antipsychotics [16]. Both categories of antipsychotics appear to raise prolactin levels above the normal range, and study authors hypothesized that these elevated levels played a role in menstrual cycle issues.
A note about medical research
Unfortunately, there are many unanswered questions when it comes to the interplay between chronic illness and the menstrual cycle, in part because much research on chronic illness is done on men, even though women are more likely to suffer from chronic illness.
Naturally cycling women are admittedly harder to study, as this article on depression and gender points out [9]. “The fact that increased prevalence of depression correlates with hormonal changes in women, particularly during puberty, prior to menstruation, following pregnancy and at perimenopause, suggests that female hormonal fluctuations may be a trigger for depression. However, most studies focus on males to avoid variability in behaviour that may be associated with the menstrual cycle.” (emphasis added)
Studying only men or only men and contracepting women is also a problem in drug research [17]. How can the field of medicine effectively diagnose and treat women if it fails to engage with women’s bodies as they naturally are?
How fertility awareness can help
If you have a chronic physical or mental illness, charting the symptoms of that illness alongside your fertility biomarkers can help you create an individualized treatment plan tailored to your particular experience. Where heavily cycle-impacted conditions like catamenial epilepsy are concerned, charting can even help with diagnosis.
Cycle syncing for chronic illness
If the severity of your symptoms varies depending on your cycle phase, cycle syncing using data from your fertility awareness chart can be especially important. Taking the example of chronic pain, fertility awareness can help you know when to remove activities or commitments that will drain your energy and worsen your pain, and also when to add in activities like gentle exercise that will help boost your energy and lessen your pain.
If you have an anxiety disorder, are feeling particularly anxious one day, and are not sure why, reminding yourself of where you are in your cycle may help to reassure you that you are experiencing cyclical hormonal changes, and this too shall pass.
Finally, if the symptoms of your chronic illness feel out of control, knowing that they worsen during certain parts of your cycle is important information you can take to your medical provider to seek help.
References:
[1] Oertelt-Prigione, Sabine. “Immunology and the Menstrual Cycle.” Autoimmunity Reviews, vol. 11, no. 6-7 (2012), pp. A486-92. [2] Verrotti, Alberto et al. “Diagnosis and Management of Catamenial Seizures: A Review.” International journal of women’s health vol. 4 (2012), pp. 535-41. doi:10.2147/IJWH.S28872 [3] Raghunath, R.S. et al. “The Menstrual Cycle and the Skin.” Clinical and Experimental Dermatology, vol. 40, no. 2 (2015), pp. 111-15. https://doi.org/10.1111/ced.12588 [4] Khan, D and S Ansar Ahmed. “The Immune System is a Natural Target for Estrogen Action: Opposing Effects of Estrogen in Two Prototypical Autoimmune Diseases.” Front Immunology, vol. 6, no. 635 (2016). doi: 10.3389/fimmu.2015.00635 [5] Alonso, C et al. “Menstrual Cycle Influences on Pain and Emotion in Women with Fibromyalgia.” Journal of Psychosomatic ResearchI, vol. 57, no. 5 (2004), pp. 451-8. https://doi.org/10.1016/j.jpsychores.2004.05.003 [6] Schertzinger, M et al. “Daily Fluctuations of Progesterone and Testosterone are Associated with Fibromyalgia Pain Severity.” The Journal of Pain, vol. 19, no. 4 (2018), pp. 410-17. https://doi.org/10.1016/j.jpain.2017.11.013 [7] Klein, D A et al. “Amenorrhea: A Systematic Approach to Diagnosis and Management.” American Family Physician, vol. 100, no. 1 (2019), pp. 39-48. [8] Golden, Neville H, and Jennifer L Carlson. “The Pathophysiology of Amenorrhea in the Adolescent.” Annals of the New York Academy of Sciences vol. 1135 (2008), pp. 163-78. doi:10.1196/annals.1429.014 [9] Albert, Paul R. “Why is Depression More Prevalent in Women?” J Psychiatry Neurosci, vol. 40, no. 4 (2015), pp. 219-221. [10] Nillni, Yael I et al. “The Impact of the Menstrual Cycle and Underlying Hormones in Anxiety and PTSD: What Do We Know and Where Do We Go From Here?.” Current psychiatry reports vol. 23, no. 2, (2021), p. 8. doi:10.1007/s11920-020-01221-9 [11] Thomas J Reilly, et al. “Exacerbation of Psychosis During the Perimenstrual Phase of the Menstrual Cycle: Systematic Review and Meta-analysis,” Schizophrenia Bulletin, vol. 46, no. 1 (2020), pp.78–90. https://doi.org/10.1093/schbul/sbz030 [12] Seeman, M.V. “Menstrual Exacerbation of Schizophrenia Symptoms.” Acta Psychiatrica Scandinavica, vol. 125, no. 5 (2012), pp. 363-371. https://doi.org/10.1111/j.1600-0447.2011.01822.x [13] Herceg, Miroslav et al. “Influence of Hormonal Status and Menstrual Cycle Phase on Psychopatology [sic] in Acute Admitted Patients with Schizophrenia.” Psychiatria Danubina, vol. 30, supplement 4 (2018), pp. S175-79. [14] Master-Hunter, Tarannum and Diana L. Heiman. “Amenorrhea: Evaluation and Treatment.” American Family Physician, vol. 73, no. 8 (2006), pp. 1374-82. [15] Marcus, Marsha D et al. “Psychological Correlates of Functional Hypothalamic Amenorrhea.” Fertility and Sterility, vol. 76, no.2 (2001), pp. 310-16. https://doi.org/10.1016/S0015-0282(01)01921-5 [16] Gleeson, Pia C et al. “Menstrual Cycle Characteristics in Women with Persistent Schizophrenia.” ANZJP, vol. 50, no.5 (2016), pp. 481-7. [17] Kyoung Yum, Sun et al. “The Problem of Medicating Women Like the Men: Conception of Menstrual Cycle-Dependent Psychopharmacology.” Transl Clin Pharmacol, vol. 27, no. 4 (2019), pp. 127-33. https://doi.org/10.12793/tcp.2019.27.4.127Additional Reading:
Cycle syncing: how to hack the natural hormonal shifts of your menstrual cycle
Menstrual migraines and hormonal headaches: how understanding your cycle can help
FAM basics: what is the luteal phase of the menstrual cycle?
