As a general practitioner and specialist in menopause and premenstrual disorders, understanding the connection between hormones and mental health is central to my work. Many practitioners I come across agree that this connection exists and is important, and yet far too many patients with hormone-related mental health conditions fall through the cracks in our medical system. Why is this, and what can we do?

Prior to training in General Practice, I had aspirations of becoming a Liaison Psychiatrist. My interest in this fascinating sub-specialty was sparked during a placement as a medical student at the University of Cambridge. My mentor was the psychiatrist Dr. Cathy Walsh, who took me under her wing and, over the course of a few weeks, opened my eyes to the incredible interface between the physical body and the mind. 

I witnessed, first-hand, paraneoplastic syndrome manifesting as psychosis in a lung cancer patient; I joined the psychotherapy session of a man with Kallmann Syndrome – a genetic disorder that, not infrequently, robs people of their sense of smell and fertility; I sat with a young liver transplant patient, struggling with the psychological impact of receiving the organ of someone whose life had ended before their time; I attended the bedside of a woman who’d just given birth, wanting a photo with her placenta, with no interest in her baby, her partner anxiously asking if this was “normal”. (Reader, it is not.)  

I was inspired. This was it! This is what I wanted to do.

Of course, as I subsequently realized, it is a false dichotomy in medicine to divide things into physical and mental health to start with; there is not, and cannot ever be any, true separation between the body and the mind. The latter is created by, while simultaneously having a profound influence upon, the latter. They are inextricably linked. 

And, yet, as medical professionals, for the most part, we persist in doing so. Liaison psychiatry, as a sub-specialty, is considered relatively niche, and I believe we have this very wrong. Indeed, I feel we have a duty to our patients, and to ourselves, to consider all our clinical interactions through this integrated lens. We need to connect the dots. 

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Mood disturbance associated with (normal) hormonal changes in the menstrual cycle is not new, but is still poorly recognized and often misunderstood by the medical profession. Everyone has heard of PMS, but rarely is this taken seriously or considered worthy of clinical attention. OCD or anxiety that worsens in the lead-up to a period, is likely chalked up to being “one of those things” without anyone truly trying to understand, or manage, the underlying premenstrual exacerbation (PME). Even in the 21st century, women are labeled hysterical if they struggle with recurrent overwhelm, agoraphobia, or suicidal thoughts in line with their cycle, as can be the case in PMDD. 

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I did not continue with my psychiatry training. I had a strong sense that I would be able to make more of a meaningful impact on my patients if I met them at an earlier juncture, and hoped that working in the community would afford me that. I had also become disillusioned by, what I perceived to be, the tunnel vision of the (general) specialty I had once been desperate to be part of. I had long been aware of the impact of hormones on mental health (not least, my own) and made a point of asking patients about their cycles, and witnessed a monthly waxing and waning in the symptoms of some of our longer-term inpatients. 

I went to my seniors full of enthusiasm, and optimism, wondering why we weren’t automatically asking our patients about their periods (I mean, it’s such a simple thing to include in a history, isn’t it?) – naively believing that I was “onto something” and that everyone else would agree. But my observations fell largely on deaf ears. I brought in journal papers reviewing evidence of the impact of changing estrogen levels on mood; my consultant tossed these into the bin, without so much as a second glance. 

Perhaps the double whammy of mental health AND menstruation was just too much. Let’s keep everything above the neck and shoulders, please. Less messy.

In the UK, premenstrual disorders are, as a general rule, the preserve of gynecologists. And gynecologists are OK with mess; they don’t bat an eye at heavy menstrual flow. It’s their bread and butter. But things can go awry when things become too emotional or too intense. Psychological medicine is NOT. THEIR. AREA. And therein lies the problem. 

Patients fall between the cracks. Lives fall apart. 

Premenstrual dysphoric disorder (PMDD) is the most severe form of premenstrual disorder, affecting 5-8% of women and those assigned female at birth (AFAB). It is a psycho-neuro-endocrine condition – an abnormal response in the brain to normal hormonal fluctuations (i.e. the menstrual cycle). Many patients describe a Jekyll & Hyde existence – often feeling well and functional for half the month, then “out of their mind”, consumed by anger and self-loathing for the rest. This condition can leave those affected unable to work. It destroys personal relationships. It’s exhausting. It’s relentless. 

1 in 3 people will attempt suicide during a PMDD crisis at some point in their lifetime. 

Despite this, and despite the fact that countless girls and women with severe cyclical mood changes are, or have been, under mental health teams, PMDD and PME are often not on the psychiatric radar. Misdiagnoses and missed diagnoses abound. And each cycle a little more damage is done, the likelihood of a concomitant psychological disorder emerging increasing substantially - only serving to complicate things further. 

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I am not writing this to criticize, or shame, my psychiatric colleagues – far from it. Nor am I saying that psychiatry should shoulder full responsibility for hormone sensitivity. 

No: this is a call to action and a call for collaboration:

We need to start connecting the dots between hormones and mental health and work together. And we need to start right now.

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The smallest of changes can have profound impacts, and the opportunity to create lasting change: 

• Encourage patients to track their symptoms against their menstrual cycle (for at least two to three months): iapmd.org/symptom-tracker

• Routinely ask your patients if they notice any cyclical changes to their (physical and/or psychological) symptoms; if this is an acute admission, ask them about where they are in their cycle – record this, as standard, in their notes

• Familiarise yourself with evidence-based treatment guidelines in this area: iapmd.org/treatment-guidelines

• Connect, and engage, with professional colleagues: iapmd.org/join-professional-community Be open to discussion. 

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The impact of severe premenstrual disorders can be devastating and far-reaching, but we have an opportunity to intervene and make a positive difference. Once we recognise the connection, we can start rebuilding hope (and, yes, lives). 

But to help, we first need to SEE.

MEET DR. HANNAH

Dr. Hannah Short is a GP Specialist in Menopause, POI, and Premenstrual Disorders, recognized by the British Menopause Society (BMS), The International Association for Premenstrual Disorders (IAPMD), and The National Association for Premenstrual Syndromes (NAPS).

Hannah has a particular interest in induced menopause, premature ovarian insufficiency (POI) and hormone sensitivity disorders. She is a member of the IAPMD Clinical Advisory Board and the Surgical Menopause Advisory Committee and has previously worked as a volunteer doctor for The Daisy Network (a charity dedicated to girls and women diagnosed with POI).

Hannah has personal experience of premature surgical menopause, having undergone a hysterectomy and ovary removal at the age of 35. This drives her passion and informs her work. She is co-author of “The Complete Guide to POI and Early Menopause”.