When I got out the mood charts I’d been keeping since my diagnosis and compared them to my menstrual cycle, it became strikingly clear. My mood, my sleep patterns, my energy levels, all fluctuated in direct correspondence with my menstrual cycle. During the week before my period, my mood dropped. I became depressed, more prone to anger; my sleep was out of whack. I also noticed another dip in mood in the middle of my cycle, this one lasting only for a day or so. This dip happened immediately before ovulation, and was characterized not so much by depression as by fury. It was during these pre-period periods that I traumatized that poor dry cleaner and picked fights with my stoical husband over issues of global importance like the proper loading of the dishwasher.
I consulted a psychiatrist recommended by the Women’s Mood and Hormone Clinic at the medical center of the University of California, San Francisco, a psychiatric clinic that treats women with mood disorders that can be attributed, in part, to hormonal influences on the brain. My new doctor immediately evaluated me for PMS.
PMS—defined as mood fluctuations and physical symptoms in the days preceding menstruation—is experienced in some form by as many as 80 percent of all ovulating women. Nineteen percent suffer symptoms serious enough to interfere with work, school, or relationships, and between 3 and 8 percent suffer from PMDD, or premenstrual dysphoric disorder, symptoms so severe that those who suffer from them can be, at times, effectively disabled.
Although it’s long been known that 67 percent of women’s admissions to psychiatric facilities occur during the week immediately prior to menstruation, only recently have researchers begun to consider the effect of PMS on women with mood disorders. Premenstrual exacerbation, or PME, is when an underlying condition is worsened during a phase of a woman’s menstrual cycle. However, because I only ever experienced mood swings during two periods in my luteal phase (the days before ovulation and the week leading up to menstruation), my new psychiatrist concluded that I did not suffer from bipolar disorder at all, even bipolar disorder complicated by PME, but, rather, from mild PMDD, not so serious as to be disabling, but troubling nonetheless. Especially to my dry cleaner.
This change in diagnosis immediately felt right to me. Though there’d been comfort in having the bipolar diagnosis to explain my shifting moods, the fact that I never experienced serious mania or profound depression had always given me pause. Many a morning I would feel fine and stable, stare at the handful of pills in the palm of my hand, and wonder whether it really made sense to swallow something that I knew would soon make me irritable and/or sap my sex drive. And yet I also knew what happened to people with bipolar disorder who said, “I feel fine!” and stopped taking their meds, so I was a good soldier and took whatever my psychopharmacologist prescribed. Now, finally, I was on the right track.
Mood stabilizers don’t work on PMDD. Instead, low doses of hormones, including birth-control pills, are often prescribed, as are SSRIs, the latter given only in the week or ten days preceding menstruation. Research has also shown a positive effect from calcium supplements, light therapy, and cognitive therapy.
Because evidence of the link between hormone replacement therapy and breast cancer made me skittish, I initially opted for the monthly short course of SSRIs. Though antidepressants normally take four to six weeks to become effective, in premenstrual women, as soon as SSRIs are absorbed, they inhibit the enzyme 3-?-HSD from metabolizing progesterone. Because the drop in progesterone is the culprit in premenstrual blues, the change is immediate and profound. In my case, within twenty minutes of taking a pill, my mood lifted.*4
Unfortunately, SSRIs don’t have the same magical effect prior to ovulation, when a woman’s hormones shift rapidly, estrogen levels peaking and LH (luteinizing hormone produced by the pituitary gland) surging. As Dr. Louann Brizendine, the founder of the UCSF Women’s Mood and Hormone Clinic, told me, “Abrupt changes in hormones are like the rug being pulled out from under the brain.” Because SSRIs don’t work during this period, I relied on techniques learned in cognitive behavioral therapy and, when I found myself flinging my children’s toys across the room or starting a social-media flame war, the occasional anti-anxiety pill. A chill pill, if you will.
Once I understood the cyclical nature of my sleeplessness, I could wean myself off sleeping pills, and throw away most of my pharmacopeia. For a while, I was far better able to control my moods. I still cycled, but because I could anticipate my rages and my periods of sadness, I was able to plan for them and deal with them. I monitored my calendar the way a pilot monitors her cockpit controls, not only to determine when to start taking my medication, but also so that I could schedule important meetings and events to coincide with less volatile days of the month. Dr. Brizendine requires her patients’ partners to take the initiative during the premenstrual period, urging them to stop all arguments, jot down the subject on a piece of paper, and reintroduce it later in the month, when it can be dismissed without rancor. My husband kept track of my cycle and developed a bland and pleasant tone in which to ask the question “Do you think you might need an SSRI today?” I did my part by neither defenestrating nor decapitating him, but instead taking my pill.
For five years, things were predictable and peaceful. Then the inevitable happened. I entered perimenopause, and my period became irregular. Some cycles lasted thirty days, others twenty. Sometimes I’d skip a period or two altogether. With my period behaving like an ambivalent Victorian suitor who drops his visiting card rarely and on no discernible schedule, I could not time my SSRIs. My doctor convinced me to overcome my trepidation and try a low-dose estradiol patch to combat my shifting moods. The patch, however, did not provide the instant and profound relief I was used to. More troublingly, the use of unopposed estrogen—estrogen taken alone—is associated with an increased risk of endometrial and uterine cancer. This risk can be eliminated by adding progestin, but that’s been associated with an increased risk of breast cancer. Furthermore, progestin has a marked negative effect on mood, especially in women with PMS or PMDD. Since the only reason I was wearing the patch was to ameliorate my low moods, I was not about to add a medication that would make me depressed and possibly give me cancer.
And then things took a turn for the worse. I found myself in a state of seemingly perpetual irritability. I seethed, I turned that fury on the people around me, and then I collapsed in shame at my outbursts. These alternating states of anger and despair came far more frequently than before, and made me feel hopeless. I couldn’t seem to find pleasure in my life, or even contentment. I saw the world through a sad and dingy scrim. I knew there was light and love on the other side, but I couldn’t manage to lift the grimy curtain of my unhappiness.
My husband, who had been dealing with my vicissitudes of mood for years, seemed finally to be exhausted by them. We fought, and we seemed to take far longer to recover from our altercations. Or perhaps that’s more of my despondency talking. Perhaps he was no less patient than before, but my depression made me newly terrified that he would once and for all pack his bags and leave me alone with my ugly self.