Motivation and emotion/Book/2015/Menstrual cycle and emotion

Overview


The menstrual cycle is something that the majority of people have experienced either directly or indirectly. Whilst men do not have a menstrual cycle, it is highly likely that they have been bystanders whilst a significant female (e.g., girlfriend, sister or wife) have dealt with the associated variables and consequences. The changes in emotion and mood associated with the menstrual cycle have frequently been stereotyped in Westernised society.

A common reoccurring perception of the emotions, paints women to be: crazy, irrational and emotional throughout their menstrual cycle. A quick google search of "girls on their period" provides a multitude of results, ranging from: memes which aim to make light of the subject, YouTube videos demonstrating how "girls act" during the menstrual cycle (click here to view an example), informative articles explaining what is occurring during the menstrual cycle and some inaccurate articles. An analysis of research conducted by Romans, Clarkson, Einstein, Petrovic & Stewart (2012) looked at a variety of research and concluded that there is no consistent information to support or discredit the existence, cause and prevalence of emotion and mood based changes during the menstrual cycle.

Menstrual cycle


The menstrual cycle occurs when a woman reaches puberty and becomes fertile (Oertelt – Prigione, 2012). Oertelt – Prigione (2012) also explained that the purpose of the menstrual cycle is to prepare the woman for the conception of a child. The average menstrual cycle lasts for a period of 28 days. Day one of the cycle occurs when the menstrual flow begins and ovulation usually occurs at day 14 (Talbi, et al., 2005). The menstrual cycle consists of three phases:
 * Menstrual Phase (Day 1 to 5)
 * Follicular Phase ( Day 6 to 14, with ovulation occurring at day 14)
 * Luteal Phase (Day 15 to 28) (Levay & Valente, 2006).

Figure 1. Shows the pattern of hormonal change throughout the average menstrual cycle and the endometrial histology.

Emotions


Emotions are a difficult construct to define; however, it is considered that the best definition is a blend of mental and behavioural aspects which include: appraisal, action tendency, subjective experience, physiological reactions, facial and vocal expression elements (Reisenzai, 2007).

Affect, feelings, and mood are often used in the same context without a clear distinction between the various terms (Shouse, 2005).
 * Affect is an abstract idea that can be described as: “ a non-conscious experience of intensity; it is a moment of unformed and unstructured potential” (Shouse, 2005).
 * Mood can be defined as: “A continued emotional state that affects one’s outlook on life.” (Sikora, 2011).
 * Feelings can be defined as: experiences that are references against our past experiences and are categorised based on previous knowledge (Shouse, 2005).

 The affective phenomenon relates to the combined study of emotions, moods and affect. Historically these terms have been used interchangeably and efforts to distinguish between the various terms have only occurred in the recent years (Ekkakkis, 2012).

Theory and research
'''The "how" and "why" of emotional change throughout the menstrual cycle is not clear. Research and theory is inconclusive as to the cause of the changes as well as the reasons for the change in emotion. '''

Menstrual cycle disorders
Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) are two mood disorders that appear to be linked to the hormonal changes that occur throughout the menstrual cycle (Freeman, 2007). However, research is inconclusive in terms of the overall relationship between the menstrual cycle and associated mood disorders (Romans et al. 2012).

PMS is the disorder that is utilised to explain the symptoms that women experience during the week prior to the menstrual phase of their menstrual cycle (Reilly & Kremer, 2001). PMS has a range of physical and psychological symptoms which may include the following (MayoClinic, 2015): The cause of PMS is undetermined, hormones may play a role and chemical changes in the brain may also be an influencing factor. (MayoClinic, 2015).
 * tension
 * anxiety
 * depressed mood
 * crying spells
 * fatigue
 * acne

PMDD is a more severe form of PMS, that is also defined in  The Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM IV - TR defines the symptoms of PMDD as: a significant depressed mood, high levels of anxiety and marked affective lability. PMDD differs from PMS in that the changes in mood are extreme (Gallenberg, 2012).

According to the DSM IV - TR the diagnosis for PMDD requires that the above-mentioned symptoms be present during the final week of the luteal phase (for a minimum of one year); the symptoms ease during the initial week of menses; and the symptoms are non-existent in the following week. The other criteria for the diagnosis include a range of symptoms (see table 1), of which the individual has to display a minimum of five, for a majority of the luteal phase.

Table 1.DSM IV - TR diagnostic criteria for PMDD

Biorhythm theory
The idea of emotions being related to a 28 day cycle was initially proposed in the form of Fliess’ Biorhythm Theory (Shermer, 2002). The theory was based on the premise that humans have three cycles that occur monthly: a physical cycle lasting 23 days; an emotional cycle lasting 28 days; and an intellectual cycle lasting 33 days. It is thought that the 28 day emotional cycle idea was related to the menstrual cycle (Shermer, 2002. & Hines 1998). The Biorhythms were developed to assist with predicting why humans experience highs and lows depending on the particular day (Cavendish, 2010). A review of the research for the Biorhythm Theory has been unsuccessful in verifying its validity. Consequently the Biorhythm Theory is often referred to as a pseudo-theory without any scientific proof (Hines, 1998).

Hormones and the menstrual cycle


The menstrual cycle is a repetitive process which is dictated by the changes of the levels of various hormones in the body. The specific hormones are produced and controlled by the: hypothalamus, pituitary glands and the ovaries. The three areas form a part of the endocrine system (Popat, Prodanov, Kalis & Nelson, 2008). The three areas of the endocrine system produce and control the specific hormones that are necessary for menstruation to occur (Babycentre, 2015 & Brzyski & Knudston, 2015).These hormones are also associated with a range of emotionally and mood based aspects as shown in Table 2.

Table 2. Menstrual cycle hormone function

The changes of hormones throughout the menstrual cycle are said to be directly related to the changes in mood (Schwartz, Romanis, Meiyappan, Souzal & Einstein, 2012). Various studies have looked at the effects of hormonal changes throughout the menstrual cycle and the implications for mood and emotional change and the results are inconclusive:

Time for a break Click here to watch a Ted Talk by Robyn Stein De Luca on the good news about PMS

Social Learning Theory (SLT)


The social learning theory focuses on behaviour in terms of  learning and is dictated by the outcomes of the behaviour. Bandura (1971) explained that: people learn by observing the behaviour of others and we perform actions that achieve a desired outcome. We are also likely to continue a behaviour if we receive reinforcement that is beneficial to us (Bandura, 1971).

It is suspected that the SLT may play a crucial role in the development of Premenstrual Syndrome (PMS). Scalise (2007) suggested that women develop a negative attitude in regard to their menstrual cycle and as a consequence they develop coping mechanisms such as overeating and mood swings. A study conducted by Woods, Mitchell and Lentz (1995), looked at the effect of social influence in terms of how an individual responds to their menstrual cycle. The researchers looked at three classes of symptoms: low severity (LS); premenstrual syndrome (PMS); and premenstrual magnification (PMM). Their results were consistent with the social learning theory, such that women who anticipated negative symptoms and reported being socially primed to expect negative symptoms throughout the menstrual cycle were more likely to report these negative symptoms. The researchers concluded that stressful experiences and social priming of negative menstrual symptoms might enforce the negative connotation relating to their menstruation (Woods, Mitchell & Lentz, 1995).

 According to the SLT, emotional changes during the menstrual cycle occur because of the social expectation that they will. For example if Anna's mum displayed severe mood swings throughout the month, which she attributed to the menstrual cycle, then Anna is likely to copy her mum's behaviour and behave in a similar manner. Moreover, if the behaviour led to a reward such as chocolate then Anna may perform the specific behaviour in the hope that she will also receive chocolate.

Cognitive theory
Cognitive attribution is important in the aetiology of PMS. According to cognitive theory, both physical symptoms and the meaning of these symptoms induce distressing emotions (Blake, Salkovskis, Gath, Day & Garrod, 1998). Therefore, when a woman feels sad, irritable or angry she may find these emotions more distressing if she attributes them to bodily functions out of her control (i.e. menstruation). In taking this view, distorted thinking is an important component of PMS, generating psychological and physiological upset (Blake et al., 1998). Blake et al. (1998) found cognitive therapy (CT) significantly improved PMS and depressive symptoms in women previously diagnosed with PMS.

Likewise, meta-analysis by Kleinstäuber, Witthöft and Hiller (2012) revealed small to medium effects for efficacy of CBT as treatment for PMS. Symptom-reduction was maintained for longer following psychotherapy compared to pharmacotherapy, possibly due to side effects associated with the latter (Kleinstäuber et al., 2012). Whilst cognitions appear to play a role in women’s experience of PMS, associated mood fluctuations cannot be explained by biological or psychological theory alone. Rather, an integrated approach best accounts for observed emotional variations.

Interpreting emotions during the menstrual cycle
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Derntl et al. (2008) conducted a study looking at emotion recognition in females during both the follicular phase (FPG) and the luteal phase. The study utilised a series of images that depicted various emotions. The participants were then asked to pick from two options in order to correctly identify the emotion that was presented to them. They measured the activation of the amygdala throughout the experiment, utilising echo-planar imaging (EPI). Derntl and colleagues (2008) concluded that amygdala activation occurred in both the FPG and luteal phase groups, with the FPG demonstrating a higher amygdala stimulation. Moreover, the results of the study concluded that women in the FPG phase demonstrated a better capacity in recognising emotions in comparison to the luteal phase group.

Further research conducted by Derntl, Exner, Fernbach, Moser & Habel (2008) also concluded that the correct identification of emotions was the most reliable during the follicular phase. The researchers also found that lower progesterone levels were related to higher accuracy when identifying emotions. Moreover, females in the luteal phase were more likely to misinterpret emotions that were negative as being angry. The correlation between levels of estradiol and progesterone were significant in relation to the identification of anger, with females in the luteal phase showing higher inaccuracies when interpreting emotions (Derntl, Exner, Fernbach, Moser & Habel, 2008).

Treatment options
 A randomised trial that utilised a placebo and experimental sample was conducted by Hosseini, Kashani, Aleyaseen, Ghoreishi, Rahmanpour, Zarrinara & Akhondzaden (2007) to assess the efficacy of saffron as a treatment for PMS. The participants in the experimental group were given two tablets per day (30mg total), which were made from saffron petals. The results were tracked over a period of two menstrual cycles for both the experimental and control group. The premise of the study was based on previous research that had concluded that saffron acts as an anti-depressant by the means of the serotonergic system (Hosseini et al. 2007). This study provided further support for the use of Saffron in the treatment for PMS, with the experimental group displaying statistically significant positive changes in their depressive mood (Hosseini et al. 2007).

 A study conducted on a sample of 1600 women, found that the treatment group that utilised a drospirenone and estradiol contraceptive pill showed reduced signs of PMS when compared to the placebo group after three months of use (Lopez, Kpatein, Helmerhorst, 2009). Further research conducted by Zervoudis, Vladareanu, Galazios, Liberis, Tsikouras and Veduta (2008) concluded that the use of an oral contraceptive was 67.9% more effective at treating PMS when compared to a baseline group.

 Typical medication treatments have been compared with alternative treatment methods such as cognitive behavioural therapy (CBT) and hypnosis. Rasht and Sari (2015) found that over a 8 week period implementation of CBT and combination of CBT and hypnosis - patients demonstrated a reduction in reported pain (p < 0.001). Further research found a decrease in anxiety prior to expected menstruation period. Group therapy was also found to reduce fear emotions prior to menstruation periods (Glover, Jovanovic, & Norrholm, 2015). Post-traumatic stress disorder (PTSD) treatment demonstrated efficacy in separating fear response with the increased presence of oestrogen in a female’s system.

Conclusion
The menstrual cycle is a complex sequence of events strongly based on hormonal change, there is no single correct answer that can explain "why" and "how" emotions change.The research of the causal factors of the menstrual cycle emotion change is inconclusive. The two key explanations relate to the hormonal changes, such that emotions change due to the fluctuation of hormones. The secondary explanation revolves around the idea that emotions vary throughout the menstrual cycle due to social aspects. You can find further /Applied examples/ on this page.

The reasons provided for the explanation of emotion change vary depending on the research. With a significant amount of discrepancy in the results further research may be conducted to explore why these inconsistencies have transpired. Future research may also be conducted in terms of emotional changes in males and females as a comparison to investigate whether females tend to have more fluctuations in terms of the emotional change. Moreover, research may also be conducted to assess the impact of external events on emotion and mood.

Various treatments have been found to be successful in assisting with emotion control. The external links provides further articles that may be of interest in terms of providing alternate treatment options.

'''This book chapter does not aim to offer a solution and should never substitute a health care professionals advice. If you need someone to talk to you can contact Lifeline on 13 11 14.'''