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Key points
- The menstrual cycle can significantly impact a person's physical and mental well-being.
- Understanding possible cycle patterns related to mental health is critical for good therapeutic care.
- We haven't been taught enough about menstruation or how to make assessment inclusive of the whole person.
Would you want to know more?
If you knew that a regularly occurring process in your body, happening roughly every 20 to 40 days, might impact all of your major body systems and change the way you feel, would you want to know more? And let’s say that research shows a correlation between certain phases of this process and a worsening of mental health conditions and emotional dysregulation. Would you want your therapist to know more about what this process means for you?
Of course, we are talking about the menstrual cycle—understudied and not given its due by science or our broader culture. Dismissed as “PMS” or present only in specific spaces, the current conversation around the menstrual cycle is largely medicalized, gendered, and heteronormative. This leaves many people out of the conversation altogether. This reductive, fertility-focused lens has altered our knowledge and understanding of menstruation, hormonal shifts, and the body.
Client and provider both suffer in this scenario
Providers are not taught how to talk about the menstrual cycle, and clients are not asked about the ways their menstrual cycle impacts their lives, identity, relationships, sexuality, emotions, and health.
The resulting gap in care contributes to an ongoing misunderstanding and deprioritization of the effects of this bodily function that does, in fact, have a whole lot to do with a whole lot of people’s mental and physical health experiences.
Certainly, there are some moments when the menstrual cycle does come up in a therapy session. We seem to be most comfortable discussing menstruation as it relates to pain or fertility. While these are useful explorations in therapy, the menstrual cycle can have an impact every time it shows up, not only in these contexts. Those who are not currently, or perhaps ever, going to relate to their menstrual cycle around pain or fertility also deserve a thorough assessment.
Imagine these assessment questions in session
1. Do you notice any patterns related to your cycle and your mental health? Does it seem there are days when things feel better or worse than others?
Research shows that certain phases of the menstrual cycle exacerbate mental health symptoms and the ways some conditions present have been linked to hormonal shifts. These include anxiety, depression, obsessive-compulsive disorder (OCD), borderline personality disorder, and posttraumatic stress disorder (PTSD), to name a few. There is also some research indicating that psychiatric hospitalizations occur at higher rates during certain menstrual cycle phases.
- If someone’s mental health symptoms are worse on a regularly occurring schedule, it seems critical that this is discussed in treatment.
- For some people, certain menstrual phases feel better, or might even bring a reported improvement in mood and mental health. If positive patterns exist, this is also very important for treatment!
2. What are your first memories of your period? I’d love to understand how the important people in your life were (or were not ) a part of that experience for you. Do you remember talking to anyone about your period?
Learning about a person’s memory of their first menstrual cycle and who did—or didn’t—support them can help the client and therapist better understand some of the first direct messages absorbed about bodies.
- Stigma and shame may have been a part of this experience—this is a great opportunity for the client and therapist to dig a bit deeper and be curious.
- For many therapists and clients, family of origin exploration is ongoing work. This is a useful window into understanding these familial dynamics.
- A few simple follow-up questions will help the client and therapist learn more about the client's unique cultural context.
- Many of us cope with narratives about our bodies that we learned when we were younger. What narrative came up in this memory?
3. How do you feel when you notice your period may be coming soon or has started? Can you describe a physical feeling or emotion that comes up for you?
- The whole-person experience of the menstrual cycle might be complicated. For some, some phases of the menstrual cycle may even instigate difficult protective responses like dissociation.
- This opens up a conversation around identity, body comfort, and relationship to bodily needs.
- It's possible that this line of inquiry might lead to the processing of some types of trauma—times when someone's body was not treated the way they would have wanted it to be treated.
4. Do you notice that relationships feel different at different times in your cycle? Have you observed a shift in feelings toward important people in your life at times in your cycle?
Research shows hormonal shifts associated with the menstrual cycle can impact how people feel emotionally and physically. As social beings, when we feel different in these ways, we can relate to those around us differently. Helpful relationships to understand include but are not limited to
- Romantic and sexual relationships
- Familial and parental relationships
- Friendships
- Work relationships and connections with colleagues
5. Do you use any substances, medication, or birth control to help your menstrual cycle feel a preferred way?
- Understanding a person’s goals for how their menstrual cycle feels as well as the methods they have been using to get there is deeply enlightening.
- Are the methods working? The therapist and client can model bodily agency by having these conversations and creating a dedicated space for the client to describe how they are taking care of their body and how it is going for them.
Bringing bodily autonomy and agency into session
Perhaps most importantly, asking about the menstrual cycle and its impacts on the whole person in a nonjudgmental way normalizes conversations about the body and hormones for everyone who menstruates, not just those coping with pain or dealing with their fertility.
We move away from a pathologizing model to a more inclusive, caring, realistic approach.
People who menstruate have historically been at higher risk of reduced bodily choice and autonomy. By not asking about this regularly occurring, natural bodily function, we are inadvertently colluding in this reduction of personal power.
References
JoAnn V. Pinkerton, Christine J. Guico-Pabia, and Hugh S. Taylor, “Menstrual Cycle-Related Exacerbation of Disease,” American Journal of Obstetrics and Gynecology 202, no. 3 (March 2010): 221–231, https:// doi.org/10.1016/j.ajog.2009.07.061.
Elizabeth M. Mulligan et al., “Effects of Menstrual Cycle Phase on Associations between the Error-Related Negativity and Checking Symptoms in Women,” Psychoneuroendocrinology 103 (May 2019): 233–240, https://doi.org/10.1016/j.psyneuen.2019.01.027.
Nina M. Carroll and Amy Banks, “Health Care for Female Trauma Survivors (With Posttraumatic Stress Disorder or Similarly Severe Symptoms),” November 4, 2022.
Tory A. Eisenlohr-Moul et al., “Ovarian Hormones and Borderline Personality Disorder Features: Preliminary Evidence for Interactive Effects of Estradiol and Progesterone,” Biological Psychology 109 (July 2015): 37– 52, https://doi.org/10.1016/j.biopsycho.2015.03.016.
Urszula M. Marcinkowska et al., “Hormonal Underpinnings of the Variation in Sexual Desire, Arousal and Activity throughout the Menstrual Cycle—A Multifaceted Approach,” Journal of Sex Research 60, no. 9 (August 26, 2022): 1297–1303, https://doi.org/10.1080/00224499.2022.2110558.
Maya Dusenbery, Doing Harm: The Truth about How Bad Medicine and Lazy Science Leave Women Dismissed, Misdiagnosed, and Sick (New York: HarperOne, 2018).
