Hormonal contraception under scrutiny — but some women report mental health benefits

Psychiatric disorders generally affect individuals differently. There are, however, some recurring gender-specific patterns.

That is according to Kristian Reveles Jensen, a medical doctor who has recently completed his PhD at the University of Copenhagen (UCPH) and who is to continue his research project as a postdoc for the next four years.

The research project is a depression study involving approximately 800 participants, examining how depression symptoms manifest in each participant and which treatment suits them best.

As part of the project, Kristian Reveles Jensen and his colleagues are also investigating how the female participants’ menstrual cycles influence their symptoms and the significance of whether they use hormonal contraception.

»For most psychiatric disorders, a proportion of women experience a cyclical worsening of symptoms after ovulation and leading up to menstruation. This applies to depression, OCD [obsessive–compulsive disorder, ed.], and anxiety,« says Kristian Reveles Jensen, adding:

»Even though more men die by suicide, more women attempt or consider it. And when we statistically examine suicide attempts, the majority occur around the time of menstruation.«

More stable on the pill?

In women, hormone balance changes throughout the cycle, explains Kristian Reveles Jensen.

Oestrogen levels rise just before ovulation and then drop again. Leading up to menstruation, there is a surge of progesterone, which disappears during menstruation itself.

Lack of awareness is currently the biggest problem in this area

Kristian Reveles Jensen, medical doctor and postdoc

The key factor is that hormone levels fluctuate, says the doctor, who points out that while hormonal contraception has been criticised in recent years for negatively affecting some women’s mental health, others find it makes them more mentally stable.

»Some women with psychiatric disorders actually become more stable when using hormonal contraception because their hormone levels do not fluctuate as much,« says Kristian Reveles Jensen, adding:

»Even among women on the pill, a slight worsening of symptoms can be observed in the week they stop taking it, as the hormones they were on are suddenly removed.«

Killer PMS

Before starting his PhD at the University of Copenhagen, Kristian Reveles Jensen worked as a junior doctor in psychiatry for two years.

He almost accidentally began studying a specific psychiatric disorder that exclusively affects women because it is directly linked to their cycle:

Premenstrual dysphoric disorder (PMDD), or as some call it, killer PMS.

Some women feel dismissed as simply having regular PMS

Kristian Reveles Jensen, medical doctor and postdoc

It is a disorder where women experience depressive symptoms every month immediately after ovulation, worsening until menstruation starts, after which they disappear as suddenly as they arrived.

»Many describe feeling extremely unwell for a period, then waking up one morning feeling completely different. They check their underwear and see blood,« says Kristian Reveles Jensen.

He first became interested in the disorder when a friend called him to ask if he knew about it. He did not, so he decided to investigate further and quickly realised that there was no literature available in Danish.

»It is a well-known disorder in Sweden, England, and Australia, but in Denmark, it has largely gone unnoticed. So after reading extensively about it, I wrote an article for the Danish-language Ugeskrift for Læger, which was published in 2017. This helped draw more attention to the disorder,« he says.

Underdiagnosed disorder

According to Kristian Reveles Jensen, most Danish doctors still do not consider PMDD when a woman presents with symptoms of the disorder.

»Women seeking help for their symptoms often find that doctors first want to rule out other conditions. And this is understandable, as what might appear to be PMDD could also be depression or anxiety that worsens cyclically. But some women feel dismissed as just having ordinary PMS,« he says.

Although »killer PMS« is a useful descriptive term, PMDD should not be confused with regular PMS, the researcher emphasises. It is a psychiatric disorder that affects approximately 1.6 per cent of women of reproductive age, and treatment is recommended with antidepressants for the 14 days during which symptoms typically occur.

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»Research shows that the most effective treatment is antidepressants, specifically SSRIs or Selective Serotonin Reuptake Inhibitors. When taken for depression, antidepressants can take weeks to show effects, but for PMDD, the effect occurs within days,« says Kristian Reveles Jensen.

He explains that, for this reason, the medication only needs to be taken during the second half of the cycle. He adds:

»However, there is a historical resistance to antidepressants, because PMDD symptoms have not been widely recognised as a legitimate psychiatric disorder. Right now, the biggest problem is simply a lack of awareness in this area.«