Are there types of anxiety that worsen during the menstrual cycle?

Anxiety Disorders That Worsen During the Menstrual Cycle

Premenstrual Dysphoric Disorder (PMDD) is the primary anxiety disorder that specifically worsens during the menstrual cycle, characterized by mood symptoms, somatic symptoms, and cognitive symptoms that begin several days before menses and improve within a week following the onset of menses. 1

Types of Anxiety That May Worsen During Menstrual Cycles

Premenstrual Dysphoric Disorder (PMDD)

• Officially recognized in ICD-11 as a distinct anxiety disorder that follows the menstrual cycle 1
• Characterized by mood symptoms (e.g., depressed mood), somatic symptoms (e.g., overeating), or cognitive symptoms (e.g., forgetfulness) that:
  • Begin several days before menses
  • Start to improve within a few days after onset of menses
  • Become minimal or absent within 1 week following onset of menses 1

Generalized Anxiety Disorder (GAD) with Menstrual Exacerbation

• Women with GAD have 7.65 times higher odds of having PMDD compared to those without GAD 2
• The association between GAD and PMDD is partially mediated by behavioral inhibition and irritability, and completely mediated by depression 2
• Women with both GAD and PMDD experience:
  • Higher anxiety during the luteal phase
  • Higher PMDD severity, depression, and irritability even in the follicular phase 2

The Reproductive Subtype of Depression and Anxiety

Evidence suggests a "reproductive subtype" of depression and anxiety related to hormonal fluctuations during:

• Menstrual cycle
• Pregnancy
• Postpartum period
• Menopause 1

This reproductive subtype is characterized by increased sensitivity to normal hormonal fluctuations, particularly the dramatic rise in reproductive hormones prior to delivery and their sudden drop after delivery 1.

Health Anxiety and Menstrual Cycle

• Women with higher health anxiety report significantly greater perceived stress during the late luteal phase compared to women with lower health anxiety 3
• During the follicular phase, women with higher and lower health anxiety report similar levels of perceived stress 3
• This suggests health anxiety may be a vulnerability factor for experiencing increased stress during specific phases of the menstrual cycle 3

Screening and Diagnosis

• The Women's Preventive Services Initiative recommends screening for anxiety in women and adolescent girls aged 13 years or older, including those experiencing menstrual cycle-related anxiety 1
• Diagnosis requires meeting specific criteria from the Diagnostic and Statistical Manual of Mental Disorders after ruling out alternative causes of anxiety 1
• When evaluating women with premenstrual complaints, clinicians should have a low threshold for ruling out underlying mood and anxiety disorders, as approximately 39% of women seeking treatment for PMS may actually meet criteria for mood or anxiety disorders 4

Treatment Approaches

First-Line Treatment

• Cognitive behavioral therapy (CBT) combined with an SSRI is the recommended first-line treatment 5
• SSRIs such as sertraline and fluoxetine are first-line medications 5
• SNRIs such as venlafaxine are also effective first-line options 5

Treatment Considerations

• Combined CBT and medication therapy is more effective than either treatment alone 5
• Treatment should be continued for at least 9-12 months after symptom remission to prevent relapse 5
• Regular monitoring for side effects, particularly during the first 4 weeks, is crucial 5

Important Clinical Considerations

• Not all anxiety disorders show menstrual exacerbation - a prospective study of women with panic disorder found no significant effects of menstrual cycle phase on anxiety ratings, contrasting with the robust increase in premenstrual anxiety in subjects with premenstrual syndrome 6
• Assessment of women with GAD plus PMS may be complicated by cyclical fluctuations in symptom severity 7
• Ratings obtained in typical clinical assessments may be influenced disproportionately by how patients feel premenstrually 7

Common Pitfalls to Avoid

• Failing to screen for underlying mood and anxiety disorders in women presenting with premenstrual complaints 4
• Inadequate dosing and premature discontinuation of treatment 5
• Overlooking comorbidities such as depression that can impact treatment effectiveness 5
• Assuming all anxiety disorders worsen during the menstrual cycle - evidence suggests this pattern is specific to certain types of anxiety 6