BPD and Cycle: How the Menstrual Cycle Affects Borderline

The Study

Perimenstrual Exacerbation of Symptoms in Borderline Personality Disorder: Evidence from Multilevel Models and the Carolina Premenstrual Assessment Scoring System
Where: In Psychological Medicine
When: May 28, 2018

The Takeaway

Women with BPD experience significant worsening of emotional symptoms during the perimenstrual phase of their menstrual cycle. The perimenstrual phase occurs just before and during menstruation and involves a drop in ovarian hormones. This discovery suggests that hormonal fluctuations could play a crucial role in symptom instability, highlighting the need for targeted treatment strategies.

What It Looked At

The study investigated whether symptoms of BPD worsen during certain phases of the menstrual cycle. Researchers focused on:

1. Emotional symptom exacerbation during the perimenstrual phase.
2. Symptom worsening during the midluteal phase.
3. The prevalence of clinically significant premenstrual symptom elevation (PME) among participants.

Methodology

Fifteen healthy, unmedicated women with BPD participated in the study. They reported their daily symptoms over 35 days, while urine luteinizing hormone (LH) and salivary progesterone (P4) levels were measured to confirm ovulation and cycle phases. The Carolina Premenstrual Assessment Scoring System (C-PASS) was used to assess the clinical significance of symptom changes.

Participants had to meet strict criteria:

• Regular menstrual cycles (25-35 days)
• No use of psychotropic medications or oral contraceptives
• No dysmenorrhea, pregnancy, or breastfeeding

What It Found

The study revealed distinct patterns in symptom fluctuation:

• Mid-Luteal Worsening: Symptoms such as anxiety and irritability increased during the midluteal phase (after ovulation, when progesterone is high).
• Perimenstrual Peak: Most symptoms peaked during the perimenstrual phase (just before and during menstruation), including depression, hopelessness, and interpersonal conflict.
• Follicular Phase Resolution: Symptoms generally subsided during the follicular phase (after menstruation, leading up to ovulation).

A significant finding was that 73% of participants met the C-PASS criteria for clinically significant PME, indicating a substantial increase in symptoms premenstrually. Depressive symptoms showed an unusual pattern, worsening during both the perimenstrual and follicular phases.

Why It Matters

Understanding the impact of the menstrual cycle on BPD symptoms can lead to better management strategies. This study suggests that hormonal changes are a key factor in symptom instability. Therapeutic approaches could include hormone stabilization and increased awareness of cycle phases in psychosocial treatments like dialectical behavior therapy (DBT).

Additionally, the study’s findings relate to premenstrual dysphoric disorder (PMDD), a condition characterized by severe mood disturbances linked to the menstrual cycle. While PMDD typically involves a remission of symptoms after menstruation, the study on BPD found that symptoms did not completely remit, highlighting a distinct but related pattern of perimenstrual symptom exacerbation (PME). This connection suggests that women with BPD may have a heightened sensitivity to hormonal changes similar to those with PMDD, yet with persistent symptoms.

The study underscores the need for further research, particularly longitudinal studies and hormonal experiments, to delve deeper into the pathophysiology of perimenstrual symptom exacerbation in BPD.

Limitations

While this study provides valuable insights, it has several limitations:

• Small Sample Size: The study involved only 15 participants, which may limit the generalizability of the findings.
• No Control Group: The absence of a healthy or clinical control group makes it difficult to attribute symptom changes solely to BPD rather than other factors.
• Cycle Phase Verification: Although ovulation was confirmed using LH tests, more frequent hormone sampling might provide a clearer picture of cycle phases.
• Participant Characteristics: The participants were self-selected and unmedicated, which might not represent the broader population of women with BPD who are on medication or have different demographic characteristics.

Conclusion

The menstrual cycle significantly affects emotional symptoms in women with BPD, with a notable worsening during the perimenstrual phase. These findings highlight the importance of considering hormonal influences in BPD treatment and suggest potential benefits from targeted therapeutic interventions. Understanding these patterns can lead to more effective management of BPD symptoms and improved outcomes for those affected.