By Rohan Mehra
Editor’s Note: This review summarized by Rohan Mehra while taking the FACTS elective highlights key insights from “Cognition and behavior across the menstrual cycle in individuals with premenstrual dysphoric disorder – A systematic review.” The study by Henderson et al. evaluates cognitive and behavioral changes associated with premenstrual dysphoric disorder (PMDD) across the menstrual cycle. The findings underscore the clinical significance of cycle-related patterns in mood, cognition, and behavior, reinforcing the importance of recognizing the ovulatory menstrual cycle as a vital sign in patient care. These insights align with fertility awareness-based approaches that equip both patients and clinicians to better identify patterns, anticipate symptoms, and guide individualized, restorative care. Readers interested in deepening their understanding of fertility awareness and its application in clinical practice are encouraged to explore Parts B and D of our CME course.
Introduction
Family planning remains a complex and challenging pursuit for many couples, with a seemingly barren landscape of resources for those struggling with fertility. The goal to have children and to raise a family remains strong for many. Fertility awareness-based methods (FABMs) are family-planning tools that offer high success rates for conception and pregnancy prevention. They help women gain control over their reproductive choices through an engaging and flexible approach.
Many couples face difficulties with limited family-planning timelines, which can cause significant stress, anxiety, and depression for women. These mental health challenges are frequently observed, particularly in women with infertility. The medical and psychiatric components of a woman’s health constantly affect each other cyclically in many ways. For example, one study showed 39% of women at an infertility clinic fulfilled criteria for major depressive disorder (MDD). [1] Subsequently, MDD can impact a woman’s ability to care for herself and her health, perpetuating the spiral.
The medical and psychiatric components of a woman’s health constantly affect each other cyclically in many ways. For example, one study showed 39% of women at an infertility clinic fulfilled criteria for major depressive disorder (MDD).
This relationship is further highlighted in the 2025 study by Henderson, et al., “Cognition and behaviour across the menstrual cycle in individuals with premenstrual dysphoric disorder – A systematic review.” The purpose of this paper is to guide avenues of research toward non-pharmacological and non-invasive modalities for premenstrual dysphoric disorder (PMDD). PMDD is a recurring mood disorder with mental health symptoms linked to hormonal changes in the luteal phase. Biologically, this is understood to occur because receptors that respond to ovarian steroids are present in multiple brain regions. The exact psychopathology beyond this is not well known. Women may experience many distressing symptoms, including marked affective lability, increased irritability and anger, marked anxiety, marked depression, and increased interpersonal conflicts.
Premenstrual dysphoric disorder (PMDD) is a recurring mood disorder with mental health symptoms linked to hormonal changes in the luteal phase.
PMDD is thought to affect about 1.6% of menstruating females. [2] These symptoms can severely affect women and those involved in their family planning and FABM tracking. Helping women with PMDD is crucial for effective family planning and safeguarding their well-being and that of their children. Women with PMDD have an increased risk of suicidal ideation, plans, and attempts. They also may engage in impulsive, risky, maladaptive behaviors such as self-harm. This results in misdiagnoses of Borderline Personality Disorder, further delaying the proper care they require.
Henderson and colleagues aim to understand how PMDD affects women’s cognition and behavior, ultimately influencing how they manage a range of challenges. This literature review observed 94 outcome measures from 21 papers.
Methodology
The paper utilized a typical search strategy with the authors identifying common phrases specific to their interest. This was used to parse through research among multiple databases in 2023. [2] The inclusion criteria required studies to include both a PMDD group and a non-PMDD comparison group, assess participants at least once during the premenstrual or luteal phase, and report at least one outcome related to cognition or behavior.
Some of the most notable outcome measures reviewed by this systematic review included attention, memory, learning and information processing, inhibitory control, higher order cognitive functioning, psychomotor speed, rumination, behavior, appetite, impulsiveness, conflict tactics, emotional regulation, mood, and affect.
Results
Evidence supporting significant interaction effects was minimal across most outcome measures assessed.[2] While some individual studies reported statistically significant interaction effects, these findings were often not replicated in similar studies or lacked comparable evidence across the literature.
For example, one study of attention identified problems with attention during the early and late luteal phase, with a greater degree in the late luteal phase using their specific cognitive test for assessing attention. A second study from the same group with the same participant sample corroborated this with self-reported problems with attention as an indicator. However, there were six other studies outlining attention as an outcome variable which did not show significant interaction effects. Many other outcome measure categories demonstrated a similar pattern. Replicability remained elusive within many individual outcome measures, and several different assessments were used across many countries that differed greatly from each other. Thus, it was challenging for these studies to demonstrate compatibility with another to support the same conclusions and determine if every test used was evidence-based and strong.
Exceptions to this included inhibitory control, appetite, impulsiveness, mood, and affect. Inhibitory control was found to be statistically poorer in the PMDD group between luteal and follicular phase. Subsequently the early and late phase were compared, and it was found that impairment starts early in the luteal phase. In regard to appetite, evidence demonstrated that those with PMDD have increased difficulty controlling premenstrual eating habits. Use of cannabis was also significantly higher in those with PMDD, which can be somewhat attributed to the increased likelihood that those with PMDD have comorbid psychiatric conditions. Impulsiveness was also found to be increased early in the luteal phase. The evidence also indicated lower levels of positive affect and mood. Many of these findings were well-known in the literature.
Inhibitory control was found to be statistically poorer in the PMDD group …and it was found that impairment starts early in the luteal phase… Impulsiveness was also found to be increased early in the luteal phase.
Discussion
As discussed in the introduction, research into this topic is extremely important for protecting women with PMDD and improving their experience with family planning. As such, it can be considered disappointing that there is a lack of any novel findings of changes to cognition and behavior from this systematic review. However, it clearly demonstrates the need for further research to be done to establish clearer evidence of whether PMDD provides a significant impact on many of the outcome variables described. This study highlights the lack of research identifying the cognitive and behavioral changes throughout the cycle in women with PMDD. It demonstrates the importance of providing assessments at different points in a woman’s cycle to be sensitive to changes within individual subjects. This systematic review highlights the weaknesses of existing studies, which don’t have statistical power or replicability to draw conclusions that could be explored further for treatment options and patient outcomes. Further research will be needed to move this field of study beyond its infancy.
This study … demonstrates the importance of providing assessments at different points in a woman’s cycle to be sensitive to changes within individual subjects.
This research illustrates that there is still a separation between the fields of fertility and psychiatry. These findings underscore the importance of advancing understanding of the unique psychiatric challenges associated with fertility and family planning, as well as the need to develop targeted resources to support affected individuals. In clinical practice, FABMs may support cycle-informed care, including scheduling visits during the luteal phase or at times identified as most symptomatic, and may be considered as part of an approach to help address anxiety and depressive symptoms related to fertility. The importance of communication and interaction between a patient’s psychiatrist and OBGYN is essential. The risk of untreated depression in pregnancy, which increases the risk of premature birth, low birth weight, and increased use of tobacco, marijuana, or illicit substances, cannot be overstated.[3] These findings underscore the importance of improving the quality of care for patients at the intersection of psychiatry and obstetrics and gynecology.
References
[1] Rooney KL, Domar AD. The relationship between stress and infertility. Dialogues Clin Neurosci. 2018;20(1):41-47.
[2] Henderson A, Gardani M, Dyker G, Matthews L. Cognition and behaviour across the menstrual cycle in individuals with premenstrual dysphoric disorder: a systematic review. J Affect Disord. 2025;371:134-146. doi:10.1016/j.jad.2024.11.033
[3] Hoffman MC, Wisner KL. Psychiatry and obstetrics: an imperative for collaboration. Am J Psychiatry. 2017;174(3):205-207. doi:10.1176/appi.ajp.2016.16111233
ABOUT THE AUTHOR
Rohan Mehra is a fourth-year medical student at Rowan-Virtua School of Osteopathic Medicine in Stratford, NJ. He completed his undergraduate education at Rutgers University in New Brunswick, NJ. He will pursue residency in Psychiatry at Capital Health Regional Medical Center. He enrolled in the FACTS elective to gain a better understanding of how mental health affects fertility and gain knowledge on fertility awareness-based methods in order to help address mental health concerns for patients that may be related to reproductive health.
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