When a woman comes for a neuroendocrine consultation to get help with hard-to-control seizures or troubling emotional changes, my ability to help her increases greatly when she has observed a ‘catamenial’ pattern to the occurrence of her symptoms (meaning they occur at a specific time during her menstrual cycle on a repeating basis). In fact, I have been faced with very unusual symptoms in some of my female patients, like shaking spells and psychotic symptoms that, because of a catamenial pattern, responded well to hormonal-based therapies.
In my last blog entry I introduced 3 patterns of catamenial occurrence of symptoms: Type 1 is within three days on either side of the onset of menses; Type 2 is within three days on either side of the midcycle ovulation (release of the egg from the ovary); and Type 3 begins around midcycle ovulation and lasts the two weeks until menses, or even up to three days after onset. Once you understand how the hormones estrogen and progesterone rise and fall during a normal menstrual cycle and how these two reproductive hormones affect the brain, the existence of these three patterns of catamenial symptom occurrence makes good sense.
The monthly rise and fall of estrogen and progesterone causes a woman’s menstrual cycle. It typically lasts 28 days, though this is not set in stone. The cycle begins on the first day of menstrual bleeding (which itself can typically last 2-7 days). At the beginning of the cycle, from day 1 through day 5, the serum levels of estrogen and progesterone are very low, as they have washed out of the bloodstream at the end of the previous cycle, causing the menstrual bleed. Between day 7 and day 12, estrogen levels gradually rise again as an egg matures. Sometime around day 12 estrogen levels, along with LH, surge to trigger ovulation, the release of the egg to be fertilized. Once this is complete, by around day 14, progesterone blood levels shoot up to prepare the lining of the uterus for implantation of a fertilized egg. Although estrogen levels drop somewhat off their very high peak soon after ovulation, both hormones remain high for the next 10 or so days. If there is no pregnancy, progesterone levels begin dropping quickly around day 25 until completely gone by day 28, while estrogen drops a few days later. These changes cause the sloughing of the lining of the uterus, the menstrual bleeding, the period.
Therefore, at the end of the cycle, during the premenstrual days, two things happen: one, there is a rapid progesterone withdrawal and two, there is an increased ratio of estrogen to progesterone in the blood stream for a few days. These two conditions form the basis of the Type 1 pattern – progesterone withdrawal and “unopposed” estrogen. Also, around the midcycle surge of estrogen, a few days before progesterone surges, there is again an increased ratio of estrogen compared to progesterone, unopposed estrogen. This is the basis of the Type 2 pattern. Finally, some women make insufficiently low levels of progesterone after ovulation and experience nearly 2 weeks of unopposed estrogen from midcycle ovulation until menstruation. This is the basis of the Type 3 pattern.
In my next blog I will review the yin and yang way that these two reproductive hormones affect the brain so this all begins to make sense.