The Complex Relationship Between Menstrual Cyclicity and Anxiety Disorders

Miki Peer, Claudio N. Soares, MD, PhD, and Meir Steiner, MD, PhD

Ms Peer reports that she has no conflicts of interest concerning the subject matter of this article. Dr Soares reports that he has received grant/research support from AstraZeneca and GlaxoSmithKline; he is a consultant for Sepracor, GlaxoSmithKline, Wyeth-Ayerst, and Neurocrine; and he is on the Promotional Speakers' Bureau of GlaxoSmithKline, Wyeth-Ayerst, Forest Laboratories, and Pfizer. Dr Steiner reports that he has received grant/ research support from Wyeth, Pfizer, and AstraZeneca; he is a consultant for Eli Lilly, Pfizer, GlaxoSmithKline, Lundbeck, Novartis, Wyeth, OrthoMcNeil, AstraZeneca, and Azevan Pharmaceuticals; he is on the advisory board of Eli Lilly, GlaxoSmithKline, Pfizer, Lundbeck, OrthoMcNeil, Wyeth, Schering, Ferring, and Azevan Pharmaceuticals; and he is on the Speakers' Bureau of AstraZeneca, GlaxoSmithKline, Eli Lilly, and Wyeth.

The ocurrence and severity of anxiety disorders have been correlated with fluctuations in female sex steroid levels in both epidemiological and experimental studies.1-5 Female reproductive hormones play a role not only in the development and course of anxiety disorders but also in treatment response.1,2,6-12 This article focuses on the premenstrual exacerbation of anxiety disorders and briefly reviews the biological pathways and physiological mechanisms thought to contribute to the expression of different anxiety disorder subtypes. Female steroid hormone influences on pharmacological properties of psychoactive drugs used to treat anxiety disorders are also addressed, because these may contribute to treatment response in women who experience premenstrual exacerbation of these disorders.

Recommendations for Clinical Practice:

A better clinical practice to manage anxiety disorders would include:

• A careful assessment of sex-specific triggers of anxiety.
• A clinical interview performed on 2 consecutive occasions (1 in the luteal phase and 1 in the follicular phase of the menstrual cycle).
• The use of a diary for at least 1 menstrual cycle to prospectively chart anxiety symptoms and help identify temporal associations with hormonal changes or possible comorbid disorders.

Once treatment is initiated, women with anxiety disorders should be evaluated during the course of the menstrual cycle for continuous effectiveness of their medications. Women who exhibit premenstrual exacerbation of anxiety disorders may respond to increased doses immediately preceding or during the luteal phase.48,59 Progesterone augmentation may be a therapeutic option for women with anxiety disorders who do not respond, or who respond only partially, to standard therapeutic regimens.2,38

See full article at Psychiatric Times....