Even though there is an abundance of literature on PTSD, we lack a thorough understanding of the biological causes that explain why it is more than twice as prevalent in women than men. Women are also more likely to experience chronic PTSD for more than a year. Despite this, women have often been excluded from studies; variable hormonal cycles have been cited as a factor, but in recent years, new findings have shed light on how estrogen and hormonal cycles can influence PTSD.(1)

In an article published in 2016, low estrogen levels were associated with symptoms of anxiety and depression. This can occur during all phases: premenstrual, post-partum, perimenopausal, and postmenopausal periods. Specifically, women with low levels of estradiol had heightened fear responses and more intrusive thoughts days after being shown violent film clips. The phasic nature of the hormonal cycle may actually make women more vulnerable to PTSD. The hypothalamus and amygdala each have many estrogen receptors, and the hypothalamus is part of the hypothalamic-pituitary-adrenal (HPA) axis, which is also associated with the vasomotor symptoms of perimenopause, i.e., hot flashes, night sweats, heart palpitations, and sleep disturbances.

The HPA axis itself is thought to be a potential underpinning for PTSD. Trauma occurring in early childhood may inhibit the development of the oxytocin system, which works with the HPA axis to regulate stress responses.(2) Lower levels of cerebrospinal fluid oxytocin concentrations were noted in women who experienced abuse as children. This means that with less oxytocin, the stress hormone cortisol isn’t regulated, and the fear persists. This is associated with the fight and flight responses. Both oxytocin and cortisol seem to be dysregulated as a result of trauma. This may also be a factor in the chronic health conditions that are associated with PTSD.

While the precise mechanism correlating estrogen and the symptoms of PTSD isn’t yet known, studies suggest that estrogen may help alleviate them. In a study comparing sexual assault victims, those who took an emergency contraceptive containing estrogen reported significantly lower symptoms of PTSD six months after the incident.(1) Hormone replacement therapy is a common option for those experiencing perimenopause, and estrogen may be a beneficial option for people who live with complex PTSD as well, and hopefully, future studies will reveal more about this connection.

Further research has shown that adverse childhood experiences (ACEs) may put women at higher risk of depression during perimenopause. This too may be related to how trauma impacts the body early in life and the resulting dysregulation of the oxytocin system. A 2017 study about ACEs as a factor for depression during perimenopause reported that of nearly 300 participants, 60.5% experienced at least one adverse childhood event. In this group, 20.7% were diagnosed with major depressive disorder during perimenopause and 22.4% were diagnosed with it before perimenopause started.(3)

PTSD can have an impact on the menopausal transition. Because we already may have sleep disorders because of PTSD, the severity can increase. The severity of menopausal symptoms hasn’t been studied in-depth, but the evidence we have does suggest a correlation. In a study of 1,148 women, 1 in 5 had experienced intimate partner violence and/or sexual assault, and 1 in 4 had PTSD.(4) Difficulty sleeping was the most frequent problem, followed by hot flashes and night sweats.

In my personal experience, complex PTSD has done some of its worst to me during perimenopause. It was the reason I finally sought help and ultimately got my diagnosis. I thought I had done a good job out trying to outrun it for decades. I had fooled myself well, but over the past year, as perimenopause entered a particularly difficult phase, my mental health grew increasingly worse. I’m still in the process of figuring out the best way to manage it all, but this knowledge has helped me considerably. I’m better at predicting when my inner critic may be louder and more vicious. My days spent lost in a fog make more sense. When I’m especially adrift, it often corresponds to something happening in my hormonal cycle. I find it comforting to pore over research to gain a better understanding of complex PTSD. A nerd by nature, reporting back on what the science says is how I best communicate what’s happening when speaking with friends and family. Understanding the link between the menopausal transition and PTSD was a starting point for my recovery, and I’m grateful to have found my way to this path of healing.

Sources:

  1. Estrogen and extinction of fear memories: implications for post-traumatic stress disorder treatment. Glover, Ebony, Jovanovic, Tanja. Biol Psychiatry, August 2015: 78(3): 178–185: doi: 10.1016).
  2. Exploring the mutual regulation between oxytocin and cortisol as a marker of resilience. Li, Yang, Hassett, Afton. Arch Psychiatric Nursing, April 2019: 33(2): 164–173: doi: 10.1016).
  3. Adverse childhood experiences and risk for first-episode major depression during the menopause transition. Epperson, C. Neill, Sammel, Mary. Journal of Clinical Psychiatry, March 2017, 78(3):298–307.
  4. Associations of intimate partner violence, sexual assault, and posttraumatic stress disorder with menopause symptoms among midlife and older women. Gibson, Carolyn, Huang, Alison. JAMA Internal Medicine, 2019; 179(1):80-87.

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