In the wake of the global COVID-19 pandemic, healthcare systems have faced a pivotal challenge. In India, catering to COVID-19 positive patients and conducting tests consumed the entire system with very little infrastructure, time and expertise allocated for other ailments, illnesses or even medical emergencies. While the battle to tackle the physical effects of COVID-19 are ongoing, the assistance we need to help with mental health has largely been self-prescribed/aided by the media.
Articles on how to manage mental health during lockdown have been aplenty. Multiple circumstances have been explored and experts have shared their two cents. For example, if you are away from your family and home alone, here’s what you can do; if you’re having troubles separating your personal life from work in a WFH situation, this could help etc.
There are two interesting aspects to this. One, all of the articles linked to above are borrowed from international media and our socio-cultural realities do not allow for its easy translation into our lives. Two, a very crucial enabler of declining mental health had been neglected – menstrual cycles.
This, however, is unsurprising considering both mental health and menstruation are taboo subjects – especially in India.
“All women are emotional and hormonal” is a sexist trope that has not only attached a double-edged sword to the way we engage with the link between menstrual cycles and mental health but has also ridiculed the effects of it. This pervasive slander and its marriage to the taboo associated with menses has affected the rate at which one can diagnose serious menstrual disorders like PMDD (Premenstrual Dysphoric Disorder), PCOS (Polycystic Ovarian Syndrome) and PME (Premenstrual Exacerbation).
Despite 1 in 20 women attesting to going through unpleasant experiences that affect physical and mental health before their period, PMS remains the most understudied in menstruation. About 90% women live with Premenstrual Syndrome (PMS), however, PMSing is still largely associated with a woman’s personality – “overemotional” – rather than a medical symptom that can get in the way of any menstruating person’s wellbeing.
Openly discussing the symptoms and ascertaining diagnosis is key to debunking this trope. At the moment, getting diagnosed for any of these disorders, especially PMDD is challenging. More than 90% of cases go undiagnosed.
Allopregnanolone, a chemical released by our brain, is said to be one of the main factors that trigger PMS symptoms.
This chemical is released as a response to the spike in the progesterone (hormone that thickens the linings of the ovary) levels in our body post-menstruation. It acts as a sedative. When the progesterone levels plummet pre-menstruation, our brain is suddenly starved of allopregnanolone and “experiences a “come-down” – kind of like an endorphin hangover. This allopregnanolone hangover is what scientists believe contributes to the PMS symptoms of anxiety, irritability and mood disturbances.”
PME and PMDD, on the other hand, are very clearly registered as disorders that can lead to suicidal thoughts. PMDD especially is not just a hormone-related disorder but is listed aside mental health disorders like depression, bipolar and general anxiety. It can result in severe mood swings, anxiety and manifest into physical symptoms like body aches as well. These symptoms usually precede the period by one or two weeks and is passed in the first few days of one’s period. This is how one differentiates PME from PMDD. PME is the premenstrual exacerbation/worsening of the symptoms of another disorder, such as major depressive disorder or generalised anxiety disorder.
PCOS is also a hormone imbalance where LH secretion is high. This contributes to the high levels of androgens (male hormones) that causes infertility, obesity, excessive facial hair in women. The mental wellbeing of people who live with PCOS is severely affected because one “can’t treat PCOS effectively unless we pay close attention to any signs of mental distress”.
The COVID-19 lockdown, coupled with mass unemployment, economic indebtedness, domestic violence and alcohol abuse had left India at the brim of a mental breakdown.
“At-risk populations include the 150 million with pre-existing mental health issues, COVID-19 survivors, frontline medical workers, young people, differently-abled people, women, workers in the unorganised sector, and the elderly,” says Nelson Vinod Moses, a leading suicide prevention advocate in India.
Women and menstruating individuals in our country were not prepared to respond to the storm caused by the socio-economic failures of the state which collided with the pre-existing symptoms of menstrual disorders. It is deeply concerning to think about the state of mind of individuals living with chronic stress, depression, anxiety and other symptoms of menstrual disorders but are yet to be diagnosed.
Even if the menstruators are prepared to seek help, India’s formal mental health system has merely 9,000 counsellors and therapists available for 1.3 billion people. Large volunteer-based organisations like Let’s Talk, with over 300 volunteers, are also “acutely aware that it is impossible to provide long-term support to the community.” Shekar Saxena, former director of the WHO’s Mental Health Division, says, “Mental health systems have always been very scanty in India and during this time, the gap between what is needed and what is available has widened markedly.”
Irrespective of the age, occupation or socio-economic backgrounds, the stories of people living with menstrual disorders during the lockdown have mostly been one of distress. “My shift at the hospital changes every day, so my sleep schedule is completely messed up. The fact that I am always scared and worried about risking myself while putting my whole family in danger creates a lot of stress and anxiety. As a result, my periods in the last few months have always been delayed. My mood swings have started fluctuating a great deal owing to the PMS of a delayed period,” says, Rushali*, a young doctor interning at a hospital in Moradabad, Uttar Pradesh.
“As a person living by themselves with two hormonal disorders – PCOS and PMDD, I rely heavily on my support system to get through life. Lockdown created dissonance and exacerbated the existing dysphoria these conditions subject me to. There were days of heightened depression and all my coping mechanisms to regulate hormones organically (endorphins and oxytocin) – running, swimming, physical support were unavailable. Getting psychiatric medicine (antidepressants and mood stabilisers) on e-prescriptions was not easy and further complicated the situation. The lockdown was undoubtedly the toughest episode of my poor mental health, and the first when I thought about ending my life,” says Sonal Jain, co-founder of Boondh.
“Going out used to be an escape from the toxic environment of my house. Now that I am stuck in the house I have to work a lot. It has majorly affected my mental health and period cycle. PCOS, already used to create a lot of problems but in the last couple of months my period stays for more than a week, are often delayed and are excruciatingly painful,” says Eshitaa Mudgal, a 22-year-old from Delhi who lives with PCOS.
However, some are using the lockdown to try and navigate a better way to deal with the effects of living with these disorders. “I was heavily dependent on birth-control pills for a year and a half but taking note of how adversely it was affecting my physical and emotional well-being, I stopped. Until college, I was not eating healthy, doing any form of physical activity or controlling the intake of external stimulants which were only worsening the problem. After coming home, I decided to make things better, a good diet, exercise and maintaining a healthy lifestyle are the only ways to treat PCOS so the sooner one adapts the change, the better it will be,” says a fresh graduate, Ishani Vats.
According to an article in The Print, Rashtriya Kishor Swasthya Karyakram (National Adolescent Health programme) has made significant changes in its interventions since February this year. The scheme has included counsellors, facility-based counselling, and the concept of social and behavioural change. However, there is limited evidence on the roll-out and implementation of these initiatives. Biological processes that include the life cycle of a menstruating body from menarche to menopause needs to be considered while designing such schemes. This must be in sync with the American College of Obstetrics and Gynecologists Recommendation that recommends menstrual health as the sixth vital sign for assessing health, programmes and interventions, especially on mental health also need to take cognisance of the same.
It is time the government and civil society addressed the mental well being of the people in our country by taking an intersectional approach to helping frontline workers, underserved communities, women, LGBTQIA+ community. This is paramount at a time where socio-cultural and economic realities have a close relationship with the mental health individuals. It is not only important to explore and openly discuss the need for psychoanalysis, it is necessary to acknowledge that the key towards a healthy lifestyle is in destigmatising taboo topics that have linkages to mental health, like menstruation.