Regular Menstrual Cycles Linked to Worse Premenstrual Symptoms in Women with Bipolar Disorder

Women with bipolar disorder who have regular menstrual cycles appear to suffer more severe premenstrual symptoms than those whose cycles are irregular, according to preliminary research presented at the 2026 ECNP Congress in Munich. The finding, drawn from one of the largest surveys of its kind, challenges a common assumption that a predictable cycle is the more benign one, and it shines a light on a corner of women’s mental health that researchers say has been neglected for far too long. For a condition affecting roughly one to two percent of women, the implications reach a strikingly large population: in a large European country such as the United Kingdom, France or Italy, an estimated 235,000 women of childbearing age live with bipolar disorder, with even higher numbers in Germany.

The study, led by Dr Sofie Ragnhild Aminoff of Oslo University Hospital together with international collaborators, surveyed 267 women of reproductive age with bipolar disorder. The questionnaire was distributed through the Norwegian Bipolar Association and professional networks over a ten-week period in spring 2025. Of the respondents, 166 women, or 62 percent of the sample, reported regular menstruation, while 101 women, or 38 percent, reported irregular cycles. Participants were asked about premenstrual symptoms experienced every or almost every premenstrual phase during the previous year, covering irritability, anger, relationship difficulties, physical symptoms, and significant distress or interference with work, daily activities or relationships.

The results showed a clear pattern. Women with regular menstrual cycles were more likely than those with irregular cycles to report this full cluster of severe premenstrual symptoms recurring month after month. In other words, the very group whose cycles followed the most regular rhythm reported the heaviest symptomatic burden in the days before menstruation. This was, the researchers acknowledge, an unexpected result, and one that raises questions about how hormonal stability and hormonal sensitivity interact in women living with a severe mental illness.

The survey also uncovered a second, closely related pattern involving contraception. Ninety-three percent of the women in the sample had tried hormonal contraceptives at some point, reflecting how ubiquitous these medications are in reproductive-age populations. Yet the women with regular menstruation were less likely to be current users of hormonal contraceptives than those with irregular cycles. A larger proportion of the regular-cycle group had stopped taking hormonal contraception because of side effects, and these women also expressed greater reluctance to use hormonal methods in general. Taken together, the data suggest that women with bipolar disorder who experience regular cycles may be a subgroup with particular sensitivity to hormonal medication.

Dr Aminoff described the contraceptive findings as raising important questions about whether some women with bipolar disorder may be especially sensitive to hormonal contraceptives, while others might potentially benefit from them. That distinction matters clinically. Hormonal contraceptives are among the most widely prescribed medications in the world, and for women with a mood disorder the risk-benefit calculation is far from trivial. Hormonal fluctuations are known to influence mood states, and a medication that stabilises the cycle for one patient might destabilise mood in another. The current findings hint that menstrual cycle regularity itself could serve as a marker helping clinicians identify which women fall into which group, although the researchers emphasise that much more work is needed before such guidance can be formalised.

Bipolar disorder is a serious mental health condition characterised by episodes of depression alternating with episodes of elevated or irritable mood, interspersed with periods of few or no symptoms. A majority of women with bipolar disorder experience some form of premenstrual disturbance, whether as standalone premenstrual symptoms or as premenstrual exacerbations of the underlying bipolar illness, in which depressive, manic or psychotic symptoms intensify in the days before menstruation. Despite how common these experiences are, reproductive mental health in women with severe mental illness remains an under-studied area, and the new survey adds to a small but growing body of evidence that the intersection of gynaecology and psychiatry deserves far more systematic attention.

The clinical stakes are considerable. Dr Aminoff noted that she has met many women with bipolar disorder who described changes in mood, psychotic symptoms or suicidal thoughts that varied with their menstrual cycle, experiences that can have a real impact on daily life. Clinicians, she said, currently have very limited guidance on how best to help. Her central message is that premenstrual symptoms in women with bipolar disorder need to be taken seriously, and that more research and clearer clinical guidelines are needed so that women and the health care system can make better-informed decisions about treatment, contraception and mood-stabilising medication. She argued that assessment of premenstrual symptom burden, alongside tailored advice on hormonal contraception and mood-stabilising medication, should be standard care, but that in practice it frequently is not.

The gap between what patients report and what the health system delivers emerged as a recurring theme. Many women with bipolar disorder report that their premenstrual symptoms are not taken seriously, and few experience receiving the treatment they need, according to the research team. This pattern of dismissal is not unique to bipolar disorder; it reflects a broader documented tendency for women’s reproductive and mental health complaints to be minimised in clinical settings. For women with severe mental illness, however, the consequences of inaction can be severe, given that premenstrual worsening can include suicidal ideation and relapse of psychotic symptoms, not merely discomfort or irritability.

Independent experts welcomed the study while stressing its preliminary nature. Professor Louise Howard, Professor Emerita in Women’s Mental Health at King’s College London, who was not involved in the work, said it was valuable to see preliminary research into the reproductive health of women with bipolar disorder being presented at the conference, adding that this has been an under-studied area for too long and that the relevance of menstrual cycle regularity to symptoms and to potential interventions such as hormonal contraception is poorly understood and deserves further investigation. Dr Clare Dolman, Co-chair of the Bipolar Commission and Ambassador for Bipolar UK, also independent of the study, said she agreed with the take-home message that premenstrual symptoms in women with bipolar disorder need to be taken more seriously. She pointed out that such symptoms can exacerbate bipolar illness, and that sensitivity to hormonal change can be a marker for potentially dangerous relapse at other times of hormonal upheaval, including pregnancy, childbirth and perimenopause. Women’s mental health generally, she argued, has been ignored for too long.

The authors are careful to frame the findings appropriately. The work is preliminary, based on an online survey rather than clinical assessment, and has not yet been submitted to a peer-reviewed journal. Self-reported cycle regularity and symptom severity can be influenced by recall and selection bias, and the sample was recruited through patient organisations, which may over-represent women with particularly troublesome symptoms. Even so, the study’s size for this field, its focus on a neglected population, and the consistency of its two main signals, greater premenstrual burden and greater contraceptive side-effect burden among women with regular cycles, give it a significance that extends beyond the conference hall. Dr Aminoff’s concluding call is for closer collaboration between psychiatry and gynaecology, and for research that looks not only at mental health symptoms but also at hormonal contraception and reproductive health. If subsequent controlled studies confirm these patterns, menstrual cycle regularity could become a simple, low-cost clinical marker, helping clinicians tailor contraception and mood-stabilising treatment for hundreds of thousands of women across Europe who currently navigate this intersection of hormones and mental illness with almost no formal guidance.

Subject of Research: Premenstrual symptoms and hormonal contraceptive use in women with bipolar disorder in relation to menstrual cycle regularity

Article Title: Regular periods, but worse symptoms: Women with bipolar disorder losing out on gynaecological care

Article References: Regular periods, but worse symptoms: Women with bipolar disorder losing out on gynaecological care. (n.d.). Original publication

Image Credits: AI Generated

DOI: Not provided

Keywords: bipolar disorder, premenstrual symptoms, menstrual cycle, hormonal contraceptives, women's mental health, gynaecology, psychiatry, reproductive health, ECNP Congress, mood-stabilising medication, premenstrual exacerbation, Oslo University Hospital