Dr Jayashri Kulkarni — Female rage

Yumi
As women, we've got a hell of a lot to be angry about. From the gender pay gap, the overwhelming mental load, men just being numbats in general, all that crap has got us absolutely fuming and quite frankly, at our wits end. Ladies, we've had enough and now people are definitely hearing our roars of rage across the world. And even though it's facts that we have got plenty to be ticked off about, it did get the ladies team wondering whether our hormones had any part to play in the extent of our rage. Dr. Jayashri Kulkarni is a professor of psychiatry and director of the Health Education Research Centre at Monash University. She's been studying the effects of hormones on women's mental health and our rage levels for over 20 years. I spoke with her for the Ladies We Need To Talk episode called, Female Rage, Why Are We So Damn Angry? And I started by asking Jayashriabout whether there are certain times in our lives when hormonal rage can become an issue for women.

Jayashri
Absolutely. And I think it's also important that we understand that there is a connection between the gonadal hormones, estrogen, progesterone and testosterone, and all sorts of mood, behaviour and other aspects like cognition. That's all brain stuff. So somehow, because estrogen and progesterone are particularly known to be the girls' hormones and they operate on reproduction, we've got ourselves into this weird situation where we haven't quite come to terms with the fact that these hormones don't operate just below the waist. They actually also operate very strongly in the brain. So rage can be a feature of fluctuations in those hormones.

Yumi
And how wouldAnd how you characterize rage?

Jayashri
It's often described by the woman herself as this intense feeling of anger and irritability and hostility where there isn't a reality basis. There are certain times when, of course, things do make you realistically angry, but this is described by the women themselves as unrealistically angry about small things but having a very big reaction to it.

Yumi
So what is going on in our bodies when we're feeling this huge wave of rage?

Jayashri
So there's a couple of particular time cycles when, or life cycles, when we do see rage as a symptom. And I think there's the premenstrual dysphoric disorder, which is a dumb name. It's actually premenstrual depression. It's a major depression that occurs in some women, up to about 10 to 15% of the reproductive age group of women. And it happens once a month. And once a month, the symptoms can be of a depression where the person feels really sad or moribund and can't get out of bed. They just don't have energy. But they can also have an accompanying rage where she feels really hostile and irritated and bites and sort of snaps and snarls at anything. And also then can have this thing called brain fog where she feels like she just can't think. The other big group where rage is a symptom is perimenopause, which is another complicating term but it means the lead in to menopause or the lead out. So it's a time around the menopause. And many women describe the onset of menopause from their mid-40s onwards with mood and cognition and rage symptoms. I've had many women who come and they say, look, I just don't get what's going on with me. I've never had anything like this before. And I can hear myself swearing or saying things that I normally wouldn't. And I don't feel like I'm completely in charge of what's happening. And also they will describe it as all going away quite suddenly as well.

Yumi
Fascinating. I heard the feminist Caitlin Moran, who is a UK author and broadcaster, talk about her hormones, especially her reproductive hormones, as like being on drugs. And when perimenopause and then menopause hit, it was like she was off the drugs and just the anger was allowed to manifest. Have you ever heard it described in those terms that she's not on love drugs anymore, so you're actually allowed to feel angry?

Jayashri
It's interesting because people do talk about middle-aged women are bossy and more determined and more opinionated. And so psychologists will say, well, that's due to the fact that there's a lot of life experience. Things have gone wrong also. And so she has every right to be angry. And we absolutely agree with that. But when the woman says, and perhaps this is what Caitlin's quote is about, is when she feels different in herself. And we're always guided by what the woman says is normal for her and what is different for her, because there's usually something that has biologically changed when women tell us that.

Yumi
How do the women you speak to and that you help with these problems of their hormones explain their experiences of hormonal rage?

Jayashri
So often the description comes from the woman as in usually midlife. And so that's a big group. That's the menopausal, beginning menopause type group. And they will say things like, I just feel so irritable and I just feel angry and I can't put my finger on what it is. And I've also heard lots of descriptions from women who say, this is not me. And they will also say things like, I get angry at the silliest things. So for example, I had the story of a lady who was very much the well-to-do woman who would never swear, et cetera. And she described that as she became enraged, she would be swearing like anything. And she said, I'd be standing there on the escalator in a shopping center and I'd be wanting to push everybody down the stairs because they wouldn't get out of my way. And then she'd laugh and say, I've never felt like that before. So interesting comparison. And then she would say it would go away after a while as well. So I think it's always important that when we're talking about behaviour and mood, that the best comparator is the woman herself. It's not about how is she compared to me or you, because everybody has different barometers of expressing anger and different cultures have different, what is allowable in expression and so on. So there's no point trying to get a gold standard of this is how you must behave. In fact, I think that's terrible and has done a lot of disservice for women in particular over the ages.

Yumi
Yeah. And I like that idea of that sort of untethering that middle-aged women can experience where they're not so shackled by politeness and those kinds of pressures. So I guess that's my concern is with this conversation is like, I don't want to be blaming apt and right behaviors on a hormone. And this group that we're talking about, middle-aged perimenopausal women who are also often caring for kids, partners and elderly parents, stretched physically, stretched emotionally, financially. How can you tell if it's hormones or just the shit sandwich that's being middle-aged woman?

Jayashri
And I guess that I will often rely on what the woman says. And I do see, you know, at my clinic is women's mental health and I see a number of women who are very clear about their own selves. They've lived in their bodies for some 45, 50 years. They have run households, they've run businesses, they've run relationships, they're looking after elderly parents. But they know a thing or two about themselves. And so I would never, ever be suggesting treatment, whatever that is, for somebody who's just angry. It's more about when she says, I don't like this. This is bothering me. I don't like it that I'm yelling at my kids. I don't like it that I am yelling at my partner. You know, it's the subjective descriptor that the woman has, that this is not something that she wants. And then we can look at, OK, what's going on?

Yumi
So I know you said there's no gold standard for behaviour, but I'm assuming there's no gold standard for rage either. But Professor, can you tell us how rage commonly plays out for women when they are impacted by their hormones in this way?

Jayashri
So what we see and what she'll describe is an intermittent explosion of a feeling of anger. And people describe it in various ways of how a red mist came down. I found myself, you know, gritting my teeth, clenching my fists. And I just, you know, I just wanted to do something, but I was stopping myself doing some harm. I wanted to throw something. I swore and I don't usually swear. I mean, it's all of those sorts of behaviours. But the feeling itself is that of intense anger. And then it gets expressed physiologically with a whole bunch of blood pressure going up, pulse rate going up, muscle tension, those sorts of things, heat. And then again, it can calm down. And often the picture for the menopause rage or the PMDD rage is that it fluctuates. So, you know, a variable pattern, but without a particular precipitating stressful situation necessarily.

Yumi
You know, I put on my social media a call out for people who have experienced rage, for women who've experienced rage. And the response was massive, Professor. The number of people that wanted to talk about the rage that they're feeling was a lot, a lot of people. So I'm wondering if they're furious and they want to punch a pillow or scream while they're alone in their car, is that OK? Is that a problem manifest or is that a way of processing their rage?

Jayashri
Well, I go back to it that if she's safe, if everyone around her is safe, if that's what she wants to do, then what's the harm in that? I also think that though, and here I'm going to probably get myself in a bit of trouble, but, you know, I think that the stiff upper lip sort of culture has led to a kind of fear of anger in women especially. And this, I think, is the other side of where we don't want to pathologise anger. You know, there's nothing wrong with anger as in emotion. People use it, can use it. It can be a sort of activated depression sometimes, but it can also be that it's a justified anger about some injustice. So I think we also have to get more used to the fact that being emotional or having emotions is a human condition and it's not something that we should all be scared of or particularly that women should not be condemned for being emotional. It is human and it's a good thing as long as there's no harm attached.

Yumi
Jayashri, what times of the month are often the worst?

Jayashri
So for the woman who's still got a menstrual cycle, that's between the ages of puberty and mid-40s, it's the low estrogen phase that women describe the most difficult with mood and brain fog and some of the other things that are happening in the brain. And that's because estrogen is a nice protective hormone. And so when the levels drop, then the depression can hit or the anxiety can hit or the brain fog can hit as well. So it is in that week, usually before bleeding, that is the pre-menstrual week. And that's often the worst week for the brain.

Yumi
Professor, how can contraception help? Are some forms of contraception better than others?

Jayashri
So contraception is kind of like taking control of the cycle from the outside with the pill. And it is a treatment for PMDD. And it makes a lot of sense because as one of my patients said, Jeepers, if it's a hormone that caused the problem, then use a hormone to fix it. And she's dead right. That's the good theory that using the pill will help. However, there isn't one pill on the market. There are lots and lots. We call it the pill, but there's lots and lots of pills on the market. And some have got quite awful progesterones in them. And they're called progestins when they're synthetic. And these progestins can actually cause depression in some women, not everybody, but in some women. And so we've got to be careful with when we're trying to treat pre-menstrual depression that we don't use the wrong pill and then make everything all that much worse. So this is another area of research that we've done for some time. And we do suggest to women that they talk carefully about which pill they would like to use because they're not all the same.

Yumi
And Professor, would you know within one cycle whether you're on the right pill or the wrong pill, or is this something that you have to endure for months at a time to get it right?

Jayashri
It's not so much months and months, but I think most women are pretty aware by the time they get to the second cycle that something's not right. And this is important for their healthcare professionals to understand because when she comes in and says, look, ever since I started that pill, I don't feel right. The healthcare professional needs to go, yep, you're right. Let's try something else. But unfortunately, we've still got too many people who haven't understood that these hormones, estrogen and progesterone are potent in the brain. And so people will say, oh, no, no, no, it must be that you've got troubles at work or you've got troubles at home or whatever else. Let's send you to counselling or here's an antidepressant.

Yumi
You mentioned the pill, the contraceptive pill. Is there a place in this conversation for a vaginal ring?

Jayashri
So here's the difficulty. People have used things like IUDs or intrauterine devices, or they've used vaginal rings, thinking that it's going to be easier on the brain because the device is kind of south of the brain. But the difficulty here is that's not correct because it doesn't take much of the particular hormone to get into the bloodstream, to get into the brain, to then impact adversely on the brain chemistry. And of course, I'm talking about a minority of the population who are vulnerable. It's still a big number, but a lot of women sail by using the ring, they're using the pill, using all sorts of contraceptives with no problem of their mental health at all. So I don't want everyone to think, oh, my goodness, everybody, every woman's going to have a problem. It's not. But if you have a problem, then you have a problem and take heed of it and convince your doctor to work with you on changing the contraception until you find one that works. And there's a lot on the market. So you can go on a bit of a journey.

Yumi
Is there a way to stop those anger outbursts when your estrogen is low, or is it just you're too far gone at that point?

Jayashri
So I think, again, for the person who is troubled by this and wants some help for it, I would suggest that in our clinic, for example, we would use the pill if she's of a reproductive age. And we know that we've got research that directs us towards the less harmful pills. So that would be the suggestion that I would have, because it means that every cycle, she's not going to dip badly into depression and rage and brain fog and lose, essentially, a week of productivity and joy. And that's pretty awful because that goes on every month. So that would be the person who is troubled by it. But if she, for example, knows that there's something a little different every cycle, but hey, whatever, I'll just sit in my car and scream a bit and deal with it, then that's fine if that's what she wants to do.

Yumi
A lot of what I'm getting from you, Professor, is that we need to listen to ourselves and be in touch with our bodies and trust our gut. What about the people around us? How can we get the people in our lives to understand our mood swings better?

Jayashri
I think it's really important that, A, you're right, we should all understand ourselves, but then we should talk about it too. And I find that partners are able to understand a bit more when she explains what it's like for her and also in the better times to actually work out an action plan. So when I say this, when I'm feeling bad, I want you to do this. This would be very helpful for me. It's almost like writing the script. And so therefore, people are not guessing. What we don't want is we don't want the pejorative thing for the non-affected partner to then turn around and go, oh, you know, it's that time of the month, is it? And that kind of invalidates. So for example, if she says, I'm having this particular problem at work, she doesn't want that to be written off as, well, what do you expect? It's that time of the month. That's not on. That's really not on. So it is about working through what's acceptable, what is needed to help her get through this difficulty, but for people to understand that there is a factor going on here that is a biological factor. And if it gets away from her, that there are things that can help if she wants that to be helped. But she's, you know, like we always work in a biological plus psychological plus social integrated treating fashion. So it is important to understand what's really going on in her environment. And we unfortunately know that there are abusive situations. There are really horrible relationships. And, you know, she might be in that position. So it cannot be that we just look at one bit of her life without the other bits.

Yumi
Yeah, well, I was going to get to that because the hormonal ups and downs are really real and they affect women hugely. But sometimes it's used against them to dismiss them or like you say, invalidate them.

Jayashri
Invalidation is a terrible thing. And far too many women are invalidated by all sorts of things. And it just keeps on keeping them down. And that's why sometimes we assist the woman by working on the biological factor so that then she's got some more armour to go fight her own battles. But it is all connected. And this is the other part about women's mental health is trying to make sure that you work in a holistic fashion because everything connects with everything else. And you need to really provide some sorts of answers and possible solutions for the different bits of what is going on in her life with her.

Yumi
That was Dr. Jayashri Kulkarni, Professor of Psychiatry and Director of the Health Education Research Centre at Monash University, speaking to me for the Ladies We Need To Talk episode on female rage. You can listen to the full episode right here in the ABC Listen app.