Using CBT in the Management of PCOS, Endometriosis, and PMDD

All women with a menstrual cycle experience an accompanying fluctuation in hormones and physiological changes. While for some (lucky!) women this is unnoticeable business as usual, many women struggle with symptoms that become debilitating month after month. An often minimized aspect of this fluctuation is the impact on mental health. Researchers of women’s health concerns are increasingly insistent that psychological treatment be a component of treatment for endocrine and gynecological conditions, and we at CTWPS are here to help identify and treat those psychological symptoms. While we work with a range of experiences at CTWPS, the following is a discussion of some common gynecological and endocrine disorders that we see.

Polycystic-Ovarian Syndrome (PCOS)

PCOS is an endocrine (hormonal) disorder which impacts 7-10% of women of reproductive age. It is associated with an elevation in certain hormones which can cause irregular periods, excessive body and facial hair, weight gain, and acne. If you have PCOS, you may be familiar with some of the stressors - months without a period, or a period that lasts weeks, insulin resistance, difficulty with weight loss - but what you may not have identified as being part of PCOS are mood changes. Research by Thomas Berni and colleagues (2018) found that women diagnosed with PCOS were significantly more likely to have depression, low self esteem, anxiety, and eating disorders. While PCOS manifests differently in each woman, it is important to take seriously any signs of sadness, hopelessness or anxiety. At CTWPS, we might help a client grapple with the meaning of a PCOS diagnosis, fears or beliefs about it, and help ensure that her mental health is managed. Below are examples of emotional experiences related to PCOS that we might address:

  1. A client struggling with the weight gain associated with PCOS may have experienced blame from others, such as “just eat less!” or “take better care of yourself!” When this blame becomes internalized, a woman is at higher risk of maladaptive, depressive thinking about herself. We might identify distortions in her thinking, such as personalization or the control fallacy, in which she is taking emotional responsibility for things outside of her control.

  2. The excess body hair or male-pattern hair loss sometimes associated with PCOS can cause extreme distress for a client and cause her to struggle with beliefs about her femininity. For example, a client may feel hopeless about her appearance, believe she is unattractive, and avoid engaging socially. We would work with this woman to identify and deconstruct any maladaptive beliefs, and give her tools for managing anxiety while re-engaging in her life.


Endometriosis is a condition in which cells of the uterine lining move outside the uterus and attach to other areas of the body, such as the ovaries, fallopian tubes, bladder, bowel, or other organs. When a woman has her period, the same hormones that cause her uterine lining to shed also cause the endometriosis to swell and bleed, which in some cases can cause severe pain, nausea, gastrointestinal distress, fatigue, and infertility. While relatively common, affecting 10% of women, endometriosis often goes undiagnosed or misdiagnosed for years before properly identified. Many studies have linked endometriosis to mental health diagnoses, specifically depression and anxiety, as well as social isolation and diminished sexual interest. One study by Antonio Simone Laganà and colleagues (2017) observed that high levels of pelvic pain due to endometriosis increased a woman’s anxiety and depression, which further amplified her pelvic pain, leading to a mind-body cycle in which both physical and mental health are compromised by the other. The study concludes that psychological treatment is a critical component of pain management associated with endometriosis. At CTWPS we are equipped to treat the anxious and depressive symptoms associated with the condition. Below are examples of issues that might come up in treatment:

  1. A woman struggling with chronic pelvic pain due to endometriosis may find that her family and friends are critical and invalidating of her pain, attributing it to normal menstrual cramps or telling her to “toughen up”. As a result, she may become depressed or excessively question her own experience. We would work with this woman around connecting to her physical experience, replacing negative beliefs about herself, and developing strategies for communicating with her loved ones.

  2. Struggling with severe menstrual pain, a woman may find her period to be very difficult to manage and dread it every month. She finds that in addition to her pain spiking, her anxiety spikes as well, exacerbating the pain. We would work with this client on addressing her fear of pain, helping her to articulate the beliefs she holds, i.e. “I have no control over my body” or “this pain is going to break me”, and reframe them. We might also help her to develop behavioral tools for coping, such as mindful relaxation or positive self-talk.

Premenstrual Dysphoric Disorder (PMDD)

PMDD is a psychiatric diagnosis involving symptoms of depression, irritability, trouble concentrating, feeling overwhelmed or moody, or disturbances to appetite and sleep during the week leading up to a woman’s period. While 3-8% of women meet strict criteria for PMDD, many women experience sub-clinical symptoms monthly. In fact the American College of Obstetricians and Gynecologists estimates that up to 85% of women experience at least one physical or psychological PMS symptom around the time of menstruation. A common challenge for women is having this experience invalidated, or being called “crazy”, “irrational” or “hysterical”. Many women with PMDD or PMS may hesitate to assert themselves or communicate openly for fear of not being taken seriously. As psychologists at CTWPS, we see these symptoms present challenges to women of all walks of life. Below are some ways we might address these challenges in therapy:

  1. Some women are aware of intensifying stress around their periods, but do not have a clear sense of timing or specific symptoms. A first step in therapy would be to collect data; keeping a journal or a log of symptoms can not only be illuminating, but can help identify targets for intervention. For example, a client’s log may indicate that when she engages in certain behaviors, such as going to yoga or meeting a friend for coffee, her mood symptoms are less severe. This allows for development of a behavioral treatment plan for PMDD.

  2. A woman with PMDD finds that her male deskmate at work makes snide, teasing comments when she feels moody, making her feel dismissed and humiliated. We might work with this client on critically evaluating her subsequent beliefs about herself, such as “he’s right, I’m a mess”, or “I don’t deserve to work here.” We might also help this client assess her options for how to address this treatment at work.

Receiving a diagnosis of PCOS, Endometriosis, or PMDD can be distressing, but it also provides a roadmap for treatment. If you find yourself struggling emotionally around these or other gynecological or endocrine conditions, take it seriously and give yourself permission to seek support.