Hormonal shifts and menstrual cycling have always been issues for women. Until a few decades ago, the physical and emotional changes in women as they grow older were rarely written about or addressed openly. Today, such interest stems, naturally enough, from the burgeoning population of perimenopausal and menopausal women, the “baby boomers.” As this generation ages, 3,500 American women enter the menopausal years, ages 45-54, every day. Between 1990 and 2010, almost 40 million American women will pass through menopause.

At Hanley-Hazelden in South Florida we have found through clinical experience that this aspect of the female development process, which is often ignored, is critical to the holistic assessment of women entering chemical dependency treatment. Hormonal shifts can trigger relapse and perhaps addiction onset. For some women, perimenopause and/or menopause can be debilitating, disruptive to their relationships and can signal the beginning of a relapse process or the onset of middle-to-late stage alcoholism/chemical addiction. Chemical dependency treatment plans need to address menstrual cycles, perimenopause, or menopause as potential problem areas.

The roller coaster role of hormones
The fluctuation of estrogen is of particular importance because this hormone impacts women’s serotonin and melotonin levels, i.e., neurotransmitters relative to a sense of well-being and sleep patterns. Connected to moods, estrogen interacts with these neurotransmitters and the levels of estrogen shift during a woman’s menstrual, perimenopausal and/or menopausal phases of life. Estrogen also interacts with endorphins in the brain. During times when estrogen levels are low and progesterone levels are maintained, cravings can be significant. These cravings often translate to a compulsive desire for sugar, caffeine, sex, alcohol, or familiar chemicals.

Progesterone is associated with memory, hunger, sex drive and anger. Surges of progesterone during a woman’s mid-cycle have been thought to be the culprit in creating PMS symptomology, such as irritability, mood swings, and crying jags. An increase of estrogen, either through hormone replacement therapy (HRT) or estrogen replacement therapy (ERT) seems to help counteract these symptoms.

When there is an upset of the hormonal balance between estrogen and progesterone, i.e., when there is more progesterone, aggressive acting out behaviors may result, which can then be exacerbated during the chemical dependency withdrawal process. When ovarian hormones surge and cycling begins, depression often increases in females, with the highest incidence between the ages of 22 and 45.

Studies have shown that some 70 percent of all women who enter substance abuse treatment suffer with trauma and/or abuse issues. At Hanley-Hazelden, we see this percentage to be higher, between 85 and 95 percent. We also know that that one in four of all women will suffer from trauma and/or abuse at some point in their lives. This often translates to a diagnosis of Post Traumatic Stress Syndrome (PTSD), a diagnosis that is sometimes missed because the criteria for it are similar to Borderline Personality Disorder. The changing levels of hormones during menstrual cycling can bring up old memories, accompanied by strong emotions. These surges can also help facilitate the clearing of these memories. As clinicians in the field of chemical dependency who treat women, we need to know how this occurs and how to identify and address it in treatment.

A holistic women’s treatment model treats mental health issues concurrently with chemical dependency
We have found that putting aside mental health issues to first treat a woman’s chemical dependency is not as effective as concurrent treatment. And concurrent treatment, we believe, is ethically and clinically responsible in a truly holistic treatment program. It is an understandable reaction for therapists and counselors to avoid this approach, since treating co-occurring disorders in women is extremely difficult in the best of situations. Today we are challenged to assess differently and develop more appropriate care plans, and to understand the complexities of women on all levels, physically, emotionally, psychologically, socially, and spiritually. This holistic approach integrates the recovery of this progressive disease for women.

At Hanley-Hazelden, we have developed a female model of treating women based on the Stone Center for Women at Wellesley College’s relational model, along with principals of Dr. Stephanie Covington’s “Helping Women Recover: A Program for Treating Addiction.” Rebuilding connections with others and rekindling a sense of self and spirituality are emphasized. Recently we have added a component that brings assessment of hormonal shifts and development of individualized and self-directed coping and recovery strategies into the care plan.

In whatever terms it has been addressed in global societies, one of the defining differences between men and women has always been the female menstrual cycle. In treatment circles today we call this the “female process” with little or no translation of how, exactly, this affects the female recovery process or that, in fact, it does. Obviously, women often experience mood fluctuations, low self-esteem, or anxiety during their menstrual cycles. However, we have compartmentalized the female experience due to a lack of awareness of how the fluctuation of hormones affects a sense of well-being. In clinical terms we define female coping skills in terms of DSM-IV, Axis I or II, diagnoses such as chemical dependency, depression, generalized anxiety, phobias, personality disorders/features, and eating disorders.

Being able to assess more appropriately became a goal for Hanley-Hazelden’s Center for Women’s Recovery as we saw women struggling with complex issues and often dual diagnoses. We knew that hormonal shifts play an important role in women’s overall sense of well-being, even without all the issues of chemical dependency and/or trauma/abuse. So, why wouldn’t it be significant for someone who was entering the recovery process? We also looked at the impact of hormonal shifts on a continuing recovery process when a woman who has had
sustained recovery is entering into perimenopause. Physical and emotional symptomology relative to hormonal shifting have been known to lead to self-medication, a familiar pattern for women who suffer with chemical dependency.

A self-assessment tool with Fourth Step inspiration
For the last year we have been implementing a new treatment protocol at Hanley-Hazelden that addresses these issues and is based on a Fourth Step Process for self-assessment, validation, and proactive relapse prevention that is rooted in the Twelve-Step philosophy. Step Four asks that we continue our self-discovery by taking a careful and in-depth look at ourselves, particularly our behaviors, attitudes, and experiences that contributed to our compulsive behaviors.

The process starts with a self-administered Holistic Hormonal Assessment tool filled out by the client, reporting her physical, social, familial, and attitudinal menstrual history, including physical symptoms such as pain, self-medication, and incidence of mood swings. PMS is assessed along with sexual attitudes and history, and perimenopausal symptoms, reactions, and attitudes. Menopausal history may be explored, including physical and psychological symptoms.
The holistic self-assessment is used in early recovery, giving us a more accurate history of the individual, and as we compile and derive data from the reports, a better history of the female experience emerges. It validates the female experience while providing a valuable format for assessing trauma and abuse issues and may provide a link to assessing pain management.

Resultant care planning helps clients identify cyclical patterns and a recovery plan with physical, emotional, social, and spiritual components. The care plan is similar in format to a traditional treatment care plan. In the self-assessment survey, the client approaches the “problem,” for instance, PMS, which would initiate cravings for sex, sweets, or alcohol. In a section of the survey entitled “evidence,” the client reports actions or feelings such as inability to focus. “Goals” are set (I will identify a relationship between my mood swings and my cravings for drugs and/or alcohol). “Objectives” are next (on a monthly basis I will identify the onset of menstruation), and finally, “method” (I will keep a monthly calendar of my menstrual cycle, including physical symptoms, etc.).

The client can now identify cyclical patterns so a process of self-monitoring and awareness begins. The resultant relapse-prevention program includes the menstrual and hormonal shift patterns, and we’ve found that by recording this, the client becomes more committed to the process. Women have told me, “Wow. I can understand this now. Just before my period (or during, etc.) I just want to use!” The client reviews the pattern of her reactions, and with her clinical team, devises healthier solutions to cravings or mood swings, including possible diet changes. Because the issues have been identified, the client is more apt to be ready to work through them and find solutions. The ongoing recovery plan includes support by her medical/mental health professionals and a sponsor.

The average age of women entering residential treatment at Hanley-Hazelden is 40 years old, so perimenopause and menopause have become more obvious issues. This experience can be debilitating for some women when it further impacts their self esteem. Sometimes a simple validation of this process is enough to get women involved with a healthy approach to this life change. Engaging with others, receiving support, and working with a clinical team help the client address this in treatment and recovery. It is important to find a gynecologist who is sensitive and/or trained in chemical dependency, i.e., someone who would be reticent to prescribe benzodizepines to relieve discomfort. This should be part of a continuing care plan.

At its core, care planning for women that addresses hormonal shifting helps women embrace their recovery process. The Hanley-Hazelden program’s holistic approach involves a multidisciplinary team for individualized care. Estrogen levels may be taken, and the care plan may include HRT therapy for pre- or post-menopausal women and/or sending on results to the client’s gynecologist.

Integrating hormonal shifts into a care plan
Start by assessing and validating the symptoms of hormonal shifts. Some women will not be able to identify this due to the interference of their chemical dependency. For example, opiate addiction impacts the natural process of menstruating. If this is the case, educate your client to this potential and either assess hormonal shifts pre-opiate addiction or postpone this assessment when cycling resumes. Work with a multidisciplinary treatment team, including medical, psychology, wellness specialists, and clinical professionals.

Engage your client in the process with personal assessment in order to identify awareness of cyclical patterns through education: physical, emotional, social, and spiritual. What is most critical here is that the client understands the impact of her hormonal shifting. Without this understanding, she will not be able to integrate any other concepts relative to identifying her cravings and developing a successful personal prevention plan.

Every woman experiences hormonal shifting in her own way. Assessments are vital to customizing care plans. Be careful not to fall into the easy trap of categorizing the female experience as the “same” for all.

Develop relapse-prevention planning to include: nutrition, exercise, meditation, therapy/treatment, women’s meetings, and connection to the Twelve Steps, especially Step Four. Attending women’s meetings, especially as estrogen is starting to deplete, is absolutely critical.

Reaction to the new treatment model
Reactions from staff and clients have been positive about the hormonal shift self-assessment tool and integration of its evaluation and recovery strategies into the Hanley-Hazelden treatment model. The assessments are being tabulated anonymously so that a two-year study can best compile trends in what women report as well as summarize effective care planning. We know, though, that clients’ care plans reflect that mood swings and cravings are cyclical, and that for the most part, women have demonstrated willingness to engage in their own coping and relapse- prevention planning.

Another tangible result of a more inclusive care plan is that we have seen the percentage of reported trauma and abuse rise because the way we are now asking the questions has made it more comfortable for women to identify or talk about it. The average length of stay is increasing for female clients, who are now given more tools to develop coping and recovery strategies and the time to implement them in a residential setting.

Donna Corrente, MS,CAS,CAP, is director of the Hanley-Hazelden Center for Women’s Recovery in West Palm Beach, FL. For more information about the center, call 800-444-7008 or 561-841-1000.

References
National Institute on Drug Addition. (1998). Drug Addiction Research and the Health of Women, Executive Summary, NIH publication No. 98-4289. (Call 800-622-3464 for copies.)
Covington, S. & Surrey, J. (1997). The Relational Model of Women’s Psychological Development; Implications for Substance Abuse. In Sharon and Richard Wilsnak, eds., Gender and Alcohol: Individual and Social Perspectives. New Brunswick, N.J.: Rutgers University Press.
Covington, S.S. (1999). Helping Women Recover. A Program for Treating Addiction, Facilitator’s Guide. San Francisco: Jossey-Bass Publications.
Hiller-Sturmofel, S & Bartke, (1998). A. “The Endocrine System; An Overview.” Alcohol World: Health & Research 22:153-164.
King, S. (2000). “Women and Alcohol: Do females face a higher risk?” Underwire: http://www.womencentral.
msn.com/health/expertAweek3.asp
Kendall, S.R. (1996). Substance and Shadow, Women and Addiction in the United States. Cambridge, MA and London, England: Harvard University Press.
Hutchinson, K.A. & Sachs, J. (1997). What Every Woman Needs to Know About Estrogen. New York: Lynn Sonberg Book Associates.
Schwartz, E. (2002). The Hormone Solution. New York: Warner Books, Inc.
Northrup, C. (2003). The Wisdom of Menopause. (Paperback edition). New York: Bantam.

This article is published in Counselor,The Magazine for Addiction Professionals, August 2003, v.4, n.4, pp. 22-25.

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