Meeting your inner Autumn - dealing with PMS, PMDD, PME
Written by Dr Peta Wright
In the fourth week of our menstrual cycle – we meet our Autumn. Progesterone and oestrogen start to plummet during this week until they reach their lowest point, and our period comes around again. This phase has the worst reputation – hell week, PMS week, homicidal rage week – and for some women it can be devastating. But as you will see – it doesn’t have to be this way. If we have nurtured ourselves during the previous weeks and if allow our wild woman to express herself in a healthy way, many women will be able to find positives in this phase.
Most women don’t have severe symptoms but many experience some of the symptoms of PMS such as increased irritability, quickness to anger, tearfulness, feeling more emotional or just blah. This is due to the fall in progesterone and oestrogen and corresponding fall in our feel-good neurotransmitters - serotonin, dopamine and GABA.
Sometimes we feel sad or flat and sometimes it is a general feeling or annoyance with anyone who enters our sphere. It’s like the rose-coloured glasses of the abundant beautiful summer have fallen off in a big way.
While around 75% of women will experience some changes in their mood, energy and physical bodies in the one to two weeks before their periods –commonly known as PMS - Premenstrual Syndrome, around 3-8% of women experience much more severe symptoms and can be diagnosed with PMDD – Premenstrual Dysphoric Disorder. Women who have another mood disorder like anxiety or depression who have worse symptoms during their luteal phase may have PME – Premenstrual Exacerbation of an underlying disorder. Generally treating the underlying issue improves the luteal phase symptoms but sometimes these women may also need specific treatment for the premenstrual symptoms.
The exact cause of PMS remains controversial and not well studied but it is thought that hormonal fluctuations do play a part in PMS, as we know that oestrogen starts to fall in the second part of the cycle, while progesterone rises mid-cycle and then goes on to fall just before menses. However, it is probably not due to the hormonal changes themselves, but to the effects of changing hormone levels on receptors in the brain and rest of the body. It is likely that it is the sensitivity of the receptors that causes symptoms. This may explain why some women have no PMS symptoms and others have severe symptoms. We also know that women who have pre-existing depression or anxiety tend to suffer more with PMS and PMDD which may be due to lower serotonin levels in the brain.
Oestrogen boosts serotonin levels in the brain, which is why a fall in oestrogen may affect some women who perhaps have lower serotonin levels to start with. In a normal cycle when progesterone is released from the ovary after ovulation, it should counterbalance the effects of falling oestrogen.
Progesterone converts into a neuro-steroid called allopregnanolone which acts like a calming neurotransmitter called GABA. It has a calming soothing effect. Women who have troubling symptoms may have shorter or lower progesterone peaks. Inflammation and or pre-existing stress may make symptoms worse.
What we do know about PMS is that it only occurs in naturally cycling women (it does not occur in girls whose periods haven’t started or in menopausal women), treatment with anti-depressants that increase serotonin are often effective, and synthetic progesterones often make symptoms worse.
The milder symptoms reflect our changing hormones, physiology and brain chemistry. When we start to understand what’s happening, are able to give our bodies more of what they need (rather than pushing up against them) and reduce stress and inflammation in our bodies, much of the distress associated with these changes in our bodies can be significantly lessened. The modern world that invalidates a woman’s body and hormonal cycle and places enormous stress due to inflammatory diets, emotional stress, lack of sleep etc really doesn’t do us any favours here. It could be said it is more of an environmental issue than a disorder of us as women.
PMDD is much more severe and can have huge implications on a woman’s life, relationships, career and self-esteem.
Symptoms include:
Mood/emotional changes (e.g., mood swings, feeling suddenly sad or tearful, or increased sensitivity to rejection)
Irritability, anger, or increased interpersonal conflict
Depressed mood, feelings of hopelessness, feeling worthless or guilty
Anxiety, tension, or feelings of being keyed up or on edge
Decreased interest in usual activities (e.g., work, school, friends, hobbies)
Difficulty concentrating, focusing, or thinking; brain fog
Tiredness or low energy
Changes in appetite, food cravings, overeating, or binge eating
Hypersomnia (excessive sleepiness) or insomnia (trouble falling or staying asleep)
Feeling overwhelmed or out of control
Physical symptoms such as breast tenderness or swelling, joint or muscle pain, bloating or weight gain
Diagnosing PMDD a woman needs to report five of these over three cycles, with at least two of the core mood symptoms (highlighted) and they need to be in the second half of the cycle resolving with in four days of getting your period.
Contributing factors:
Childhood trauma – rewires the nervous system and makes the hormone receptors in the brain less resilient to hormonal fluctuations
Pre-existing Depression, anxiety – if this is the case the diagnosis is PME – premenstrual mood exacerbation
After childbirth and big hormonal fluctuations
Stress
Lack of sleep
Inflammation
Cultural expectations that women should operate on a flat line with no recognition of the fact that we do have hormonal fluctuations thoughout our cycle
If you resonate with feeling so out of control or so low during this phase that you are unable to cope, I hope this blog helps you to understand what is happening in your body.
The first thing you should do is start paying attention and journaling how you feel across a few cycles.
Try some of the simple lifestyle strategies I outline here and if you are still struggling, please see a doctor or naturopath who are familiar with hormonal mood issues, as there are many effective treatment options such as lifestyle changes, supplements, hormone treatments, psychological strategies and anti-depressants.
Lifestyle
Move
As we move into this phase where we are often feeling more tender and our body’s ability to recover is lower due to elevated core body temperatures, it is a good time to lower the intensity of exercise again. Strength training, Pilates, yoga, walking and gentle cardio are good options. High-intensity or endurance activities may feel much harder during this phase, and you will need to give your body longer to recover between sessions.
Hydration and adequate carb loading here is important to boost performance.
Movement in any form, such as dance, can be amazing. It is fantastic for boosting endorphins and improving mood and has been shown to improve PMS and mood symptoms during this part of the cycle, so make sure you make the time to move in a way that feels good for you. Embrace your wild woman and dance like no one is watching. Move that energy through you. I promise this is a game changer and it can take two minutes.
Nourish
Your stress resilience is often low during this phase and, combined with lower happy brain chemicals, means you may tend to want to soothe with carbs and sugar.
Make sure you are having protein with every meal and eat healthy nourishing carbs like sweet potato and healthy whole grains. Eat foods high in magnesium and B vitamins such as nuts, legumes, healthy grains and greens.
Avoid raw veggies and fruits and opt for cooked or stewed foods as these are easier to digest. If you do want a nourishing sweet treat, try my favourite PMS busting brownies from Alissa Viti or chickpea blondies.
As prostaglandins start to rise in preparation to shed the endometrial lining, you will want to avoid inflammatory and high histamine foods that can worsen pain and PMS symptoms – so reduce your intake of coffee, alcohol, processed foods, dairy, fermented foods, dried fruit, shellfish, avocado and bananas here. Also steer away from high salt foods as this may worsen bloating.
And don’t forget that your metabolism is still high, like in week 3, you need those 300 extra calories – so make sure you factor this in to keep your blood sugar stable and avoid those big binges!
Connect
We often crave alone time and feel resentful of people (even our own children and partners) who place many obligations and tasks on our shoulders. Unfortunately, society often demands we continue to operate as if we are on day 14 and superhuman for the whole cycle. When we can’t, we feel like a failure.
This doesn’t stop us trying though, which often makes things worse. Instead, let’s flip the script to find the positives. We often aren’t afraid of calling things out during this phase. Sometimes it’s PMS, sometimes it’s just that we’ve been putting up with something all month long that we can no longer tolerate. If you are feeling the same way cycle after cycle and feel tempted to just put it down to that time of the month – really look at it – you might need to decipher whether it is really you or whether it’s the situation or person you need to let go of. Don’t be afraid of feeling and expressing anger – we don’t have to be the nice girl all the time – just make sure you do it in a way that doesn’t harm others. At Vera we like throwing bricks or banging a rubber axe handle against a tractor tyre – very therapeutic! Angry dancing is also highly recommended!
This phase is all about surrendering and receiving. You have poured from your cup all month long and hopefully you have remembered after this guide to save a little and be mindful of depletion. This is the time to set boundaries. Say no instead of yes with gritted teeth and a bucket-load of resentment, then recognise and ask for what you need.
The people around us are not mind readers and women are conditioned to be people pleasers - to keep the peace and survive from a young age. The greatest lesson for this phase is this; if we can tune into and name what we are feeling, then have the courage to ask for what we need, irritability, anger and depletion can be greatly dissipated. If you can scaffold yourself by scheduling more alone time, and more activities that fill your cup rather than drain it, most women will find it easier to manage their PMS symptoms.
Say yes here only if it’s a ‘hell yes’ and you know it’s something that fills you up rather than depletes you. Don’t be afraid to set clear boundaries with those close to you, especially those people and situations you know will trigger you and drain your energy. This is not selfish. It is the opposite. You need to have the courage to own your feelings here and live in alignment rather than trying to have the same giving and doing energy that you were able to express earlier in the cycle. You will then be a much more pleasant person to be around and you will be able to do far greater good in the world. Remember that kindness and compassion must start with ourselves. Then watch it ripple outwards.
No one needs another depleted woman.
The world is full of them.
It is my great hope that when we start to connect to our inner voices and follow their lead rather than living in a way that is out of alignment, the world will become a kinder and more compassionate place that honours each person’s uniqueness. What starts on the inside is eventually what we see reflected in the outside world. This is why developing a deep understanding of yourself in all your glory is so transformative and life changing.
Feel your feelings, name them and communicate with those around you. Let your wild woman out and love her by allowing her to express herself and giving her time to just be 💟
I have seen this alone transform many women’s lives.
Journal prompts
How can I protect my energy this week?What boundaries do I need to set with myself and those around me so that I have the space and time I need?How can I communicate with those around me and them what I need?What are my strategies when I do feel angry, irritated or overwhelmed?Is this my problem or is it the situation?How can I find space between feeling and reacting?How can I take responsibility and own my feelings and actions?What do I need to let go of and how can I surrender?How can I move my body during this phase to release repressed emotions?How can I be my true self and drop the mask of perfection?What are you really angry about and what do you need to do to address it?How can I love and accept and myself even when I feel slower, or more fragile?How can I honour my Wild woman?
Week 4: Do more
Setting boundaries
Increase fibre and natural sugars
Alone time and going inward
Communicating your feelings and needs
Communicating your feelings and needs
Schedule and stick to self-care practices
More dance, yoga, long walks
Listening to your body – journaling
Make a play list of your favourite expressive music- angry, sad wild and dance!
Week 4: Do Less
Caring for everyone else
Coffee, alcohol and inflammatory foods
Putting yourself in depleting situations
Internalising and expecting those around you to be a mind reader
Long hours at work
Endurance training
Ignoring what you really need
Supressing your emotions
Note – Seeking some professional support to help teach you tools to regulate your nervous system, treat underlying anxiety, depression or address trauma can be invaluable and another wonderful treatment option. A counselor, psychologist, somatic or trauma therapist may be a great additional support.
Natural Supplements
Magnesium – 300mg a day in the second half of the cycle enhances the action of GABA and can ease symptoms.
Vitamin B6 – is essential for the production of progesterone and GABA and reduces inflammation. 50mg daily can help symptoms, especially when taken with magnesium.
Elemental calcium – 1200mg a day can also be beneficial.
Premular – is a herbal extract from the Chaste tree. A review of 17 randomised control studies showed it to be an effective and safe option for treating PMS. You usually take one tablet each day of the cycle.
Evening primrose oil – 3g a day in the second half of the cycle can help with breast pain.
Saffron 30mg daily has been shown to be as efficacious as an anti-depressant.
Medical Therapies
Some women may have such severe symptoms that they may consider hormonal therapy. There is good evidence that many synthetic progesterones alone and in some of kinds of oral contraceptive pills may make PMS worse.
Pills such as Zoely taken continuously so you don’t get a period have shown to be the most efficacious oral contraceptive pill for PMS and PMDD symptoms. It works by switching your own ovarian hormone production off and providing a steady state of oestrogen and progesterone throughout the cycle. Some women find adding some extra estrogen through a gel or patch helpful.
Low dose oestrogen patches and natural progesterone can also help as they prevent crashing hormone levels in the second half of the cycle thought to precipitate symptoms.
An anti-depressant taken in the luteal phase or continuously can help increase serotonin levels and is an effective treatment for women not wanting to manipulate their hormones.
If these treatments are ineffective and symptoms are very severe, sometimes we can use a GnRH agonist which is a medication that switches off the ovaries all together. This is a a very effective treatment but can cause menopausal symptoms such as hot flushes and fatigue and so needs to be used in conjunction with hormonal add back therapy – often in the form of an oestrogen patch and progesterone as described above.
Lastly, for women with very severe symptoms, who have shown to improve with treatments to switch off the ovaries, taking the ovaries out surgically, again with hormonal add back, can be a last resort.
As you can see, there are many effective treatments available so that women who are affected by PMS or PMDD don’t need to suffer needlessly or be told that they are just being hormonal! Our Vera doctors have an in-depth knowledge of the intricate way in which the hormones dance with one another during the menstrual cycle and the way they interact with the other parts of our body, to help guide you through the treatment options and treat you holistically to improve your quality of life.
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