Pre-Menstrual Syndrome & Pre-Menstrual Dysphoric Disorder
by Dr Peta Wright
Symptoms of PMS and PMDD can be debilitating for some women. Around 40% of women experience symptoms of PMS and around 5-8% suffer with severe symptoms.
They are made worse at times due to the lack of understanding in the general community regarding these disorders and the tendency for people around you to perhaps shrug it off as a ‘women’s issue’ or that you are just ‘being hormonal’.
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 boost 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.
We know that PMS symptoms occur in the 5-10 days before menses and are relieved within 4 days of the onset of your period. Symptoms must be present over at least 3 cycles. Symptoms can be both physical and mental, and include:
Breast tenderness
Bloating and abdominal pain
Swelling of hands and feet
Headache
Depression and anxiety
Irritability and angry outbursts
Social withdrawal
Brain fog
The good news is that there are many effective treatment options for PMS and PMDD. It is important to seek help from someone who understands the menstrual cycle and the complicated way in which hormones can affect many parts of the body and mind. There are both natural and medical treatments that can help, as well as lifestyle changes that can also make a difference.
Lifestyle changes – Reducing stress by getting adequate sleep, practicing mindfulness or meditation and getting regular exercise. Exercise relieves stress and naturally boosts serotonin levels in the brain. Stress can deplete GABA in the brain, which may make PMS symptoms more likely.
Reducing inflammatory foods and sugar can help, as less inflammation can enhance the sensitivity of both progesterone and GABA receptors. Some women find that reducing dairy helps their symptoms. Reducing alcohol can also help, as alcohol can interfere with the soothing effect of progesterone.
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. 100mg a day in the second half of the cycle 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.
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 Yaz, which contain a special kind of progesterone called drospironone 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.
Low dose oestrogen patches can also help as they prevent crashing oestrogen levels in the second half of the cycle thought to precipitate symptoms. If oestrogen patches are used it is important to protect the lining of the uterus with a progesterone – either a progesterone containing Mirena IUD or with micronised (body identical) progesterone for the second half of your cycle. Even though Mirena does contain a synthetic progesterone – blood levels are 100-1000 times lower than in pills so far less likely to cause progesterone side effects.
An anti-depressant called an SSRI such as Zoloft or Lovan taken from days 19 to onset of menses 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 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 wholistically to improve your quality of life.
References:
[1] ACOG Practice Bulletin 2000; 15:1-9.
[2] Rapkin A, Mikacich J. Premenstrual syndrome: Gynaecology or psychiatry, Reproductive Medicine Review, 2001; 9: (3), 223-239
[3] Briden, Lara, Period Repair Manual, 2018
[4] RCOG, Management of Premenstrual Syndrome, Green-top Guideline no. 48, November 2016
[5] Eden, John, WHRIA website content
