Premenstrual syndrome (PMS)?

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What is PMS?

Do you have certain symptoms that come on before your period such as lowered mood, irritability, anger, anxiety, tearfulness, brain fog or physical symptoms such as fatigue, breast tenderness, migraines or other headaches.  In fact, there have been over 150 different symptoms identified as being associated with PMS.

If this sounds like you, read on to learn more as there are ways you can do to improve your quality of life.  

Is PMS normal? 

PMS is probably much more common that we currently realise. Many people assume it is part of normal life and adapt to that “time of the month”. Some people use lifestyle approaches to use these different phases of the menstrual cycle for optimal productivity – doing high energy/detail-focused tasks in the first 2 weeks after the period, and more reflective maintenance tasks that allow time to recharge in the second half of the cycle.  However, if you have troublesome premenstrual symptoms there are definitely treatment options that can be considered to help.  

What is PMDD?

Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) both describe troublesome cyclical symptoms that occur before the menstrual period, improve rapidly after you start to get your menstrual bleed with at least one week symptom-free each month. PMDD is a North American term, that refers to a severe subset of PMS where the symptoms are so debilitating, they affect your quality of life, relationships and ability to work.  Whether you are diagnosed with “PMDD” or “severe PMS” the treatment approaches are likely to be the same.

Premenstrual exacerbation (PME) is where you might have an underlying mood disorder – generalised anxiety, depression or another mood condition, for example, where symptoms persist to some degree throughout the month but worsen before your period.  The treatment options below have an evidence base for PMS and PMDD, however may sometimes be considered for people with PME on a case-by-case basis. 

How is PMS diagnosed?

Unlike most medical diagnoses, you are more important than the doctor in making the diagnosis! Only you know what symptoms you are having, and there are no physical signs or tests that are confirmatory.  The standard way of diagnosing PMS/PMDD/PME is to complete a symptom diary, documenting your symptoms each day for three months.  There are various apps, charts and tools on the internet that you can use to do this. Your doctor may undertake some tests to exclude other diagnoses, but reproductive hormone levels are usually normal.

What causes PMS?

PMS seems to be a sensitivity of the nervous system to the normal fluctuations of hormones in the menstrual cycle.  We consider the first day of the period as day one of the menstrual cycle, and the week or so after the period is called the follicular phase. This is when oestrogen levels are increasing and generally energy and mood is best.   Oestrogen  then peaks at ovulation and then drops quickly in the second half of the cycle and some people get oestrogen-withdrawal symptoms of fatigue, low mood and even hot flushes or sweats in some cases (akin to oestrogen-withdrawal symptoms in menopause!).  As progesterone rises in the second half of the cycle, some people get symptoms of bloating and irritability.  Progesterone rapidly drops with the onset of the menstrual bleed, oestrogen starts to rise again and symptoms usually improve at this time of the month. 

We don’t know why some people get more severe cyclical symptoms than others.  Sometimes but not always there may be a history of anxiety, trauma or other factor that may cause central nervous system sensitisation, when your your body to be on “high alert”, looking out for changes in your environment (which in the case of PMS and  your hormones include the internal environment) and sends you “danger signals” in the form of symptoms in response to these changes.   This is why in the medical treatment options, we see 2 general approaches: reducing hormone fluctuations with hormone manipulation and reducing the sensitivity of the nervous system with SSRIs (a type of antidepressant) for part of the cycle. 

How is PMS treated?

Non-medical approaches to reducing the “hyper-alert”state of the body are important (especially in PME where the medication approaches may not be as helpful for cyclical symptoms as in pure PMS and PMDD).  There is evidence that an increase in stress and sleep deprivation can worsen symptoms.  

Lifestyle approaches include reducing general stress with stress management strategies that you can learn to use at times of stress, gentle graded introduction of exercise and good sleep.   For people who get premenstral food cravings, eating complex carbohydrates (eg. brown bread or brown rice) over the day can help to curb the cravings.

Psychological approaches include working with a therapist to work through previous experiences that may make your mind anxious or your body tend to be on high-alert and stress management strategies.

There is some (weak) evidence that magnesium, vitamin D, calcium and B6 are helpful so you could take a multivitamin with these if you wish.  Evening primrose oil can be helpful for those who specifically have premenstrual breast swelling and/or tenderness.

For medication treatments for PMS/PMDD cyclical SSRI (usually citalopram or escitalopram) is often used first-line as these can be introduced for part of the cycle.  Usually you start taking the medication on day 15 of the cycle until you get your menstrual period, but the starting time could be earlier or later depending on when in the month your symptoms usually come on.  

In terms of first line hormone treatments, combind oral contraceptive pills  (COCPs) can be helpful, particularly if you also need contraception anyway.  COCPs contain a potent synthetic oestrogen and a progestin (synthetic form of progesterone).  The progestins vary from brand to brand and have different properties.  For PMS/PMDD a COCP with a progestin that is less likely to cause mood side effects (eg Yaz/Yasmin) is often used, although some may still get side effects. 

Another hormone approach is to use an MHT-type regime (menopausal homone therapy) which is the same as the treatment regime given in menopausal women but can be used in any age for PMS.  This is usually an oestrogen patch with natural progesterone pills which might be better tolerated than the COCP and may be safer in those with migraines.  If contraception is required with this regime, Mirena interuterine device can provide the progestin component and provide contraception.

Sometimes when other interventions failed, injections are used to suppress ovary function but MHT has to be added back for bone and general health which may cause side effects in some.  

Progestin or progesterone is important to use with oestrogen to stop the oestrogen from causing thickening of the uterus lining.  Very occasionally hysterectomy is considered in those who have severe progestin/progesterone intolerance to allow oestrogen to be given alone.  

How do I know what to do?

If you have very mild cyclical symptoms you may wish to try lifestyle approaches like optimising your sleep, gradually adding gentle exercise, stress management strategies, good nutrition and arranging your schedule to maximise productivity in the first half of your cycle and rest in the second half of the cycle.  If your symptoms are troublesome however, there are medical approaches that can help.  You could discuss the UK NAPS guidelines with your doctor and if necessary ask for a referral to an endocrinologist (such as the ERH team) or gynaecologist with specialist expertise in cyclical symptoms.  (In contrast to New Zealand and UK in the USA PMS/PMDD may be more likely to be managed by a reproductive psychiatrist and therefore psychotropic medications may be more likely to be used than hormone manipulation approaches.) 

We are also currently developing an app-based course for more in depth information and guidance on PMS -subscribe to the newsletter to hear when it launches!

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