When Your Cycle Feels Like a Crisis: Breaking Down PMS and PMDD
PMS (pre-menstrual syndrome) refers to a group of physical and emotional symptoms that a woman may experience in the week or so leading up to the beginning of her menstrual cycle (when she starts menstrual bleeding) and subsides within a few days of menstruation.
PMDD (premenstrual dysphoric disorder) is a more severe, sometimes disabling extension of premenstrual syndrome (PMS). Although PMS and PMDD both have physical and emotional symptoms, PMDD causes more extreme mood shifts that significantly impact a woman’s quality of life.
Ovulation is a requirement to be diagnosed with PMS or PMDD, so if a woman is on oral contraceptives or has an anovulatory cycle (a cycle without ovulation), she cannot technically be diagnosed with PMS or PMDD. (Some women experience PMS-like symptoms as a side effect of being on a combined oral contraceptive.)[1]
It was once thought that PMS and PMDD were caused by hormone imbalances, specifically progesterone deficiency or estrogen dominance (high estrogen in relation to progesterone).[2] We’ve come to learn that what happens in PMS and PMDD is that women develop a sensitivity to their own hormonal fluctuations. Their hormones are doing what they're supposed to be doing, but the woman’s body develops a negative reaction to hormone changes.[3]
I recall Dr. Jordan Robertson explaining PMS/PMDD as, “A woman’s stress response and her hormones getting married, when they shouldn’t have gotten married.”[4]
What typically happens in PMS/PMDD is that a woman experiences a stressful event – any kind of trauma….parents getting divorced, an accident, or something that was stressful during a hormonally sensitive time in life (so, picture puberty, pregnancy, etc.). Her brain essentially connects the stress response with her hormones, so she now perceives hormone fluctuations as a stressor. This elicits a negative reaction to hormone changes, especially before her period. Women who experienced a stressor in their youth, or had trauma around the time of becoming pregnant, are at increased risk for the future development of PMS and PMDD.
Causes of PMS/PMDD
We just talked about stressors during hormonally sensitive times as a risk factor for developing PMS/PMDD. Studies looking at PMS and PMDD point to several factors that likely contribute to PMS/PMDD including:
Genetics – PMDD is believed to be heritable, as shown in studies on families and twins.[5]
Alterations in the HPA (hypothalamus-pituitary-adrenal) response
Alterations in the brain’s reaction to luteal phase changes in allopregnanolone (ALLO), one of the primary progesterone metabolites that make most women feel calmer and less anxious. In PMDD, it seems to have the opposite effect, which is why giving progesterone can often worsen symptoms; the sudden withdrawal of progesterone may also cause or worsen symptoms.
Altered circadian rhythms
Altered immune function
Alteration in the brain’s response to serotonin fluctuations
Abnormal responses in the brain regions that process emotions during the luteal phase[6]
Women with PMDD tend to have lower estrogen in the early luteal phase of their cycle (compared to women without PMDD), which may contribute to the effect caused by late luteal phase progesterone. The working theory is that this low estrogen primes the brain to struggle with elevated progesterone levels. Decreased estrogen may cause the hypothalamus to release the neurotransmitter norepinephrine, which triggers a decline in the other neurotransmitters (acetylcholine, dopamine, and serotonin) which leads to insomnia, fatigue, and depression.[7]
There are many ongoing areas of research into the causes of PMS and PMDD, so we will continue to learn more over time.
Diagnosis of PMS/PMDD
A thorough history and baseline labs should be performed to rule out other health issues that might mimic PMS or PMDD or worsen symptoms, such as pituitary issues, hypothyroidism, etc.
For a woman to be diagnosed with PMS/PMDD, she must be ovulating and her symptoms must be recurring only during the luteal phase.
A woman who suspects PMS or PMDD should keep a symptoms diary prospectively (going forward) for a minimum of two cycles to ensure that symptoms occur consistently during the luteal phase.
The DRSP (Daily Record of Severity of Problems) is a symptom tracker used to help diagnose PMS/PMDD. It uses a rating system to help clinicians determine whether a woman has PMS/PMDD. Diagnosis may be confirmed if the diary shows a prominence of symptoms during the premenstrual phase and a relative absence of symptoms during the follicular phase.
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[8]
The symptoms should be so impairing that the family life, social life, and ability to work are impaired for at least three days, or family life and social life are impaired for five days.
If a woman prefers to use an app to track symptoms, Me PMDD may be downloaded to record symptoms.
Managing PMS/PMDD
Diet/Lifestyle Recommendations
Alcohol, especially during the luteal phase may worsen symptoms[9]
Soy protein (68 mg isoflavones) has been shown to decrease headache, swelling, breast tenderness, and cramps[10]
Increasing whole grains, especially during the luteal phase, may improve symptoms[11]
Reducing sodium may decrease bloating[12] - Women with PMS have exaggerated renin and aldosterone (which is correlated to progesterone levels) in the late luteal phase, which impacts fluid retention
Supplements that may improve symptoms
Vitex (Chaste Tree) 40 mg per day[13] - not recommended for women with PCOS
Calcium 500-1200 mg per day[14]
Zinc 30 mg per day[17]
Omega-3 fatty acids – 1000 mg per day[18]
Oxaloacetate with vitamin C[19]
Salvia[20]
Phosphatidyl Serine and phosphatidic acid[21]
Chamomile[22]
Hormone Therapy
Topical estrogen with a cyclical dose of progesterone may help to improve PMS symptoms in some women.[23]
Some women feel better using progesterone delivered vaginally or transdermally (avoids upper GI metabolites).
Cognitive Behavior Therapy (CBT)
While CBT has been shown to improve anxiety and depression in women with depression and anxiety disorders, there is limited research on the use of CBT in women suffering from PMS/PMDD. Some studies have shown an improvement in symptoms, so CBT may be worth exploring.[24]
Medication
SSRIs are considered first line treatments for PMS/PMDD and may be used exclusively during the luteal phase or as a continuous dose.[25] SSRIs that have been approved for PMS/PMDD include:
fluoxetine (Prozac, Sarafem)
sertraline (Zoloft)
paroxetine (Paxil)
citalopram (Celexa)
Oral contraceptives (OCP) containing drospirenone may be considered for mild to moderate PMS/PMDD. OCPs have been known to worsen PMS/PMDD symptoms in some cases.
Combined use of fluoxetine (SSRI) and OCPs containing drospirenone may be indicated for women severe PMS
GnRH inhibitors – these medications essentially put women into a type of chemical menopause and are a more dramatic treatment that comes with a number of side effects[26]
If you suffer from PMS or PMDD, it’s important to seek help. For more information on PMS and PMDD, visit The International Association for Premenstrual Disorders.
Explore this article about PMDD from Carol Peterson.
For a deep dive into PMS/PMDD, see the references below.
Important medical disclaimer
The contents of this blog are for informational purposes only and are not a substitute for professional medical advice. None of the recommendations, suggestions, or written information provided is intended to replace a one-on-one relationship with a qualified health care professional. The information presented is not intended to diagnose, treat, cure, or prevent any disease but rather as a sharing of knowledge and information from the research and experience of Jill Chmielewski, RN, BSN. You are encouraged to make your own health care decisions based on your research and partnership with a qualified healthcare professional of your choosing.
References
[1] O’Brien, P. M. S., Backstrom, T., Brown, C., Dennerstein, L., Endicott, J., Epperson, C. N., Eriksson, E.,Freeman, E., Halbreich, U., Ismail, K. M. K., Panay, N., Pearlstein, T., Rapkin, A., Reid, R., Schmidt, P., Steiner, M., Studd, J., & Yonkers, K. (2011). Towards a consensus on diagnostic criteria, measurement and trial design of the premenstrual disorders: The ISPMD Montreal consensus. Archives of Women’s Mental Health, 14(1), 13–21. https://doi.org/10.1007/s00737-010-0201-3
[2] Yen, J.-Y., Lin, H.-C., Lin, P.-C., Liu, T.-L., Long, C.-Y., & Ko, C.-H. (2019). Early- and Late-Luteal-Phase Estrogen and Progesterone Levels of Women with Premenstrual Dysphoric Disorder. International Journal of Environmental Research and Public Health, 16(22). https://doi.org/10.3390/ijerph16224352
[3] De Berardis, D., Serroni, N., Salerno, R. M., & Ferro, F. M. (2007). Treatment of premenstrual dysphoric disorder (PMDD) with a novel formulation of drospirenone and ethinyl estradiol. Therapeutics and Clinical Risk Management, 3(4), 585–590.
[4] Robertson, J. The Confident Clinician Club: PMS/PMDD Lecture. 2022. https://theconfidentclinicianclub.com/
[5] PMDD Research — UNC Center for Women's Mood Disorders. (2016).Med.unc.edu. Retrieved October 15, 2022, from https://www.med.unc.edu/psych/wmd/research/pmdd
[6] Lanza di Scalea, T., & Pearlstein, T. (2019). Premenstrual Dysphoric Disorder. Medical Clinics of North America, 103(4), 613–628. https://doi.org/10.1016/j.mcna.2019.02.007
[7] Gudipally, P. R., & Sharma, G. K. (2020). Premenstrual Syndrome. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK560698/
[8]The International Association for Premenstrual Disorders. Last accessed October 21, 2022.
[9] Fernandez, M. del M., Saulyte, J., Inskip, H. M., & Takkouche, B. (2018). Premenstrual syndrome and alcohol consumption: A systematic review and meta-analysis. BMJ Open, 8(3). https://doi.org/10.1136/bmjopen-2017-019490
[10] Bryant, M., Cassidy, A., Hill, C., Powell, J., Talbot, D., & Dye, L. (2005). Effect of consumption of soy isoflavones on behavioural, somatic and affective symptoms in women with premenstrual syndrome. The British Journal of Nutrition, 93(5), 731–739.
[11] Esmaeilpour, M., Ghasemian, S., & Alizadeh, M. (2019). Diets enriched with whole grains reduce premenstrual syndrome scores in nurses: An open-label parallel randomised controlled trial. The British Journal of Nutrition, 121(9), 992–1001. https://doi.org/10.1017/S0007114519000333
[12] Rosenfeld, R., Livne, D., Nevo, O., Dayan, L., Milloul, V., Lavi, S., & Jacob, G. (2008). Hormonal and volume dysregulation in women with premenstrual syndrome. Hypertension (Dallas, Tex.: 1979), 51(4),1225–1230. https://doi.org/10.1161/HYPERTENSIONAHA.107.107136
[13] Csupor, D., Lantos, T., Hegyi, P., Benkő, R., Viola, R., Gy.ngyi, Z., Cs.csei, P., T.th, B., Vasas, A., M.rta, K., Rost.s, I., Szentesi, A., & Matuz, M. (2019). Vitex agnus-castus in premenstrual syndrome: A meta-analysis of double-blind randomised controlled trials. Complementary Therapies in Medicine, 47,102190. https://doi.org/10.1016/j.ctim.2019.08.024
[14] Thys-Jacons, S. Micronutrients and the Premenstrual Syndrome: The Case for Calcium Pages 220-227 14 Jun 2013. https://doi.org/10.1080/07315724.2000.10718920
[15] Tartagni, M., Cicinelli, M. V., Tartagni, M. V., Alrasheed, H., Matteo, M., Baldini, D., De Salvia, M., Loverro, G., & Montagnani, M. (2016). Vitamin D Supplementation for Premenstrual Syndrome-Related Mood Disorders in Adolescents with Severe Hypovitaminosis D. Journal of Pediatric and Adolescent Gynecology, 29(4), 357–361. https://doi.org/10.1016/j.jpag.2015.12.006
[16] Bahrami, A., Avan, A., Sadeghnia, H. R., Esmaeili, H., Tayefi, M., Ghasemi, F., Nejati Salehkhani, F., Arabpour-Dahoue, M., Rastgar-Moghadam, A., Ferns, G. A., Bahrami-Taghanaki, H., & Ghayour-Mobarhan, M. (2018). High dose vitamin D supplementation can improve menstrual problems, dysmenorrhea, and premenstrual syndrome in adolescents. Gynecological Endocrinology: The Official Journal of the International Society of Gynecological Endocrinology, 34(8), 659–663. https://doi.org/10.1080/09513590.2017.1423466
[17] Jafari, F., Amani, R., & Tarrahi, M. J. (2020). Effect of Zinc Supplementation on Physical and Psychological Symptoms, Biomarkers of Inflammation, Oxidative Stress, and Brain-Derived Neurotrophic Factor in Young Women with Premenstrual Syndrome: A Randomized, Double-Blind, Placebo-Controlled Trial. Biological Trace Element Research, 194(1), 89–95. https://doi.org/10.1007/s12011-019-01757-9
[18] Behboudi-Gandevani, S., Hariri, F.-Z., & Moghaddam-Banaem, L. (2017). The effect of omega 3 fatty acid supplementation on premenstrual syndrome and health-related quality of life: A randomized clinical trial. Journal of Psychosomatic Obstetrics and Gynaecology, 1–7. https://doi.org/10.1080/0167482X.2017.1348496
[19] Tully, L., Humiston, J., & Cash, A. (2020). Oxaloacetate reduces emotional symptoms in premenstrual syndrome (PMS): Results of a placebo-controlled, cross-over clinical trial. Obstetrics & Gynecology Science, 63(2), 195–204. https://doi.org/10.5468/ogs.2020.63.2.195
[20] Abdnezhad, R., Simbar, M., Sheikhan, Z., Mojab, F., & Nasiri, M. (2019). [Salvia officinalis Reduces the Severity of the Premenstrual Syndrome]. Complementary Medicine Research, 26(1), 39–46. https://doi.org/10.1159/000490104
[21] Schmidt, K., Weber, N., Steiner, M., Meyer, N., Dubberke, A., Rutenberg, D., & Hellhammer, J. (2018). A lecithin phosphatidylserine and phosphatidic acid complex (PAS) reduces symptoms of the premenstrual syndrome (PMS): Results of a randomized, placebo-controlled, double-blind clinical trial. Clinical Nutrition ESPEN, 24, 22–30. https://doi.org/10.1016/j.clnesp.2018.01.067
[22] Khalesi, Z. B., Beiranvand, S. P., & Bokaie, M. (2019). Efficacy of Chamomile in the Treatment of Premenstrual Syndrome: A Systematic Review. Journal of Pharmacopuncture, 22(4), 204–209. https://doi.org/10.3831/KPI.2019.22.028
[23] Green LJ, O’Brien PMS, Panay N, Craig M on behalf of the Royal College of Obstetricians and Gynaecologists. Management of premenstrual syndrome. BJOG. 2017;124:e73–105
[24] Weise C, Kaiser G, Janda C, Kues JN, Andersson G, Strahler J, et al. Internet-Based Cognitive-Behavioural Intervention for Women with Premenstrual Dysphoric Disorder: A Randomized Controlled Trial. Psychother Psychosom. 2019;88:16–29.
[25] Carlini SV, Deligiannidis KM. Evidence-Based Treatment of Premenstrual Dysphoric Disorder: A Concise Review. J Clin Psychiatry. 2020 Feb 4;81(2):19ac13071. doi: 10.4088/JCP.19ac13071. PMID: 32023366; PMCID: PMC7716347.
[26] Dilbaz B, Aksan A. Premenstrual syndrome, a common but underrated entity: review of the clinical literature. J Turk Ger Gynecol Assoc. 2021 May 28;22(2):139-148. doi: 10.4274/jtgga.galenos.2021.2020.0133. Epub 2021 Mar 5. PMID: 33663193; PMCID: PMC8187976.