PMS & PMDD

What is PMS & PMDD?

Premenstrual syndrome (PMS) is a common, recurrent condition affecting those who experience a menstrual cycle. It’s most often categorized by psychological and physical symptoms that occur during the luteal (post ovulatory) phase of the menstrual cycle. 

Those with more severe symptoms are classified as having a related condition called PMDD, or premenstrual dysphoric disorder, a type of depressive disorder categorized by the Diagnostic and Statistical Manual of Mental Disorders.

75% of people who menstruate are affected by premenstrual symptoms, which includes physical and mental health effects, with around 8% of them experiencing severe pain and disruption.

3-8% of people who menstruate are diagnosed with PMDD, which is a condition focused mainly on mental health effects experienced in the second half of the cycle (luteal phase) leading up to menstruation, with physical effects being secondary.

Causes

  • Mast cells are a type of immune cell that release prostaglandins, inflammatory cytokines, and histamine. Mast cell activation and the subsequent release of histamine cause symptoms that overlap with PMS including irritability, insomnia, breast tenderness, and migraines. Estrogen has two major peaks in the cycle, once before ovulation and once during the luteal phase (see below). Estrogen stimulates mast cells which release histamine and stops DAO enzymes from clearing histamine. Histamine also stimulates the ovaries to make more estrogen which can result in a feedback loop. Progesterone reduces histamine. This may link healthy estrogen metabolism and proper progesterone levels in the luteal phase to reducing PMS symptoms.

  • Premenstrual mood symptoms are the result of neurosteroid change sensitivity, or altered sensitivity of GABA receptors to allopregnanolone (the metabolite made from progesterone). This means those who suffer from PMDD have more sensitivity to the changes of progesterone that normally occur in the luteal phase. So it’ not that the menstrual cycle hormones are imbalanced, but that the body reacts in a more extreme way to the normal fluctuations. This altered sensitivity of the GABA receptors is considered a key physiological driver of PMDD symptoms and the behavioral effects of them. Typically progesterone has a positive effect on mood because its metabolite, allopregnanolone, calms GABA receptors in the brain. For some reason with PMDD, allopregnanolone in its normal levels can produce intense mood symptoms.

  • Prolactin is a hormone made by the pituitary gland that causes the breasts to grow and make milk during pregnancy and after birth. Levels are normally low for non-pregnant people. Prolactin is also androgenic, because it increases the adrenal based androgen DHEAS. High prolactin has been linked to premenstrual mood symptoms.

  • Mineral deficiencies in magnesium, zinc, and b vitamins, especially b6, can cause severe menstrual mood issues. They help synthesize hormones, help manufacture brain neurotransmitters like GABA, dopamine, and serotonin, lower prolactin, promote anti-inflammatory compounds, help you metabolize estrogen properly, and lower histamine levels. 

PMDD Symptoms

  1. Markedly depressed mood, feelings of hopelessness, or self-deprecating thoughts

  2. Marked anxiety, tension, feelings of being “keyed up” or “on edge”

  3. Marked affective lability (e.g., feeling suddenly sad or tearful or increased sensitivity to rejection)

  4. Persistent and marked anger or irritability or increased interpersonal conflicts

  5. Decreased interest in usual activities (e.g., work, school, friends, hobbies)

  6. Subjective sense of difficulty in concentrating

  7. Lethargy, easy fatiguability, or marked lack of energy

  8. Marked change in appetite, overeating, or specific food cravings

  9. Hypersomnia or insomnia

  10. A subjective sense of being overwhelmed or out of control

  11. Other physical symptoms, such as breast tenderness or swelling, headaches, joint or muscle pain, a sensation of “bloating,” or weight gain

Diagnosis

PMDD diagnostic criteria is outlined in the Diagnostic and Statistic Manual of Mental Disorders. In it, PMDD is a "depressive disorder not otherwise specified," emphasizing emotional and cognitive behavioral symptoms.

The criteria states that

  • At least 5 of 11 symptoms (DRSP below) must be present for a diagnosis.

  • Symptoms should be limited to the post ovulatory, luteal phase

  • Symptoms should not amplify pre-existing depression, anxiety, or personality disorder

  • Symptoms should subside during the follicular phase of the menstrual cycle

  • These symptoms must present for two consecutive menstrual cycles

The Difference Between PMS and PMDD

  • PMDD symptoms are severe and last for 7-14 days before menstruation

  • PMDD causes full episodes of uncontrollable emotion that damages relationships at work, home, and otherwise

  • PMDD causes those suffering from it to rearrange their lives to accommodate their condition

  • PMDD can manifest itself in extreme anxiety and suicidal thoughts

  • PMDD is focused on mental health changes whereas PMS is all encompassing of physical and mental changes before menstruation

Treatment

  • Stabilize GABA receptors & progesterone levels by supplementing with magnesium glycinate and vitamin b6.

  • Herbal antidepressants include St. John’s Wort, Common Mugwort, Rosemary, Lemon balm, Lavender, Motherwort, and Valerian.

    Make sure you read about drug interactions and contraindications for these herbs before use.

  • Reduce premenstrual symptoms with omega 6 fatty acids and vitex herb which calms and stabilizes progesterone.

  • Work on the liver and gut pathways to strengthen estrogen metabolism. Iodine promotes healthy estrogen metabolism by down-regulating estrogen receptors and stabilizing estrogen sensitive tissue. If you want to up your dosage of iodine or have thyroid issues, please pair it with selenium and read about the risks of excess iodine.

  • Body-identical progesterone is a solid treatment for the luteal phase by stabilizing progesterone levels.  Progesterone is called oral micronized progesterone and requires a doctor’s prescription, however, you can still purchase progesterone cream made from wild yams over the counter. Aim for 200 mg per day. Dosage is important to getting the right effects from progesterone capsules or creams, too low or too high may be aggravating, so keep notes about your usage.

  • Reduce inflammatory foods like sugar, gluten, Holstein conventional cows dairy, and other histamine containing foods to avoid the effects of insulin resistance and histamine intolerance

    Take magnesium and zinc to reduce inflammation.

  • Start to ritualize the premenstrual phase in preparation for menstruation. This may include modified exercise, periods of rest, eating more, and being more socially introverted.

    Focus on foods rich in nutrients, mainly seafood, organ meats, egg yolks, grass fed butter and seaweed, mushrooms, and leafy greens.

How Charting Helps with PMS & PMDD

Learning to chart your cycle with fertility awareness increases your skill of body literacy. In turn, it helps you engage in cycle-based self care that helps you understand and respond to the symptoms of PMDD and other menstrual issues you may be dealing with. 

Turning the menstrual cycle into four quadrants and tracking your hormones estrogen and progesterone with basal body temperature and cervical fluid observations can give you key insights to the root cause of your individual presentation of PMS or PMDD. 

    • no cervical fluid, or very little wet fluid at all

    • cervical fluid present every day of the cycle

    • menstrual bleeds that are scanty and like spotting

    • menstrual bleeds that are heavy, dark, with large clots

    • breast pain

    • fibroids, ovarian cysts

    • no thermal shift (no ovulation)

    • weak/ambiguous thermal shift

    • temperatures that straddle the coverline

    • post-ovulatory phases that are less than 10 days long

    • irritability and mood swings

    • diet and food triggers

    • alcohol consumption

    • energy levelsmoods (as basic as happy face sad face will do!)bowel movements and bloating

    • any other kind of chronic pain like migraines or depressive episodes

PMDD is a serious but rare condition

  • Only a small minority of people who menstruate fit the criteria for PMDD which requires medical support

  • The vast majority of people who menstruate can utilize the strategies above to treat their PMS successfully and improve their experience of menstruation by reducing menstrual related symptoms in just 3-6 months

  • PMDD is not to be used to argue that the menstrual cycle is a form of illness or that all people who experience a menstrual cycle are diseased and inferior

  • Recognizing our culture of menstrual stigma and countering the myth of the irrational female is important to distinguishing the way PMS is described and managed today

Questions About This Condition Remain

  • In 2000, the FDA approved four different drugs to treat PMDD, except the condition did not yet exist. Two years earlier in 1998, the FDA met privately with Eli Lilly, as their most famous antidepressant Prozac (fluoxetine) was about to expire. Eli Lilly determined independent of the American Psychiatric Association that PMDD was a distinct clinical disorder and that SSRI’s such as Prozac were effective treatments.

    "The pharma industry went out trying to promote the condition so that more women self-presented with this disorder and consequently, put pressure on doctors to prescribe medications for them," said Saddichha Sahoo, MD, a psychiatrist at Ipswich Hospital in Brisbane, Australia, who wrote a paper about disease mongering in psychiatry, which included PMDD.

    Eli Lilly changed the capsule color from green and yellow to pink and purple, and rebranded it Sarafem. Sarafem was FDA approved in 2002 and in the years immediately after, Zoloft (sertraline), Paxil (paroxetine) and the birth control pill Yaz (drospirenone/ethinyl estradiol) all won approvals for treating PMDD.

  • Similarly, treatment guidelines to help doctors decide how to treat PMDD were issued before the condition was recognized as an official psychiatric disorder.

    Typically such guidelines, which can be influential, are issued by medical societies or other groups. In this case, the 2006 guidelines were issued by a small group of researchers and were paid for by GlaxoSmithKline -- the maker of Paxil. The guidelines proclaimed antidepressants "the treatment of choice" for PMDD.

    PMDD wouldn’t be declared a distinct psychiatric condition until 2013, when a panel of the American Psychiatric Association panel decided it was. However, 70% of the panel had direct ties to drug companies. By 2013, the demand had grown because of pharmaceutical sponsored marketing.

    In contrast, Sarah Gehlert PHD ran a study in Illinois and Missouri and found that only 1.3% of premenopausal people have PMDD, so around 1 million in the USA, not the 6 million officially reported. "We did become convinced that some women had PMDD," Gehlert said, "but we could also see that it had the potential to harm women if it became a quick-and-dirty diagnosis."

  • “Over the past thirty years, clinical descriptions of PMS have remained predominantly psychological in focus, especially since the inclusion of premenstrual disorders in the American Psychiatric Association’s DSM (Diagnostic and Statistical Manual of mental disorders). First in the form of Late Luteal Phase Dysphoric Disorder (LLPDD) in 1987, and later its replacement, Premenstrual Dysphoric Disorder (PMDD), since 1994 (American Psychiatric Association 2000). 

    Even reputable clinical sources sometimes refer to PMDD as ‘severe PMS’; implying that PMS is simply a less severe form of a mental health disorder (for example, Lopez, Kaptein, and Helmerhorst 2012; Maharaj and Trevino 2015; Naheed et al. 2017). In comparison, thyroid conditions, which are also ‘hormonal’ in origin and commonly cause severe mood changes, are not listed in the DSM” said Sally King.


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