PMS & PMDD

Articles

11 Sept

Premenstrual syndrome (PMS) consists of a variety of symptoms that take place during the luteal phase of the menstrual cycle (the time between ovulation and onset of menstruation, from approx. day 15 until your period starts).

What is PMS?

It’s called a syndrome because it has a variety of different symptoms that vary from person to person in type and severity. Symptoms include (but are not limited to) irritability, low mood, breast pain, spots, bloating, food cravings, fatigue, sleep problems, headaches and brain fog.

Most women experience physical and emotional changes leading up to their periods but around 20% of women experience PMS severe enough to disrupt their daily activities. As common as it is, these symptoms can be managed, and in a lot of cases, cured.

Four sub-types of PMS have been identified:

PMS-A (anxiety) – related to high oestrogen and low progesterone. Symptoms are irritability and anxiety.

PMS-C (cravings) – blood glucose imbalance, hypoglycaemia and magnesium deficiency. Symptoms include increased appetite and sugar cravings.

PMS-D (depression) – low oestrogen:progesterone ratio and imbalances in neurotransmitters (e.g. low serotonin). Symptoms include depression, insomnia, forgetfulness, confusion, withdrawal.

PMS-H (hyperhydration) – water retention, excess salt intake, excess oestrogen, stress, magnesium deficiency. Symptoms include weight gain, bloating, swelling of hands and feet, breast tenderness.

It is possible to have a combination of the above sub-types.

What is PMDD?

PMDD stands for premenstrual dysphoric disorder and is similar to PMS but with more severe symptoms. Symptoms include anger, irritability, anxiety, panic attacks, depression, suicidal thoughts, fatigue, cravings, binge eating, insomnia, mood swings, headaches and migraines. PMDD affects up to 10% of women.

What causes PMS?

The exact cause is uncertain (possibly because medical issues in women have historically been under-researched and possibly because of the nature of syndromes, that there are multiple things that feed into it and there are so many variations in symptoms). But the most accepted reason is that it’s caused by a hormone imbalance, likely a surplus of oestrogen and insufficiency of progesterone.

Mood disorders in PMS have also been linked to oestrogen-serotonin regulation. According to research studies, decreased oestrogen triggers the hypothalamus to release noradrenaline which triggers a drop in acetylcholine, dopamine and serotonin that leads to insomnia, fatigue, depression, common symptoms of PMS and PMDD. This goes some way to explaining some of the symptoms of PMS, and it could be one reason why some people get cravings for sugary foods - when we eat sweet foods, the brain’s reward system gets activated and releases dopamine. It also explains the sleep issues – serotonin is a precursor to melatonin which we need to help us to fall asleep. Without sufficient serotonin and melatonin, we can experience problems falling asleep and staying asleep.

Another contributor to PMS is inflammation. Chronic inflammation is a problem in a couple of ways – it impairs the production of progesterone and gamma-aminobutyric acid (GABA – a neurotransmitter which produces a calming effect), and it affects the responsiveness of progesterone receptors on our cells (the progesterone sensitivity mentioned earlier). Inflammation also interferes with oestrogen detoxification and the result is oestrogen dominance, where oestrogen is too high in relation to progesterone.

What causes PMDD?

As with PMS, the exact causes are largely unknown, but fluctuating levels of oestrogen, progesterone and serotonin is the most accepted cause. Some other possible factors that contribute to PMDD include genetics, pre-existing mood disorder, smoking, trauma and stress.

How does oestrogen cause PMS and PMDD?

Normal levels of oestrogen are good for us, but problems arise when levels are too high. When oestrogen is too high, or too high in relation to progesterone, this is called oestrogen dominance and can result in PMS symptoms. Too much oestrogen can cause breast pain, irritability, headaches and fluid retention. A drop in oestrogen can also cause symptoms. From the beginning of our cycles, oestrogen rises, and peaks just before ovulation when it then drops, and progesterone rises. This drop in oestrogen can cause fatigue, night sweats and migraines. The reduction in oestrogen also reduces dopamine and serotonin (for the reasons explained above), causing low mood, fatigue, lack of concentration and sleep issues. Oestrogen dominance can be caused by over production of oestrogen, not enough progesterone (causing an imbalance in the oestrogen:progesterone ratio), or impaired metabolism and/or elimination of oestrogen (meaning that oestrogen is recirculating around the body).x

How does progesterone cause PMS and PMDD?

Progesterone is the sister hormone to oestrogen. It counterbalances the effects of oestrogen and converts to a substance called allopregnanolone which enhances GABA, and this has a calming, anti-depressant, pro-sleep influence on the brain. However, the problem arises when we’re not making enough progesterone, if levels drop away too quickly or if we have an altered sensitivity to progesterone (meaning that our cells aren’t as responsive to progesterone as they should be). If any of these issues are present, then low mood symptoms may occur (along with other symptoms such as premenstrual bleeding/spotting and prolonged or heavy periods).

Does histamine have an effect on PMS/PMDD?

Histamine is a stimulating neurotransmitter. It fluctuates with the monthly cycle because it’s influenced by oestrogen and progesterone. Histamine is released from mast cells within the body, and signs of high histamine (mast cell activation) include irritability, anxiety, insomnia, brain fog, headaches, breast pain, hives, nasal congestion, joint pain, fluid retention, nausea and period pain. A lot of these symptoms cross over with PMS which indicates a link between histamine and PMS. Histamine reaches its peak just before ovulation and during the luteal phase. One way to see if you have a histamine issue is to take an over-the-counter antihistamine when you have symptoms. If it helps then histamine could be a problem for you, and you can look at natural ways of reducing histamine to improve your symptoms (see below).

How do I get a diagnosis of PMS?

If you want a diagnosis and/or want medical help with your PMS or PMDD, it’s best to keep a daily diary of your symptoms for two or three cycles and take this to your GP. Include any emotional and physical symptoms and keep the diary every day throughout the whole of your cycle. If you have any extra data such as temperatures or you use ovulation predictor kits, record this information on your diary too so that your doctor can work out your date of ovulation. This is important because PMS and PMDD are diagnosed based on a prominence of symptoms being in the luteal phase of your cycle. They also look for an absence of symptoms when your period starts, or very soon after.

Other conditions will be ruled out (such as depression, hypothyroidism, anaemia, IBS and endometriosis). When these have been ruled out, and you have demonstrated that your symptoms are affecting your day-to-day life, then your doctor will diagnose you and offer various treatment options.

Click here to download a daily record of severity of problems sheet which can be used to track your symptoms and cycle to take with you to the doctor.

How do I get a diagnosis of PMDD?

As with PMS, it’s best to keep a daily diary of symptoms for two or three cycles and take it to your GP. Again, the GP will be looking to see if symptoms are concentrated in the luteal phase of your cycle.

A doctor will diagnose PMDD if a woman suffers from at least five out of 11 psychological symptoms, one of which must include mood. The 11 symptoms are:

1) Mood swings, suddenly feeling sad, increased sensitivity to rejection

2) Irritability or anger or increased interpersonal conflicts

3) Depressed mood, feelings of hopelessness, self-deprecating thoughts

4) Anxiety, tension, or feeling on edge

5) Less interest in usual activities

6) Difficulty concentrating

7) Lethargy, fatigue, lack of energy

8) Change in appetite, overeating or food cravings

9) Hypersomnia or insomnia

10) Feeling overwhelmed or out of control

11) Physical symptoms e.g. breast tenderness, joint pain, bloating, weight gain.

These symptoms must be present during the luteal phase and improve within a few days after the onset of menses.

How is PMS and PMDD treated?

All women should be offered lifestyle advice by their GP, including advice on diet, smoking, exercise, alcohol, sleep, stress reduction. Depending on the severity of symptoms, the doctor may prescribe pain relief, cognitive behavioural therapy or the oral contraceptive pill (if not wishing to start a family). For more severe symptoms, an anti-depressant (selective serotonin reuptake inhibitor or SSRI) may be prescribed.

Women should be reviewed by their doctor after 2 months of treatment and referral to a specialist clinic may be considered if symptoms are not improving.

Are anti-depressants an effective treatment for PMS and PMDD?

SSRI’s will address the lack of serotonin which causes low mood issues in PMS and PMDD. The issue though is that it’s a sticking plaster which is treating the symptoms but not the cause. SSRI’s won’t affect your oestrogen or progesterone levels and so if you decide to come off them, your symptoms may return exactly as before.

Is the oral contraceptive pill an effective treatment for PMS and PMDD?

Hormonal birth control (oral contraceptive pill, implant or IUD/coil) usually is effective in treating the symptoms of PMS and PMDD because it stops ovulation and therefore stops the natural fluctuation of our hormones. But by suppressing ovulation with a synthetic hormone, it prevents the release of natural progesterone and that means we can’t benefit from the protective actions of progesterone on other areas of the body such as brain and bone health. As with anti-depressants, if you stop taking hormonal birth control, your symptoms may return, until you address the root cause.

Can nutrition and lifestyle changes help PMS and PMDD?

Yes! There is a lot that we can do to regulate our hormones and reduce the symptoms of PMS and PMDD with nutrition and lifestyle, including supporting the production of progesterone, supporting and metabolising oestrogen and reducing histamine activity…

Support progesterone:

1. Reduce inflammation

Reduce inflammatory foods like sugar, wheat, cow’s milk, processed vegetable oils. Chronic inflammation suppresses ovulation and therefore progesterone too. Inflammation also decreases the sensitivity of progesterone receptors in our cells. Cow’s dairy can be significant for PMS, possibly because it can also trigger the release of histamine. Anti-inflammatory foods include turmeric, ginger, garlic, extra virgin olive oil, oily fish, leafy green veg, berries, green tea, nuts, whole grains, tomatoes. Try to eat these every day and include as much variety as possible in your diet.

2. Reduce alcohol

Alcohol reduces allopregnanolone, reduces progesterone’s soothing effect, and can worsen histamine intolerance.

3. Reduce stress

Stress can worsen PMS. Adrenaline blocks progesterone receptors, and over a long period of time, chronic stress affects ovulation, depleting progesterone.

4. Exercise

Exercise helps to reduce stress and inflammation, thereby contributing to an improvement of PMS symptoms.

5. Eat foods that support progesterone production.

o Leafy dark green veg, herbs, nuts, seeds – contain magnesium which is needed to make progesterone.

o Whole grains – a good source of B vitamins

o Fish, organ meat, potatoes, squash - a good source of vitamin B6

o Beef, shellfish, lentils, eggs – a good source of zinc

o Bell peppers, strawberries, citrus fruits - a good source of vitamin C

6. Supplements

o Magnesium – needed for the manufacture of progesterone, also reduces inflammation and helps to regulate the stress response.

o Vitamin B6 – needed for manufacture of progesterone, reduces inflammation, helps with oestrogen detoxification, helps histamine intolerance.

o Agnus Castus (Vitex / Chasteberry)* – this has been found in scientific trials to be a safe treatment for PMS. It inhibits prolactin and enhances ovulation and therefore progesterone. Don’t take for more than 6 months consecutively and don’t take if you are under 18.

Support and Metabolise Oestrogen:

1. Eat cruciferous vegetables

Cruciferous vegetables such as broccoli, cauliflower, cabbage, brussels sprouts, kale contain compounds (including sulforaphane, indole-3-carbinol and 3,3′-Diindolylmethane (DIM)) that help the liver to metabolise oestrogen. Broccoli sprouts are even better – they contain up to 100 times the amount of compounds as normal broccoli.

2. Reduce alcohol

Reduce the burden on your liver to improve the metabolism of oestrogen.

3. Maintain a healthy weight

Body fat produces oestrogen which contributes to overall oestrogen levels.

4. Avoid endocrine disrupting chemicals

Some pesticides, some plastics (such as BPA), PFAs (used in non-stick coatings), flame retardants and other chemicals have been found to have hormone disrupting effects. They can impair the metabolism of oestrogen and have an oestrogenic effect in the body (these are known as xenoestrogens).

5. Improve gut health

Gut health and a healthy microbiome is incredibly important in assisting the excretion of oestrogen after it has been used in the body. Studies have found that harmful bacteria can deconjugate oestrogen (oestrogen that has been metabolised and conjugated ready for excretion) and this leads to the oestrogens being reabsorbed into the bloodstream.

6. Eat phytoestrogens

Phytoestrogens are plants which may have a mild oestrogenic effect. They are believed to be beneficial in cases of oestrogen dominance because they bind to oestrogen receptors and exert a mild oestrogenic effect, buffering you from the stronger circulating oestrogen. There is still some debate about this mechanism of action however studies have also shown that they improve oestrogen metabolism. Phytoestrogenic foods include soy (e.g. organic tofu, edamame beans), and flax seeds.

7. Reduce inflammation

Chronic inflammation interferes with hormone production and communication, so by reducing inflammation it can help to regulate the balance between oestrogen and progesterone.

Reduce Histamine:

1. Reduce mast cell stimulating foods such as alcohol and cow’s dairy.

2. Reduce histamine-containing foods such as red wine, cheese, avocado, tomato, bone broth, and fermented foods (including sauerkraut and kombucha)

3. Reduce inflammation (inflammation activates mast cell activity which releases histamine).

4. Consider taking a histamine-reducing supplement* such as quercetin, magnesium or vitamin B6

*Note: please note that some supplements have interactions with medicines and other supplements. Please only use supplements under the care of a nutritional or medical practitioner. Your practitioner will advise on which supplements (and doses) to take based on your individual history.

References

https://www.ncbi.nlm.nih.gov/books/NBK560698

https://cks.nice.org.uk/topics/premenstrual-syndrome/#!diagnosis

https://www.mind.org.uk/information-support/types-of-mental-health-problems/premenstrual-dysphoric-disorder-pmdd/about-pmdd/

https://www.ncbi.nlm.nih.gov/books/NBK279045/table/premenstrual-syndrom.table1diag/

https://www.aafp.org/pubs/afp/issues/2011/1015/p918.html

https://www.sciencedirect.com/science/article/pii/S2451965022000187

https://onlinelibrary.wiley.com/doi/10.1155/2017/4595016

https://europepmc.org/article/med/6684167

https://www.larabriden.com/period-repair-manual/

https://www.larabriden.com/histamine-intolerance-pms-pmdd/

https://www.ncbi.nlm.nih.gov/books/NBK558960/