Premenstrual Syndrome / Tension (PMS / PMT)

What is Pre-Menstrual Syndrome / Tension (PMS/PMT)?

PMS and PMT refer to the physical and emotional symptoms which occur between ovulation and the onset of the menstrual period.

Unfortunately some women will not experience symptom resolution with the onset of their period and may not experience symptom relief until as late as the third to fifth day after the onset of their period.

How do I know I’m suffering from PMS and not depression?

In PMS, symptoms occur (and, thankfully, resolve) at regular, more or less predictable fixed, points during the monthly menstrual cycle. Frequently patients will tell me they are aware of when they ovulate and often know exactly how soon after ovulation their symptoms will occur: “I know when I have ovulated and then I know when my symptoms are going to arrive………….”

What are some of the common symptoms of PMS?

No two patients have absolutely identical symptoms and, in a given individual, may vary considerably from cycle to cycle. There is a range of symptoms including:

  • Brain and mood symptoms include depression, over-sensitivity, irritability, anger, anxiety, concentration problems, brain fog, and sleep problems.
  • Appetite changes and food cravings include increased desire for sweet, chocolate or salty food, eating binges, increased desire for alcohol.
  • Physical changes may include constipation, headaches, bloating, increased by day, or both, palpitations, joint pains. Fluid retention may cause swollen breasts and swelling of the hands or feet.
  • Hair and Skin may become more oily, acne breakouts may occur.
  • Energy and vitality may drop hugely resulting in fatigue, loss of interest, social withdrawal and loss of libido. Sometimes patients may become super-charged and highly energetic and find themselves doing 18 to 20 hour ironing and cleaning session once a month!

Which women’s age group does PMS most frequently affect?

PMS sufferers are usually women in the 30 to 45-year-old age group. The problem is less common in younger women.

What causes PMS?

  • PMS is hormonal – it is neither a psychological disorder nor a female conspiracy!
    In the past, some doctors both men and even women considered PMS was a feminist-initiated plot for revenge on husbands and boyfriends (!) Thankfully, nowadays we know better.
  • Doctors used to blame low progesterone but rapidly falling oestrogen levels are probably more significant in the majority of PMS sufferers.
    PMS is hormonal and related to an excess, deficiency or imbalance between the hormones oestrogen and progesterone.
  • Rapidly decreasing estrogen levels approaching the monthly period means ‘happy’ body chemicals are present at that time.
    Decreasing estrogen levels coming up to the menstrual period, cause decreased production of endorphin, serotonin and dopamine. In addition, at this time, there is an increase in the enzymes that break the ‘happy’ substances down –hence a double whammy –lower supplies and quicker breakdown of whatever is available. Hence with less up-beat, calming natural substances around it’s no surprise that most women - even the non-PMS sufferers - may feel a bit ‘off’ and anxious in the day or two immediately preceding their menstrual period.
  • Falling estrogen levels may cause anxiety and irritability.
    Falling estrogen levels may set off a burst of nor-adrenaline in the brain activating a fight-or-flight response thus adding to the feelings of irritability and anxiety.
  • Progesterone levels fall steeply just before the bleeding days.
    Falling progesterone levels cause a drop in endorphin levels contributing possibly leading to feelings of depression and irritability.
  • Professor John Studd’s research has shown rapidly falling estrogens rather than rapidly falling progesterone is the most common abnormality.
    There was a vogue for giving all women suffering from PMS progesterone to take but this has not proven effective in may cases and , additionally, many women have reported feeling ‘doped’ and ‘spaced out’ by the inappropriate prescription of progesterone.
    Many women with PMS have normal progesterone on laboratory testing – though there will always be exceptions – hence the importance of carrying out detailed laboratory testing.
    Another clue to the importance of falling estrogens is that many women feel at their absolute worst on the day prior to bleeding and the first day of their bleed –this is the point when oestrogen levels have fallen most sharply.
    Yet another clue to too-rapidly-falling estrogens is that some women may get quite significant night sweats coming up to their period. Therefore, PMS is not always about progesterone deficiency research demonstrates it is not an open-and-closed case. The best solution is: check the hormone levels in the laboratory and then a logical solution is possible. Test and then treat what you find - not what you think might be the problem.

How can PMS be treated?

Investigation of PMS

A full medical history including a menstrual history is critical and, usually, will be helpful in raising suspicions of a hormonal deficiency or imbalance. At a minimum, check oestrogen and progesterone levels during the menstrual cycle on day 1 to 3 and again on day 18 to 21. Checking FSH on day 1-3 is helpful to exclude early ovarian failure. I also like to measure the testosterone level, the thyroid hormones, and will sometimes include adrenal salivary testing.

Treatment of PMS

Treat based on the medical history and the blood test results.
Do not just presume that it is an estrogenic deficiency or progesterone. Pay attention to the thyroid and adrenals, also.
Prof John Studd in the UK used oestrogen supplementation with some excellent patient outcomes and there are studies to prove it.

If progesterone levels are low after ovulation then it makes sense to boost progesterone levels.

If there is a low oestrogen level and relatively normal post-ovulation progesterone thus creating a reduced estrogen to progesterone ratio then it makes sense to boost oestrogen levels as a first step. This may apply especially to women who begin to experience PMS soon after mid –cycle just as they have ovulated and when estrogen levels are falling fast and progesterone are actually rising.
Sometimes a useful clue to falling oestrogen levels is the complaint of night sweats and/ or a dry vagina resulting in discomfort during intercourse.

Bio-identical hormones are now available to treat PMS.
Nowadays with the increasing availability of bio-identical hormones, it is possible to balance hormones with treatments, which are biologically identical to those present in a human female’s body usually applied in a cream form thus avoiding the hazards, which may be associated with the use of oral synthetic hormonal preparations.

Other Important Considerations in PMS Treatment

Treat the whole patient:
Treat any vitamin (e.g. B6) mineral (e.g. magnesium) or hormonal problems (e.g. weak adrenals) which may be present.
Is the liver o.k.? The liver which ‘balances’ estrogen and progesterone may need nutritional support.
Make sure that the patient’s bowels and digestive system are functioning well.
Assess brain / neurotransmitter balance if necessary.
I do not prescribe antidepressants for PMS, since my view, PMS this is primarily a hormone-related problem.
I do not advocate the use of antidepressants in the treatment of PMS since the problem is primarily hormonal.

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Veronica (Dublin 14)