Premenstrual Syndrome (PMS) & PMDD
What is Premenstrual Syndrome (PMS)?
What is premenstrual syndrome or PMS? For something many people can relate to, it’s a medical concern that is actually quite misunderstood. Typically, PMS is defined as a set of symptoms that occur in the luteal phase of our cycle (typically the 14 days from ovulation to when our period begins), and resolve when our period starts. Anyone with ovaries can experience PMS/PMDD.
The symptoms of PMS range greatly, which adds to our challenge of understanding why it occurs.
They may include:
Physical changes
Bloating
Cravings for certain foods
Headaches
Upset stomach
Breast tenderness
Cramping & menstrual pain
Mood Disturbances
Anxiousness
Irritability
Anger
Sadness
Lethargy
Fatigue
A feeling of being out of control
Trouble sleeping or sleeping more than normal
Premenstrual Dysphoric Disorder (PMDD)
PMDD is considered the most severe form of PMS that impairs functioning and quality of life to the greatest degree. This may impact our ability to work, get along with others or complete our education.
What causes PMS/PMDD?
We still don’t fully understand what causes PMS/PMDD, but new theories are emerging.
Estrogen & Progesterone
Previously, it was thought that low progesterone before our cycle may play a role in causing PMS symptoms (progesterone is suppose to be it’s highest during our luteal phase). However, when we give progesterone as a treatment it doesn’t impact PMS/PMDD symptoms, and in PMS/PMDD research progesterone levels have been mixed - either high or low in PMS patients, causing us to leave this theory behind.
Estrogen may play a role, but not in the way that social media wellness would have us think. Our current understanding is that estrogen might be lower than we like before our luteal phase, which sets up a situation in which our brain and nervous system has a harder time dealing with our (normal) but elevated progesterone. Lower estrogen may also cause changes to our brain neurotransmitter signalling, increasing norepinephrine and decreasing serotonin, and dopamine, which may lead to insomnia, fatigue and depression.
Stress Axis & Hormonal Axis
Newer theories of the “why” behind PMS and PMDD continue to point at a connection between our hormonal axis (Hypothalamus Gonadal Axis) and our stress hormone axis (Hypothalamus-Pituitary-Axis). It’s thought there is essentially a marrying of these axis if we are exposed to increased stress, or trauma in our life.
This results in a situation where our hormones (estrogen and progesterone) are normally fluctuating with our menstrual cycle but our body interprets as stressful situation. We also see changes in the levels of allopregnanolne (a brain hormone that is influenced by progesterone) that PMS/PMDD patients have, and their ability to increase these levels appropriately in the face of stress. Allopregnanolne impacts our GABA levels and receptors, another neurotransmitter that is involved in having a calming effect on the nervous system. Essentially, with stress or a history of trauma, our ability to respond to hormonal fluctuations may be different than others, however, we still have a lot to learn about why this happens and to fully understand the mechanisms behind how all these hormones and neurotransmitters overlap.
Serotonin Changes
Serotonin, a neurotransmitter, is involved in creating PMS/PMDD symptom experience. This again, may be due to fluctuating hormones, however we don’t fully understand how or why they influence serotonin. We know serotonin is involved because medications that influence serotonin (like selective serotonin re-uptake inhibitors or SSRIs) can treat and improve PMS symptoms. We have also seen in research that PMS/PMDD patients have lower quantities of serotonin receptors, their serotonin signalling is different than people without PMS/PMDD and the response to serotonin may change across the menstrual cycle.
Calcium Signalling & Changes
Calcium signalling changes across our menstrual cycle and may be altered in those with PMS/PMDD. It’s thought that estrogen may lower our calcium levels, which leads to altered signalling in the brain and decreases serotonin receptors. It’s also been shown that both dietary intake and supplementation can improve PMS/PMDD symptoms.
Inflammation, Immune System Activation, Genetics & Circadian Rhythm
Further theories of why PMS/PMDD occur consider the impact of our immune system (which may cause inflammation), circadian rhythm, and our genetic predisposition. Hopefully we will learn more to support patients in these areas in the future.
Who is at risk of PMS/PMDD?
Anyone who ovulates & has ovaries is at risk of experiencing PMS and PMDD. Other risk factors that have been established include:
Past experience of trauma & anxiety
Experiencing childhood trauma puts us at increased risk for PMDD. We don’t fully understand why this is the case, however experiencing childhood trauma may influence our HPA axis signalling, hormones and inflammatory markers. Anxiety disordered are another risk factor for developing PMS/PMDD, as is competitive sport as a youth, with the risk of PMS increasing with the number of days athletes train and the number of years they compete in their sport.
Cigarette Smoking
Current smokers have an increased risk of PMS, with the likelihood increasing based on how much they smoke, and if they started smoking in their teens. We do not fully understand why!
Weight & Increased BMI
The risk of experiencing PMS increases with elevated body mass index. The higher our BMI increases the higher our likelihood of experiencing PMS.
How do we diagnose PMS/PMDD?
Due the nature of PMS/PMDD and the fact that we understand hormonal levels don’t correlate with the severity of PMS or even it’s likelihood to occur (if we ran hormonal blood work on a bunch of different women, we wouldn’t be able to tell who has PMS based on looking at it), we don’t typically run blood work for this concern. What helps us diagnose PMS is the following:
Tracking symptoms
Often we are asking patients to not only track their cycle, but also which symptoms they experience, how frequently, for how long and how intense these are (or how they disrupt your life!). Tracking symptoms in PMS is important because we know that PMS patients have a harder time recalling symptoms once they have passed (like many health related symptoms!). Therefore this helps us gradually track improvements or exacerbations throughout each month and month to month.
Ruling out other health concerns
Another important part of ensuring we are accurately diagnosing (and therefore treating!) PMS is to ensure that the symptoms patients experience pre-period are not an exacerbation of another mental health concern (like depression, bipolar, panic disorder or personality disorder). For the best care we are often recommending that patients work alongside a practitioner with prescribing rights to mood medications, like an GP or Psychiatrist.
What can I do for my PMS/PMDD?
Despite a lack of information around why PMS occurs, fortunately we have a lot of great options across our lifestyle pillars of health, intentional supplementation, medication options, talk therapy and acupuncture.
To learn more about how we can support you and your well-being book a complimentary 15 minute meet and greet to discuss with one of our Naturopathic Doctors about what makes sense for you.