PMS & PMDD

What are Pre-Menstrual Syndrome and Premenstrual Dysphoric Disorder?

Most women ovulating monthly experience some physical and mood symptoms during the premenstrual phase. Medically significant premenstrual syndrome (PMS) is apparent when at least one moderate to severe physical and psychological symptom occurs during the premenstrual phase. [1].

PMDD is a much more severe condition. The diagnosis is defined by the USA psychiatric association and excludes other mood disorders, such as bipolar disorder. The UK use the terms “PMS” and “Severe PMS.”

There seems to be three main elements to help us understand PMS

• The Brain – areas that control mood are very sensitive to the menstrual cycle. Part of this is likely to be genetic. The “PMS-brain” seems to “like” oestrogen but typically dislikes many synthetic progestins (synthetic forms of the natural hormone, progesterone) as found in oral contraceptive pills or contraceptive rods and injections (e.g. Implanon or Depot-Provera). The synthetic progestins can actually aggravate the mood causing depression and irritability. 
• The ovarian cycle – an ovulatory cycle is required for PMS. Thus, women who suffer from PMS or PMDD typically feel good when pregnant or breast-feeding (which suppress ovulation); although they do appear to be vulnerable to post-natal depression.  PMS typically becomes worse as women age. Part of this is due to cycle variability increasing with age. For example, the oestrogen level peaks around ovulation. A 20 year old woman’s peak oestradiol (E2, the main human oestrogen) level might fluctuate between 800-1,000 pmol/l; in contrast to a 45 year old where the peak E2 may fluctuate between 500 to 5,000 pmol/l from one month to the next.
• The “Black Box” – this represents everything else. Any stressful event can greatly aggravate PMS.

Diagnosis of PMS & Premenstrual Dysphoric Disorder

The criteria for PMD have been clearly stated by the American College of Obstetrics and Gynaecology as follows [1]:

1. More than one of the following mood and physical symptoms during the five days before menses, over at least 3 menstrual cycles:

2. Symptoms should be relieved within 4 days of onset of menses, and don’t return until at least day 13 of the cycle (Day 1 of the cycle is the first day of bleeding.)

Premenstrual dysphoric disorder (PMDD) is a more severe form of PMS. In this condition the main symptoms are psychological. Premenstrual symptoms typically worsen after the mid-30s and some women notice their problems were triggered by an episode of postnatal depression.

A. Symptoms – timing 

In the majority of menstrual cycles, at least 5 symptoms must be present in the final week before the onset of menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week after menses

B. Symptoms – one of more of the following must be present

• Marked mood swings, feeling suddenly sad or tearful, or increased sensitivity to rejection (marked affective lability).
• Marked irritability or anger or increased interpersonal conflicts.
• Markedly depressed mood, feelings of hopelessness, or self-deprecating thoughts.
• Marked anxiety, tension and/or feelings of being keyed up or on edge.

C. Additionally, one of more of the following must be present to reach a total of 5 symptoms (including the symptoms above)

• Decreased interest in usual activities.
• Subjective difficulty in concentration.
• Lethargy, easy fatigability, or marked lack of energy.
• Marked change in appetite; overeating or specific food cravings.
• Hypersomnia or insomnia (sleeping too much or unable to sleep).
• A sense of being overwhelmed or out of control.
• Physical symptoms such as breast tenderness or swelling; joint or muscle pain, a sensation of “bloating” or weight gain.

D. Severity

The symptoms are associated with significant distress or interference with work, school, usual social activities, or relationships with others.

Other conditions often mistaken for PMDD

PMD / PMDD can easily be confused with bipolar disorder (a different mood disorder where mood fluctuates between bouts of depression and mania). It is important to keep in mind that mood disorders such as depression and physical problems such as migraine can swing with the cycle too.
It is very useful to track your symptoms to take to your doctor. This can be done very easily with a menstrual app or  you can download this chart. The key to the diagnosis of both PMS and PMDD is that the physical and psychological symptoms come and go at the same time of the menstrual cycle.

PMS Symptoms – what you need to know

These aspects of PMS are well known [2]:

• The symptoms are present in regularly ovulating women.
• The symptoms do not occur if you are not ovulating (e.g. prepubertal girls, during pregnancy or after menopause).
• Treatment is available. Medications that increase serotonin in the brain are immediately effective treatment for PMS.
• Women who already suffer from depression or anxiety often find that their symptoms worsen in the pre-menstrual phase (pre-existing mood disorder).
• Women who suffer from mood disorders, including PMS often find that progestins such as Provera® make their symptoms worse.

How are PMS and PMDD treated?

Natural Therapies

It is important to remember that not all herbal extracts are the same. Some herbal products sold in Australia have no or little quality control (which determines the effective dose of a remedy) or scientific studies.

However, some natural therapies do have scientific studies showing that they work better than a placebo (dummy tablet):

• Premular®  is an extract of the berries from the chaste tree (also called Agnus castus) sold in Australia by Flordis. It is made by a Swiss company, Zeller, who produce a number of high quality, tested herbals. At least two clinical trials have shown that Premular 1 tab daily is better than a dummy tablet for cyclical physical symptoms such as headache and breast pain, as well as psychological symptoms of PMS / PMDD.
• Vitamin B6 in doses of 50-100 mg daily. Very high doses of B6 can cause nerve damage, especially in the hands and feet, so don’t take more than 100mg daily.
• Elemental Calcium up to 1,200mg per day and Elemental Magnesium up to 400mg daily.  “Elemental” is a key word here. Some products may state that they contain 500mg Calcium ascorbate, but when you read the fine print, it usually states that this is equivalent to 100mg elemental calcium. Higher doses of magnesium can have a laxative effect. High dose calcium can cause constipation.
• Evening Primrose oil 3000 mg daily. More helpful for cyclical breast pain than for mood swings.
• A bee pollen extract call Femal has been shown in clinical trials to be helpful for PMS (not available in Australia).

Lifestyle changes

Many women find that the following lifestyle changes can really help improve their PMS:

• Vigorous exercise
• A diet low in salt and high in fruit and vegetables
• Relaxation therapies such as meditation
• Seeing a counsellor or psychologist for strategies to cope with the symptoms

Drug therapies

Serotonin Re-uptake Inhibitors (SSRI)

The most tested and clinically proven drugs for severe PMS and PMDD are the modern antidepressants called “SSRIs”. When used for depression they take 2 to 4 weeks to work. When used to treat PMS they only take 2 days to work. So if a woman has significant PMS symptoms from days 21-28 of her cycle, then she needs only to take the drugs from days 19 and stop it when she starts a period. The most tested SSRI for PMS is Fluoxetine (Prozac®, Lovan®). The main side effects are headaches and nausea which tend to occur with the first 2-3 doses and then rapidly improve with time.

In Australia, Fluoxetine comes in a capsule or dissolving tablet form. It can be helpful to start with very low doses such as a ¼ tablet daily from day 12 of the cycle until the first day of menses, then stop. One way of dosing a ¼ tablet is to drop ½ dissolvable Fluoxetine in a 30ml cup and drink half and discard the other half. Alternatively, the medication can be taken daily. The most common side effects include nausea, headache, trouble sleeping. These often disappear over time.

Zoladex® and Synarel®
Zoladex® is a monthly injection and Synarel® is a nasal system (the drug is sniffed twice a day). Started day 1-3 of the cycle, over 1-2 months, these reversibly suppress the cycle. They act like a reversible menopause, and so if used alone, hot flushes, vaginal dryness etc can occur. They are typically given for six months to help control pain due to endometriosis. Zoladex® is also used long-term to treat some hormone dependent cancers such as breast or prostate cancer.
Sometimes these can be used with a low dose of natural oestrogen and progesterone (called “add-back therapy” in this situation), to give a woman with PMDD a “menstrual holiday.” This can be very helpful as part of a strategy to help women with very severe symptoms such as premenstrual anger, rage or having suicidal thoughts.
A trial of Zoladex® / Synarel® with add-back hormones can be helpful as a “trial-run” for a woman considering removal of uterus, tubes and ovaries to cure her PMDD. A trial of these drugs can also confirm the diagnosis of PMDD. If a 3-6 month course of treatment completely resolves the symptoms, then the diagnosis is PMDD, however, if the symptoms continue a different mood disorder should be investigated.

Progesterone – newer pills or IUD

Some women find that the modern pills such as Yaz® can help. The Mirena® device contains a progestin but the blood levels are 100-1,000 times lower than tablets and so unpleasant mood side-effects are far less common. However, many women with severe PMDD find that they can’t even tolerate a Mirena® device.

Progesterone is often recommended for PMS, but clinical trials have failed to show any benefit over placebo. Synthetic progestins (e.g. Provera®, Primolut®) can make PMS worse and should be avoided. The older contraceptive pills such as Nordette® and Triphasil® usually make the symptoms of PMS worse. 

Some British authors suggest trying a 100mcg Oestradiol patch used continuously with natural progesterone (Prometrium®) used orally or vaginally in the second half of the cycle. This can result in irregular bleeding and some women suffer mood swings even with oral natural progesterone.

PMDD Surgical treatments

Removal of the uterus / hysterectomy does not improve PMDD. It is the ovarian cycle that triggers the mood centre of the brain and so if the ovaries are left behind, then the PMS will continue after the hysterectomy. However, if a woman with severe PMDD is going to have a hysterectomy, then discussion with your surgeon should include removing the ovaries and giving back some natural oestrogen (as an implant, patch or gel) to prevent menopausal symptoms and long-term problems such as osteoporosis.

Surgery should be considered a last resort because:

• It is a surgical procedure requiring a full anaesthetic and so carries the risks associated with pelvic surgery and having a general anaesthetic.
• This surgery means you are permanently infertile.
• If oestrogen is not given to a woman under the age of 40-45 years with surgically induced menopause (meaning ovaries at least are removed), there is likely an increased risk of heart disease, osteoporosis and perhaps some neurological diseases. As such oestrogen replacement (as a tablet, get, patch or implant) is usually recommended at least to the age of 50 years or older.

Approximately 20-30 years ago around 40% of women had a hysterectomy, often for heavy periods or problems such as endometriosis. With better medical options (Mirena device, contraceptive pills etc) the current hysterectomy rate is around 3-4% of women.

Most gynaecological surgeons are reluctant to remove both ovaries without a very clear indication and often only after a second opinion that agrees the removal of both ovaries is appropriate. So, if you are seeking definitive surgical cure of your PMDD when you see your gynaecologist, don’t be upset if they delay or suggest a “cooling off period,” or a trial of Zoladex (perhaps with low dose HRT) or suggest another opinion. It is very reasonable to be cautious. Once the surgery has been performed the results are permanent.

Final thoughts
PMDD continues to be a little-known area of medicine. Part of the problem is that PMDD “falls” in between endocrinology, gynaecology and psychiatry. There has been a improvement in diagnosis and management in the last decade. The best starting point is to track your symptoms with a menstrual app or a chart then show the charts to your GP and seek out a specialist, likely a gynaecologist (some endocrinologists, psychologists, psychiatrists will be helpful too) to help.

References:

• [1] ACOG Practice Bulletin 2000; 15:1-9.
• [2] Rapkin A, Mikacich J. Premenstrual syndrome: gynaecology or psychiatry? Reproductive Medicine Review, 2001; 9: (3), 223-239

More Information:

If you’d like more information you can view health information fact sheets on our Health Information page, such as:

• Herbal Medicines
• Reproductive Services