Spotlight on PMS

Many women will have experienced the classic symptoms of irritability, tearfulness and

sometimes abject rage that can descend as quickly as a passing tropical rainstorm for

seemingly no reason, only for the tell-tale signs of the start of a period to arrive and explain

all. The mental symptoms of the premenstrual syndrome (PMS), as well as the physical ones

such as bloating and breast tenderness, are common, but for most women are an

unpleasant but manageable nuisance. However, for some, the symptoms can be so

debilitating that they have a serious impact on their ability to function normally; to work, be

productive at school and to have a fulfilling family and social life. When PMS is severe in this

way, it is referred to as premenstrual dysphoric disorder (PMDD).

How common is PMS and PMDD?

Some symptoms leading up to the period are very common but when it is severe enough to

have a considerable impact on women’s lives, it is estimated to affect up to 8% of women,

but it may be much more common than this. Women may not appreciate the cyclical

nature of the ‘black cloud’ coming and going with their periods with so much else going on

in their busy lives, or they may simply accept it as part of womanhood and so never seek

help.

How do I know if I have it?

Symptoms typically start in the week before your period, getting worse the closer it gets and

improving as the bleeding starts. It can sometimes be difficult to put your finger on this

pattern unless you have given it some real thought, so if you do seem to be having

significant ups and downs, it would be worth starting a menstrual diary and noting down the

timing of your period and when your symptoms occur.

If you have mood symptoms that are continuous throughout the month, then you may be

suffering from anxiety or depression rather than PMS. Having said that, if you have already

been diagnosed with a mood disorder but have also noticed that your symptoms are worse

pre-menstrually, this could be PMS exacerbating your mental health.

PMS tends to start in your twenties, although it can worsen as you get older. If you have

never experienced these symptoms and then you start developing them anew in your 40s

and 50s, then it is more likely to be the perimenopause rather than PMS.

Symptom checker:

• Mood symptoms

• Physical symptoms

• Mood swings

• Bloating

• Sudden sadness

• Fatigue

• Increased sensitivity to rejection

• Breast tenderness

• Anger Headaches

• Irritability

• Hot flashes

• Difficulty concentrating

• Dizziness

• Depressed mood

• Back pain

• Self-critical thoughts

• Muscle aches

• Anxiety

• Joint pains

• Food cravings

• Water retention

What causes PMS?

It happens because of the abnormal response some women have to the normal changes in

levels of oestrogen and progesterone toward the latter half of the menstrual cycle. This

then impacts the level of the ‘feel good’ chemicals in our brain, namely serotonin. We don’t

know why some women have this abnormal response while others don’t.

How can you manage your symptoms?

Sometimes just being aware that you aren’t going mad and that there is a reason for your

symptoms is comforting enough to many women. If you have regular periods, you may be

able to predict when you will be feeling more fragile and adjust your lifestyle accordingly if

your symptoms are mild. If your symptoms are more severe there are still lots of things you

can try before reaching for the prescription pad.

One of the findings from studies in women with PMS is that they have lower serotonin levels

in the second half of their cycles compared to women without PMS. Levels of serotonin can

be boosted naturally with exercise. It may feel hard to motivate yourself to exercise pre-

menstrually, especially as one of the symptoms of PMS is fatigue but pushing yourself to

increase your heart rate (ideally outside in nature) will boost your serotonin levels and in

turn help improve your mood and the physical symptoms of PMS. There is also evidence

that relaxation techniques such as meditation can be beneficial.

Many studies have shown that women naturally increase their intake of carbohydrates in

the premenstrual period, so you are not alone in reaching for that chocolate bar. However,

try not to overdo the junk food as it can actually make your symptoms worse. Salty foods

and caffeine can make the physical symptoms in particular worse, whilst there is some

evidence that a diet rich in omega 3 fatty acids, calcium and vitamin D can help.

There are lots of vitamins and supplements that have been studied to assess their benefit

for PMS. Unfortunately, the results have not been conclusive; some studies show no benefit

whilst others show an improvement (although that could be just because of a placebo

effect). These include supplements such a vitamin B6, vitamin E, calcium and magnesium.

The one supplement that has some evidence behind it is Vitex agnus castus extract from the

chaste tree, so called as it was thought to suppress sexual desire in monks in the middles

ages. It does seem well tolerated and safe but as with all unregulated products, it is difficult

to know if what they say is in the pill is actually in it, at the dose they say and that it doesn’t

contain anything else. But it certainly seems promising; hopefully a drug company takes

note and produces something we can trust.

How we can help you manage your symptoms?

With severe PMS or PMDD, changing your lifestyle alone is unlikely to be enough, so we

have 2 main treatment options we can try: either we can boost your serotonin levels in the

2nd half of your cycle or prevent the natural up and down changes of your hormones during

your menstrual cycle.

The first option involves using a type of antidepressant, which increases the amount of

serotonin in your brain. These can be effective when taken only in the 7-14 days before

your period, but some women will prefer the convenience of taking them continuously,

which may also help more with physical symptoms. If you are already on this type of

medication but notice you have PMS symptoms overlying, you can simply increase your

dose in the 2 weeks before your period and then go back to your normal dose afterwards.

The second option involves using hormonal contraception to turn off your hormonal cycles

by taking the combined oral contraceptive pill. It can be taken in the traditional way with a

week break between packets, but some women will find this doesn’t improve their

symptoms sufficiently, in which case it is advisable to take it continuously, without the 1-

week break (do get advice from your doctor on how to do this correctly). Not having regular

bleeds whilst taking the pill continuously is completely safe and means you might be less

affected by the changes in your hormone levels.

Some women, particularly those with the most severe form of PMS, PMDD, will benefit from

seeing a psychologist or counsellor for cognitive behavioural therapy. Studies have shown

that women with PMDD receiving CBT have less anxiety and depression as well as improved

coping skills. It can be used alone but with severe symptoms, it works well together with

medical treatments.