What is PMS and PMDD?

Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) are conditions that affect many women, causing a range of physical and emotional symptoms in the days or weeks leading up to menstruation. This can range from a few niggly symptoms that pop up every month to a complete change in who you know yourself to be that feels uncontrollable and fundamentally disruptive to your life.

The difference between PMS and PMDD

PMS and PMDD are both related conditions characterised by cyclic symptoms that occur during the luteal phase of your menstrual cycle (luteal phase is after ovulation and before menstruation). 

PMS is much more common and typically involves mild to moderate symptoms.

PMDD is a more severe form, affecting a smaller percentage of women. PMDD symptoms are often debilitating and can significantly impact daily functioning and quality of life. 

Both conditions share similarities in symptoms, but PMDD is distinguished by the severity and duration of symptoms.

Why does it happen?

TLDR (If you don't want to get too technical, here are the main points)
‍Progesterone is an important hormone in the luteal phase of the menstrual cycle for helping you feel calm and stable. 
If progesterone is deficient it can bring on premenstrual symptoms
Some women have an abnormal response to normal hormonal fluctuations, which can drive PMDD

Through the whole phase of the menstrual cycle, hormones are fluctuating dramatically to bring on or support what is occurring in each phase. The fluctuations are normal but how women respond differs a lot and this can cause an onset of symptoms in the menstrual cycle.

Progesterone and Allopregnanolone

Progesterone is one of the primary female sex hormones. It steadily rises from ovulation (the production of progesterone is triggered by ovulation) and peaks in the middle of the luteal phase, dropping off at menstruation. Progesterone is a very potent hormone in the brain. 

Allopregnanolone is a neurosteroid which is a metabolite of progesterone (made from progesterone). It has potent effects on the central nervous system. Allopregnanolone is very calming and stabilising to the brain. 

Alterations in progesterone and allopregnanolone levels may contribute to changes in neurotransmitter activity, including gamma-aminobutyric acid (GABA), which plays a key role in anxiety and mood regulation and can increase susceptibility to PMS or PMDD. 

The reason you may lack progesterone (and therefore allopregnanolone) is: 

• Hormonal birth control (combination pills or progesterone only pills contain progestin, synthetic progesterone which does not have the calming effect on the brain, but also doesn't allow your body to make its own progesterone). Read more on the Oral Contraceptive Pill here
• Lack of ovulation
• Polycystic ovarian syndrome (PCOS) - impacts ovulation and therefore progesterone production
• Perimenopause and menopause - both naturally low progesterone states
• Stress
• Deficiency 
• Excessive exercise 
• Obesity 
• Thyroid disorders

Other women may have normal levels of hormones but have an abnormal response to the natural fluctuations of these hormones, which can bring about changes in the brain leading to PMS or PMDD. It is often found that PMDD is more often associated with this sensitivity to hormonal fluctuations than those with PMS. 

Why does this occur:

• Stress/grief/trauma
• Inability to cope with stress in the luteal phase
• Sensitivity to neurosteroids
• Structural or functional differences in the brain like an increased amygdala response
• Altered serotonergic activity
• Increased neural sensitivity to normal allopregnanolone
• Fluctuation abnormalities in GABA–A receptor plasticity

Other contributing factors can be:

• Genetic predispositions to PMS or PMDD
• Environmental factors like stress, poor diet, lack of exercise, and inadequate sleep
• Psychosocial factors such as stress, trauma, and negative life events
• Pre Existing neurotransmitter imbalances such as serotonin, dopamine and GABA
• Inflammation and immune dysregulation is emerging in research suggesting a potential link between immune activation and symptom severity.

Common symptoms 

Physical symptoms

• Bloating
• Breast tenderness
• Headaches
• Fatigue
• Weight gain or fluid retention
• Joint or muscle pain 
• Changes in appetite

Emotional symptoms 

• Mood swings
• Irritability
• Anxiety
• Depression
• Tearful
• Sadness
• Confusion
• Brain fog
• Difficulty concentrating 

Behavioural changes 

• Food cravings
• Social withdrawals
• Disruptions in sleep and insomnia

If you tick one of those boxes, usually in the more physical category you likely suffer from Premenstrual Syndrome (PMS). If you tick more than 5 on that list, especially more severe emotional and psychological symptoms that affect your daily functioning and relationships, it is more likely you're suffering from PMDD. 

Also, if the onset of menstruation relieves symptoms—even if you start to get an onset of new symptoms like period pain—then the change in hormones that bring on menstruation should relieve premenstrual symptoms. 

PME Premensutral exacerbation 

Another option is PME, which is an exacerbation of existing conditions during the premenstrual phase. Say you have arthritis, you might find this gets worse the week or 2 before your period, this is not PMS or PMDD, and the treatment of those won’t improve your condition. 

Same with depression, if you are suffering from depression and it gets worse during this time, again, this is more likely not PMS or PMDD.

This doesn't exclude you from perhaps having both PME and PMS or PMDD. This will be up to your practitioner to help you determine.

How you can try to distinguish this for yourself is asking yourself 
Do I have symptoms that come up every month before your period that you don’t experience anywhere else in your cycle? 
Do I have symptoms that get a lot worse during this phase?

Some Points to Note 

Testing 

There is no specific test you can take to diagnose you with these conditions. You can test your hormones using a blood test (cheaper, easier, more subjective) or a dried urine test (more expensive, more accurate, more data) but this is not going to tell you distinctly if you do or do not suffer from PMS or PMDD. As far as testing neurotransmitters, this can only be done through a spinal tap, and no one will ever do this in practice! Trust me, you wouldn’t want to either! 

Your symptoms are the best determiner. Therefore, sitting down with a trained and experienced naturopath to help identify key symptoms and patterns that illustrate PMS or PMDD is much more helpful.

It is also these symptoms that we will track to identify if you're responding to treatment, so important to get a really good base line.

Start tracking your cycle

Your symptoms are really important in helping us determine your condition, the severity of it and then monitoring how you improve in response to treatment. I believe every woman should track their cycle (more importantly if they are having a natural cycle without hormonal intervention from the Pill, IUD etc.). This is because your symptoms throughout the cycle tell you so much about how your body as a whole is functioning. It is information that is too vital not to pay attention to. Even if you don’t know how to use that information yourself, this is information that you can share with your practitioner(s) to inform treatment direction.

Your symptoms throughout the cycle tell you so much about how your body as a whole is functioning

Period pain is not a sign of PMS

A common misconception is that period pain is a sign of PMS. A painful menstrual bleed is another thing entirely! However you can experience bloating, cramping and abdominal pain leading up to your period that is a symptom of PMS or PMDD.

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So what do I do?

Here's where the good news comes in: you do not have to feel this way! 

So many women I see both professionally and in my personal life think that the symptoms leading up to their period are ‘normal’ or ‘something they just have to deal with’, but trust me, they’re not! There are so many wonderful solutions available.

A word of caution: Every woman's reason for suffering these symptoms are unique, and it can be a delicate art treating it. Therefore I would always recommend seeking professional support in the form of a degree-qualified Naturopath so they can determine the root cause and monitor you closely during treatment. There are a lot of over the counter products that claim to help with PMS, and some might. But mostly you might be missing the boat for what you actually need. The herbs to help ‘balance hormones’ (a broadly-used term that doesn't actually say anything) are powerful and hormones are very sensitive, so if you get the herb wrong, it could exacerbate your symptoms.

When you come to see one of the team here, your treatment plan will include:

Support for stress and modulating the stress response in the body: this might include herbal medicine or nutritional supplements and perhaps stress-reduction techniques or a referral to a counsellor/psychologist. 

Nutritional support that could include treatment using iron, magnesium, calcium, B6, iodine, zinc, Vit D, E or C and/or essential fatty acids, all have been shown to help manage PMS and PMDD. (You won’t be prescribed all of these, they are some of the options!)

Herbal medicines that are powerful in helping to support hormonal imbalances or deficiencies, the brain's response to hormonal fluctuations and stress and adrenal support including Chaste Tree (Vitex Agnus-Chaste), Withania, St John's Wort, Saffron and Turmeric are all excellent options depending on what your needs are.

Nutritional guidance to reduce aggravators like caffeine, alcohol, processed foods, damaged fats, refined sugar and emphasise protein intake, healthy fat consumption and getting plenty of fruits, vegetables and whole grains. 

Lifestyle suggestions such as regular exercise (even if all you feel like doing is watching reality TV), stress management techniques such as yoga and meditation and getting adequate and healthy sleep. As well as mind-body practices like acupuncture and aromatherapy to promote relaxation.

PMS and PMDD are not treated the same

For PMS we focus primarily on ovulation, possible hormonal and nutritional deficiencies that could be contributing, and of course factors that can contribute to these, like stress.

For PMDD it is much more about primarily treating the stress response in the body and the underlying cause to a higher sensitivity to hormonal change.

For PME, we treat the primary condition that is worsened during pre-menstruation.

Important to note

It is ok to feel a degree of ‘change’ in your body leading up to your period and during your period. There are a lot of hormonal shifts, and this can make you feel more withdrawn, less social, more sleepy, lower libido, more hungry etc.. This is because evolutionarily the body is prepared for a possible conception during this phase. As opposed to the opposite side of your menstrual cycle, the follicular phase where evolutionary biology is prioritising you reproducing! So you are feeling more energetic, less hungry, high libido, more social etc.. Where this switches into a condition that requires treatment is if these symptoms are unpleasant and starting to affect your day-to-day life. 

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