May is Mental Health Awareness Month, so it’s a great time to talk about…periods. Wondering how the two are connected? Most women experience at least one symptom in the week or so before their periods start, be it bloating, fatigue, etc. But for a very small percentage (3-8%) of women who experience moderate to severe premenstrual syndrome (PMS), along with an even smaller percentage (up to 2%) who have its more extreme cousin, premenstrual dysphoric disorder (PMDD), the time before “that time of the month” can elicit significant, even disastrous, mental health effects. Here, I explain the symptoms of PMDD and compare PMS vs. PMDD. I also show how reproductive hormones like estrogen and progesterone may impact PMS and PMDD. I explain why the ratio of estrogen to progesterone in PMDD sufferers may be more important than the actual number level of either estrogen or progesterone for PMDD treatment.
PMDD symptoms
Both PMS and PMDD symptoms occur during the luteal phase of each ovulatory cycle. They can start after ovulation and last through the first few days of menstruation (your period). According to UptoDate, “The most common symptoms of premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) are fatigue, bloating, irritability, depression, and anxiety.”
The full range of potential PMDD symptoms includes:
- “Sadness, hopelessness, or feelings of worthlessness
- Tension, anxiety, or ‘edginess’
- Variable moods with frequent tearfulness
- Persistent irritability, anger, and conflict with family, coworkers, or friends
- Decreased interest in usual activities
- Difficulty concentrating
- Fatigue, lethargy, or lack of energy
- Changes in appetite, which may include binge eating or craving certain foods
- Excessive sleeping or difficulty sleeping
- Feelings of being overwhelmed or out of control
- Breast tenderness or swelling, headaches, joint or muscle pain, weight gain”
What distinguishes PMS vs. PMDD? Both are considered chronic (because symptoms occur every single cycle). But PMDD is more severe because it is truly debilitating and impairs daily functioning. PMDD is also specifically a depressive disorder, according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) of the American Psychiatric Association.
Ruling out anxiety or depression
Of note, both PMS and PMDD symptoms clear up or resolve after the first few days of a woman’s period. In contrast, UptoDate notes, a woman who has an anxiety disorder or depression may experience an exacerbation, especially of depressive symptoms, during the luteal phase. But she will likely continue to experience those symptoms to a greater or lesser degree every day, regardless of where she is in her cycle.
PMDD vs. PMS, and why hormonal supplementation might help one but not the other
A small 2019 study of Taiwanese women suggested why PMS symptoms may be alleviated through hormonal supplementation whereas premenstrual dysphoric disorder symptoms may not be [1]. In the Taiwan study, 63 women who experienced five or more PMDD symptoms for at least two consecutive months had their estrogen and progesterone levels measured multiple times during the early luteal (EL) phase and the late luteal (LL) phase of one cycle. Their levels were then compared to those of 53 healthy participants.
A Fertility Appreciation Collaborative to Teach the Science (FACTS) analysis summarized the state of research before the Taiwanese study: “[Previous] Studies have shown that estrogen or progesterone supplementation may reduce symptoms of PMS.” Naprotechnology research found that women with PMS symptoms often have low estrogen and progesterone and beta-endorphin levels. According to the Napro website, when patients with PMS receive “either cooperative progesterone replacement therapy or targeted HCG [human chorionic gonadotropin] support (which should also improve both progesterone and estrogen production) and/or with the use of naltrexone as an opiate receptor antagonist, a high degree of success can be obtained with hormonal treatment.”
However, the FACTS analysis noted, “for women diagnosed with PMDD, adding these hormones [via supplementation] has a tendency to exacerbate the symptoms of PMDD” (emphasis added). How can this be?
Estrogen, progesterone, and PMDD
Consistent with previous research, in the Taiwanese study there were no significant differences between progesterone levels during the EL or LL phase in women with PMDD symptoms compared to women without.
But, the FACTS analysis observed, “the PMDD group had statistically significant lower levels of estrogen than the control group throughout both the EL and LL phases.” While the LL phase estrogen levels were only marginally different in women with PMDD symptoms versus those without, “the EL estrogen levels seen in the PMDD group were drastically lower compared to the EL phase estrogen levels of the control group.” What’s more, “Individuals with lower estrogen levels in the EL phase were also noted to have more severe symptoms of PMDD.” Most interestingly, “The individuals with lower estrogen and higher progesterone in the early luteal phase were more vulnerable to severe PMDD symptoms” (emphasis added).
Historically, some restorative reproductive medicine (RRM) providers have focused especially on progesterone supplementation for treatment of PMS and/or PMDD symptoms. But the Taiwanese study results suggest that a more successful PMDD treatment plan should not focus solely on progesterone. A better approach may be to consider and intervene based on the estrogen-progesterone ratio, “as opposed to progesterone or estrogen levels in isolation.”
Does this research apply to all women who have PMS or PMDD?
The 2019 research study had several limitations. The sample size was small. It also didn’t include women with irregular cycles, which affect 14-25% of women, per the National Institutes of Health (NIH).
Also, the timing of each woman’s luteal phase (and her hormone level blood draws) was predicted based on previous menstrual cycle length. It was not verified through biomarkers like cervical mucus observations, basal body temperature (BBT) readings, or other biological data recorded in fertility awareness charting. Several women were excluded from the final research results because bloodwork showed they weren’t actually in their luteal phase after all. Lack of accuracy in identifying the specific phases in women’s cycles has unfortunately historically plagued other research into reproductive hormone levels, not just the Taiwanese study. Future research could be even more informative if women’s cycle phases were more accurately determined through fertility awareness charting.
How might fertility awareness help?
Certainly, cycle charting is not, on its own, a cure or treatment for PMS or PMDD. Johns Hopkins Medicine advocates for numerous lifestyle changes along with “anti-inflammatory medicines” (they don’t specify, but this could mean NSAIDs like Ibuprofen) and either antidepressants (which unfortunately come with the possibility of serious side effects) or hormonal birth control (which can also have significant side effects and deprives women of the health benefits of ovulation). But cycle charting as part of a fertility awareness method could still play a role in PMDD treatment.
When a woman knows her period is approaching, she feels more in control rather than taken by surprise. She can practice cycle syncing to work with, rather than against, the significant hormonal changes her body undergoes. When she knows where she is in her cycle, she can incorporate authentic self-care practices to better cope. And, she can seek out a healthcare provider trained in restorative reproductive medicine (RRM). An RRM provider can use her cycle charting to correctly time hormonal supplementation.
Hopefully, future research into PMS, PMDD, and other women’s health issues will give the nuances of the female cycle the credence they deserve, to the benefit of girls and women everywhere.
References:
[1] Yen, Ju-Yu et al. “Early- and Late-Luteal-Phase Estrogen and Progesterone Levels of Women with Premenstrual Dysphoric Disorder.” International journal of environmental research and public health vol. 16,22 4352. 7 Nov. 2019, doi:10.3390/ijerph16224352Additional Reading:
PMDD: Are women’s periods making them mentally ill?
Cycle mindfulness: what happens when you teach fertility awareness to teen girls
Supplements for PMS symptoms that really work
“Why do I get pre-period bloat?” and other PMS questions answered: a Natural Womanhood PMS FAQ
