Menstruation

PMS and PMDD — natural solutions

by Marcy Holmes, NP, Certified Menopause Clinician

Here are the topics covered in this article:

• Diagnosing symptoms of PMS and PMDD
• What your PMS or PMDD is trying to tell you
• Progesterone and PMS treatment
• The hormone sensitive brain
• A diet for PMS and PMDD
• Exercise and PMS
• Emotional stress and PMS
• PMS relief begins with you

It’s a rare patient at Women to Women who hasn’t experienced some symptoms of PMS; in general, the pain, bloating, food cravings, fatigue, moodiness, and sleep irregularities that many women feel at the onset of their monthly period are so common that feeling “hormonal” is a widely accepted state. It’s estimated that 12–25 million women of reproductive age in the US describe themselves as having premenstrual syndrome. Women resign themselves to feeling terrible during that time of the month, thinking it’s just the luck of the draw. But this isn’t an outlook that serves us. Chronic symptoms of PMS — or its more serious counterpart, PMDD (premenstrual dysphoric disorder) — are not normal and may indicate a larger imbalance going on in the body.

At our medical practice, we’ve been listening to women with PMS and PMDD for years, long before these “disorders” became officially recognized as diagnoses. We know that PMS and PMDD symptoms are all too real and all too debilitating for some. Moreover, they may also be an indicator of how your body will react to perimenopause and menopause — another good reason to pay attention now. Our 20-plus years of experience in functional medicine have verified that there is simply no reason for any woman to suffer from PMS or PMDD. No matter how severe your symptoms are, you can find natural, permanent relief and set the stage for a healthy, balanced future.

So let’s learn more about the cyclical nature of PMS and PMDD and the many things you can do to support hormonal balance every day of the month, and for all the years to come.

Diagnosing symptoms of PMS and PMDD

Most women feel slightly fatigued, tense, or emotionally low the week before menstruation — with the emphasis on slightly. It’s when premenstrual symptoms begin to worsen or disrupt your personal life, work or self-confidence that it could be time to take a closer look at what’s really going on. Patients often tell me that they feel out of control right before their periods — as though they are on an emotional and physical rollercoaster with devastating dips into fatigue, pain, anger, and depression. Some women are completely disabled each cycle by PMS, while others with more moderate symptoms hold out as best they can, knowing the ride will be over in a few days.

Either way, this is no way to live, even if it’s only for a few days. Many women who turn to their medical practitioners for help leave empty-handed because their symptoms don’t merit an official diagnosis. The good news is that PMS and PMDD treatment are finally getting some respect in the conventional medical world — the bad news is that their narrow definitions leave many women out in the cold, and many others facing the years ahead on prescription drugs.

According to the American College of Obstetricians and Gynecologists (ACOG) and the American Psychiatric Association (APA), a menstrual disorder can’t be officially “diagnosed” unless it interferes with some aspect of a woman’s life — whether it’s school, work, or family. In other words, it’s the level of disruption and discomfort that delineates so-called normal premenstrual symptoms from premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD). So it’s official now — suffering isn’t normal.

Recently, PMS and PMDD became official diagnoses, as established by the ACOG and the APA, respectively. But their diagnosis is somewhat complicated. For instance, a diagnosis of PMS has multiple requirements — at least one out of 10 different symptoms must occur during the five days before your period for three consecutive cycles; the symptom/s must go away by day 4 of the cycle and not resume until day 13 (day 1 being the first day of your period); and the symptoms must clearly disrupt your social or economic performance. Once you’ve relayed your symptom/s to your practitioner, he or she has to be able to record them for two additional cycles — and the symptoms must also be noted in the absence of any form of drug or hormone therapy.

For some women, having a clear diagnosis can be a relief. Others may question how well being labeled serves them. At Women to Women, we recognize a far wider range of cyclical symptoms, physical and psychological — whether or not they precisely mirror the above diagnostic criteria. (See our list of PMS symptoms.)

We understand that even mild symptoms can be the first slip down a slope to persistent hormonal imbalance, and that a wise woman will heed her body’s call on the first few rings. We encourage women to pay attention to any patterns that worsen or linger. And whether you feel you are “functionally impaired” by PMS or not, it can be useful to chart your symptoms for a few months to get a clear understanding of your individual tendencies.

More severe PMS cases are now being categorized as premenstrual dysphoric disorder (PMDD). From the diagnostic criteria for PMDD outlined below, it’s clear to see how it could easily be confused with other depressive disorders. What sets it apart is that it occurs for a finite length of time each month — crashing down on you before your period and lifting when you start to bleed. It is diagnosed when five of the following symptoms, including at least one of the core symptoms, have occurred in the week prior to a woman’s period for most of the previous year.

Core symptoms of PMDD

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

Other symptoms of PMDD

• Decreased interest in usual activities, e.g., work, school, friends, hobbies
• Difficulty concentrating
• Marked fatigue
• Marked change in appetite, overeating or cravings for specific foods
• Hypersomnia or insomnia
• Feeling overwhelmed or out of control
• Physical symptoms, including headaches, breast tenderness and/or swelling, joint and/or muscle pain, a sensation of “bloating,” and weight gain

If you experience any of the above on a regular basis, your body may be struggling with some core imbalances that deserve care and attention. Instead of looking at PMS or PMDD as a kind of body-snatcher, consider the notion that it’s a truth serum — one that tells you where you and your body really live, without the whitewash of hormones. By this, I mean — among other things — the state of your hormones, neurotransmitters, metabolism, and detoxification capabilities, all of which interact and influence your ability to cope with emotional stress.

What your PMS or PMDD is trying to tell you

Though premenstrual symptoms can be disruptive to the flow of our normal lives, there is a hidden power in these disruptions. Symptoms of PMS have multiple causes in each woman, but they are united in their ability to call a woman to action. This is the blessing in PMS. The more severe your symptoms, the more inspired you may be to pay closer attention. If you feel overwrought, anguished or frustrated in those days before your period, ask yourself why? What in your life isn’t working for you?

I heard one expert, who advocated the concept of a hormonal link to PMS in the 1970’s — long before it became widely accepted — explain that at this time of the month a woman’s hormones give her the courage to speak her truth — no matter how aggressive or unsettling it may be to others. Having the ability to convey our truth is powerful medicine, but if PMS sabotages the delivery with anger and upset, the important message can get lost in translation.

So don’t be afraid of who you are when you are in the grip of PMS. Understand that this is your starting point — the place where you begin to really know yourself and your vulnerabilities. It’s where you begin to help yourself.

Because PMS can be a preview of what lies ahead in perimenopause and menopause, it’s important to tune in to your symptoms and the lessons they serve early on. Learning how to support your body naturally during this time, on both the emotional and physical level, will mean an easier transition later on. And in looking at your individual health picture and your lifestyle, you may begin to see where the seeds of your PMS lie.

Progesterone and PMS treatment

Every woman has a natural, individualized ratio of estrogen and progesterone that surges and recedes to make up her unique menstrual cycle. Uncomfortable hormonal symptoms like those that appear right before your period are usually the result of some kind of disruption in this ratio. In some women, estrogen levels may be slightly high while progesterone levels are adequate; in others, estrogen levels may be normal but progesterone levels are deficient, and symptoms can simply occur if progesterone levels are lower than her body requires.

Conventional doctors often suggest temporary use of the birth control pill as a cheap quick fix, but this is not our first-line approach — unless a woman truly desires to be on the Pill for contraception. A more sustainable approach is one that normalizes progesterone levels naturally. This effect can be achieved with a phytotherapeutic formulation such as our Herbal Equilibrium, which contains passionflower, chasteberry, Ashwagandha and wild yam, herbs known to gently support the progestogenic pathways and alleviate the symptoms of PMS.

We may first try a low-dose bioidentical progesterone cream, or, if symptoms are more intense, a form of prescription-strength bioidentical progesterone. Options include custom-compounded formulas, as well as brand name natural progesterone products such as Prometrium capsules. Some women may require up to 400 mg daily, spread out over course of the day during the luteal phase or PMS time of the month. But not all women respond equally, and it may take much higher doses to implement change when symptoms are more entrenched.

Why does phytoprogestogenic supplementation work? In the brain, natural progesterone often has a calming, mood stabilizing effect — exactly opposite the effect seen with synthetic progestins commonly found in HRT and oral contraceptive pills. Researchers describe botanical sources of progesterone as modulating the brain’s response to amino acid neurotransmitters that help regulate mood, sleep, cravings and so on. Without getting into too much detail, progesterone has a natural hypnotic, “anesthetizing” effect mediated through its breakdown products, and a natural anxiolytic (anxiety-dissolving) effect by down-regulating the brain’s GABA receptors. This is like Valium — except good for you.

Ideally, when women use phytotherapy in combination with optimal diet and lifestyle changes, the ratio of estrogen to progesterone eventually evens out, the devastating peaks and troughs of premenstrual symptoms even out, and supplementation is no longer needed.

Additionally, targeting neurotransmitter support in the form of supplemental amino acids can be an effective way to treat PMS naturally. This is an excellent option for women who, for whatever reason, don’t find full relief in phytotherapy.

The hormone sensitive brain

A deeper understanding of brain chemistry and the influences of reproductive hormones on our neurotransmitters has led me to appreciate that a subset of women exists whose brains are more hormonally sensitive. These women describe more severe physical and emotional distress premenstrually, as well as during other periods of hormonal fluctuation, such as post partum and perimenopause.

Keep in mind endocrine glands within the brain function as master endocrine regulators, sending dominant messages to the other hormone factories in our bodies. Female hormones circulating in the body travel back to the brain to provide feedback. In some premenstrual women, this otherwise normal and minor flux of crosstalk disrupts the function of neurotransmitters such as serotonin in the brain — interfering with mood and causing more pronounced symptoms. So, just as there is a recognized “migraine brain,” there is also the “PMS or PMDD brain.”

This realization within the conventional medical community has led to a surge in prescriptions for antidepressants to treat premenstrual syndrome. In fact, there is now a renamed, repackaged form of Prozac called Sarafem for PMDD, marketed directly to women suffering from these symptoms.

While antidepressants may be prescribed as a bridge treatment in some of the most severe cases of PMS or PMDD, I prefer to use cutting-edge natural methods that support neurotransmitter health and reduce PMS, PMDD and general mood disorders. I offer these patients urine neurotransmitter testing and blood or salivary hormone testing. This gives us a guide to make recommendations for a more natural approach to balance. For more information on repleting your neurotransmitters naturally, see our page on advanced treatment measures for severe PMS and PMDD.

When a woman with PMS has widely fluctuating hormones, she can often smooth things out with either or both bioidentical progesterone and targeted neurotransmitter support. But the fundamental place to start for women with PMS is through nutrition and diet. Women who are mindful of our nutritional and lifestyle guidelines can create natural hormonal balance and see amazing improvement in their premenstrual symptoms.

A diet for PMS and PMDD

Many of us don’t realize how dramatically diet and lifestyle can affect our hormonal balance. Our culture bombards us with processed food, sugar and designer coffee and it’s hard to resist these things until something goes awry. One of the first indications that your diet is falling short of your body’s needs is worsening symptoms of PMS.

Commonsense dietary and nutritional changes, such as taking a good multivitamin-mineral supplement and lowering sugar, salt, alcohol, and caffeine have proven successful for many women. One researcher linked an excess of these substances with depleted levels of magnesium in the body, and found that magnesium supplementation reduced bloating, fluid retention, and breast tenderness in premenstrual women. Another study on over 450 women concluded that calcium supplementation also significantly lowered premenstrual symptoms.

In addition, your hormones and metabolism are interdependent. A diet high in simple carbohydrates and sugars can influence your insulin sensitivity, leading to insulin resistance and weight gain. Fat cells produce estrogen, so the more you have, the higher your levels of estrogen, which in turn can throw off your natural hormonal balance and exacerbate PMS.

When dealing with PMS and PMDD, it is also important to consider what you may be missing. Even the healthiest eater could be lacking specific nutrients, particularly during times of stress or hormonal fluctuations. And even someone who considers herself active may not be doing enough exercise to reap its benefits.

Exercise and PMS

Regular aerobic exercise can help ease premenstrual symptoms. During the luteal phase of our cycles (i.e., the second half), endorphin levels in the blood and brain drop. Endorphins are opioid (painkilling), euphoria-producing chemicals produced naturally in our brains and released in high quantities during certain activities, such as orgasm. We can also increase our body’s production of endorphins and other natural analgesics by increasing our heart rate and oxygen exchange through regular aerobic exercise. Studies have shown that consistent exercise reduces symptoms of PMS, possibly by boosting levels of dopamine as well as endorphins, and — like natural progesterone — enhancing GABA activity.

Exercise likewise boosts our detoxification capabilities, pumping up the cleansing action of the lymph system and ridding our body of toxins and excess hormones through sweat. In addition, exercise increases our metabolic rate, encouraging the body to burn fat for energy, thereby assisting us to maintain a healthier hormonal balance.

These days, with so many women working sedentary jobs, driving everywhere, and too maxed-out to find time for exercise, it’s easy to overlook the fact that we’re biologically preprogrammed to move our bodies — not just a little, but a lot! Our biochemistry needs activity to stay fit, just like our muscles do.

Emotional stress and PMS

When you feel stressed out, your levels of cortisol and adrenaline — those “fight or flight” hormones — surge. Chronic stress leads to chronically high levels of these hormones, which result in depleted adrenal glands and fatigue. Most of the time, our bodies compensate for this depletion by relying on stimulants that trigger the central nervous system (like caffeine and nicotine), or on other hormones (like insulin) to maintain blood sugar and neurotransmitter levels. This explains why women often have strong PMS cravings for sugary treats — and why so many over-the-counter preparations for PMS contain caffeine.

When our reproductive hormones begin to shift, either in PMS or in perimenopause, the body’s ability to compensate is temporarily compromised. How you feel premenstrually shows you how well your body and mind are coping with stress. If you have symptoms, one of the best things you can do is begin to honestly address your emotional health — and this includes unresolved issues from the past — your “story.”

PMS relief begins with you

At Women to Women, our approach to PMS is one that is individualized to the patient, with many layers. It takes into account all of the above as it applies to the woman’s unique health picture. Similarly, we recommend that you work with a trusted healthcare practitioner to define areas where you need supplemental support and guidance. Together you can take charge of the root causes of imbalance and build a foundation of health that will see you through all of life’s stressors without uncomfortable symptoms.

If you are already on prescription antidepressants or mood stabilizing medications for PMS or PMDD, you may be able to get off them — but do so under a medical provider’s care. Your body’s chemistry changes when you are on them, and you can have severe symptoms such as anxiety, headaches, or chest pain if you stop them abruptly. We recommend you consult your prescribing doctor before making any changes in or discontinuing your medications, but you can certainly add fundamental nutritional and lifestyle support measures as we’ve discussed to enhance your progress. If you choose to order the online Personal Program for added support, call to speak with our Nurse–Educators for one-to-one guidance.

Start slowly at first with these natural remedies for PMS, and keep track of your symptoms. If you don’t respond to the initial steps outlined in, you may want to investigate more advanced measures for treating PMS and PMDD.

• Track your symptoms along with your menstrual cycle, now and as you move forward on implementing various other measures described below. Observe the progress you make as months pass and identify any obstacles. This information can be extremely useful for you and your healthcare provider.

• Get a complete physical exam and request time to discuss your PMS. Ask for basic hormone testing to be sure your thyroid function is good and that you’re not experiencing premature menopause, anemia, or an electrolyte imbalance.

• Eat a balanced diet rich in whole foods, nonstarchy vegetables, and healthy proteins and fats. Embrace fruit daily as a healthy desert choice instead of sweets. Be sure to eat regular meals and snacks throughout the day to support balanced blood sugar, which helps mood. For more detailed information, refer to our nutritional and lifestyle guidelines.

• Take a potent multivitamin–mineral formula daily like that offered in our Personal Program. Usually the best supplements require more than one tablet or dose per day to get optimal amounts. Vitamin E and the B-complex vitamins can really make an impact.

• Supplement with EPA/DHA from a fish oil source, as this provides the most clinically effective form of omega–3 fatty acids (compared to flax oil and other plant-derived sources). Anywhere from 1000–3000 mg daily can be considered.

• Try a high-quality calcium and magnesium supplement. We often recommend a ratio of calcium citrate to magnesium glycinate of 2:1 for women in general, but if your premenstrual symptoms are severe, you may want to try 1:1. (Remember, you also need adequate stores of vitamin D to efficiently process these minerals.)

• Try phytotherapy like our Herbal Equilibrium. The passion flower, chasteberry, Ashwagandha and wild yam in this formulation have been shown to alleviate the symptoms of PMS in multiple research studies.

• Acupuncture can be very effective in relieving pain from monthly cramping. It can also help with detoxification.

• Allow time for rest before your period. Honor your vulnerabilities and don’t overschedule or push through this time. If your body is telling you to hibernate or slow down, listen. This alone may help your symptoms.

• Investigate methods for dealing with unresolved issues from the past, and better coping strategies for present-day demands and relationship issues. Look at patterns of behavior that may need to change to create better emotional health. Consider the many avenues available, including psychotherapy, counseling, shamanic journeying, neuro-emotional technique, and Emotional Freedom Technique, based on what speaks to you.

If you are not responding to any of the above measures, consider evaluation of your hormones by blood levels or salivary panels, as well as urine neurotransmitter analysis. This testing should be done at the time of the month when you are most symptomatic. We use a saliva test for basic testing at Women to Women, with the understanding that it only provides us a snapshot of a woman’s hormonal balance at a certain point in time — not the whole story. For more information on testing, see our article on severe PMS and PMDD treatments.

You don’t have to live with PMS

I don’t believe any woman should suffer from hormonal symptoms — it’s not natural or necessary. While the symptoms of PMS are very real and devastate many women’s lives, neither the negative cultural mindset surrounding our periods, nor the medicalization of PMS treatment, fully serve women or heals its underlying causes.

It may seem hard to believe that the simple natural approach we propose can have a significant impact on your physical and emotional symptoms of PMS — but it can. Our bodies have an incredible ability to heal. I’ve seen it time and again with my patients at our clinic, and with the women on our Personal Program.

So before you resign yourself to discomfort or a life on medications, consider the steps you can take today to alleviate your PMS. With optimal diet, exercise, and nutritional supplementation, you can reduce the frequency and severity of your symptoms, even free yourself entirely. And once you know how to handle your PMS, there is little to fear from hormonal transitions down the road.

Related to this article:

References & further reading on PMS & PMDD

 

Original Publication Date: 01/29/2007
Last Modified: 02/16/2010
Principal Author: Marcy Holmes, NP, Certified Menopause Clinician