PMS, PMDD and the menopause

Why PMS and PMDD can worsen during the perimenopause

Do you ever feel overwhelmed, tearful, anxious or even angry in the run up to your period?

Then it might be premenstrual syndrome (PMS). Some women experience a very severe form of PMS known as premenstrual dysphoric disorder (PMDD).

But what kind of impact can you expect the perimenopause and menopause to have on your PMS or PMDD, and what steps should you take to manage the condition?

Here, we take you through your options.

What is PMS?

PMS covers a wide range of physical and emotional symptoms that you may experience before your period.

According to the NHS, the most common of these are mood swings, feeling upset, anxious or irritable, tiredness or trouble sleeping, bloating or tummy pain, breast tenderness, headaches, skin breakouts, greasier hair and changes in appetite and sex drive.

While the causes are not known exactly, they are thought to be related to changes in hormones during the second half (luteal phase) of your cycle.

This phase usually begins about day 15, after an egg has been released from your ovary and as the lining of your womb starts to thicken in preparation for a pregnancy.

The timing of symptoms is crucial to make a diagnosis of PMS, says Newson Health GP and Menopause Specialist Dr Hannah Ward.

‘About 90% of women will experience some PMS symptoms,’ she says.

‘They can vary a lot, and for about a third of women, they will interfere with their daily activities. To be PMS, the symptoms must occur in the luteal phase and resolve within a few days of your period starting.’

RELATED: Podcast: PMS and the menopause

What is premenstrual dysphoric disorder (PMDD)?

PMDD is a very severe form of PMS, which is thought to affected around 5% of women [1].

The symptoms are similar to PMS but much more intense and have a much greater negative impact on the life of those affected, the NHS states.

Definitions vary slightly, but the most commonly used is the Diagnostic and Statistical Manual of Mental Disorders, which says a woman must experience at least five out of 11 distinct psychological premenstrual symptoms, one of which must include mood [2].

Other symptoms on the list include marked anxiety, lethargy and decreased interest in usual activities.

Again, timing is key and the five symptoms should be there in the final two weeks before your period and start to improve within a couple of days of your period starting, and be minimal in the week after your period.

One of the symptoms can be suicide ideation: a recent international study found that a third (34%) of 2,700 women affected by PMDD who completed a questionnaire said they had attempted suicide [3].

‘PMDD can be very severe but it is often not acknowledged,’ says Dr Ward. ‘Often women will discuss it with their doctor who may dismiss the symptoms as they are not aware of PMDD and don’t realise how bad it can be.’

How will the perimenopause affect my PMS or PMDD?

Unfortunately, the perimenopause – when your hormone levels start to decline ahead of your periods stopping – can make your PMS or PMDD worse.

Women who have not had PMS before can develop it, and those who have experienced it before will often find symptoms will get worse, says Dr Ward.

‘Symptoms are often more severe around times of hormonal change – so puberty, after having a baby and the perimenopause are key times for this,’ Dr Ward says.

‘If a woman had PMS before, they tend to get similar symptoms they have always had, but they are more severe, particularly the emotional and psychological ones.’

The amount of time that you experience the symptoms can also increase as your cycle becomes more erratic and starts to change.

As you may not be regularly releasing an egg (ovulating), the symptoms can spread throughout your cycle as the changes in hormones start to fluctuate.

What can I do to help manage my symptoms?

Before you see a healthcare professional, keep a dairy of your symptoms and menstrual cycle for a month.

The free period tracker on the balance app is a good option for this, and the National Association of Premenstrual Syndrome (NAPS) also has an online menstrual d iary.

When you see a GP, the first option is likely to be lifestyle advice, such as exercise and diet, as well as being directed to information about PMS, that could be signposting to a support group such as NAPS or the International Association for Premenstrual Disorders.

Guidance for healthcare professionals says those with PMS should be advised on ways to improve diet and sleep, increase exercise, stop smoking, reduce alcohol intake and reduce stress.

These lifestyle changes, particularly increasing movement, can have a beneficial impact, Dr Ward says.

You can read more about healthy eating and the benefits of activity here.

What about treatment options?

For those who have moderate PMS symptoms, the next step recommended in NAPS guidance is a combined oral contraceptive pill, such as Yasmin. This should be taken continuously without a break for the most benefit.

Both the National Institute of Health and Care Excellence and the Royal College of Obstetricians and Gynaecologists (RCOG) also recommend that cognitive behavioural therapy, is considered.

RELATED: Managing menopause beyond HRT

If you have severe PMS or PMDD, you should be offered all of these, and also have the option of a type of antidepressant called a selective serotonin reuptake inhibitor (SSRI).

But Dr Ward recommends that for women who are perimenopausal, HRT is a better approach than the contraceptive pill.

‘The standard approach will be to take Yasmin, the pill, which is fine if you’re 25 but if you’re over 35 it doesn’t always work on PMS symptoms.

‘It stops ovulation but it contains a synthetic type of estrogen and progestogen which comes with risks including blood clots and increased breast cancer risk over time. It can also cause side effects which worsen mood.

‘But HRT helps even out the fluctuations of hormones that can be causing the problem. We also know that part of the cause of PMS or PMDD is the sensitivity of a woman’s brain to these hormonal fluctuations, and HRT can help with this too.’

SSRIs are a standard approach to moderate PMS and PMDD, and while useful for some women, Dr Ward feels it would be better to consider trying HRT too.

‘You can take both, and often antidepressants work better when someone takes HRT as well,’ she says.

The RCOG and NAPS guidance agree that HRT, through an estrogen skin patch combined with cyclical progestogen, is a good way to manage the physical and psychological symptoms of severe PMS.

And it’s worth pointing out that often women will be prescribe estrogen or progesterone separately, and some women’s symptoms will improve with (body identical) progesterone alone.

Progesterone is a hormone produced the corpus luteum, a hormone body produced following ovulation.

For most women, progesterone has calming, anti-anxiety (anxiolytic) properties when it acts on the GABA receptors in the brain. But some women are particularly sensitive to progesterone, known as progesterone intolerance, and the hormone can have a paradoxical effect of worsening mood and anxiety.

RELATED: Progesterone intolerance

In the last week of your cycle, known as the late luteal phase, progesterone levels drop off rapidly and this fall in progesterone may well be one of the underlying causes of PMS and PMDD.

This theory was originally suggested by Dr Katharina Dalton, author of a number of books on PMS including the PMS Bible and Once a month.

Using high doses of body identical progesterone in the form of Cyclogest 400mg vaginal pessaries twice daily may improve symptoms, however this treatment is not currently part of any recognised treatment guidelines.

‘For women who are perimenopausal, HRT will often bring other useful benefits and help with other menopausal symptoms that the Pill won’t,’ says Dr Ward. ‘It will also help protect your future risk of osteoporosis and cardiovascular disease.

‘It can be a journey to find exactly the right combination of medication that will work for you. Expect to have to be persistent, as sadly many doctors don’t know enough about this. If the first treatment doesn’t work, go back and tell the GP that you need something else. Ask to be referred to a PMS specialist if you’re not getting the help you need.’

What if my PMDD still can’t be controlled well?

For the most severe cases, the surgical removal of your womb and your ovaries is an option, but this should only be considered after all other options have been unsuccessful.

Removal of your womb and ovaries will trigger what is known as a surgical menopause.

Most women are under the age of 51 years when they have surgery to remove their ovaries; their body’s requirements for hormones is greater compared to that of older women going through the menopause naturally, so it is important to consider taking estrogen until at least the usual age of menopause for the long-term health benefits.

Unfortunately, some women continue to experience cyclical mood symptoms, even after a surgical menopause. This suggests the underlying causes (aetiology) of PMDD are not completely understood and the menstrual clock in the brain may have more control of women’s hormone cycles that we realise.

It’s important that treatment is individualised and your healthcare team work with you to take into account your medical history, symptoms and preferences.

What about when I reach the menopause?

The good news is when you reach menopause – officially 12 months after your last period – your PMS symptoms will likely resolve.

However, you may find that you experience menopause symptoms, which can include low mood, hot flushes, night sweats, joint aches and pains and vaginal dryness. HRT will replace your hormones and ease symptoms and provide long-term health benefits.

References

1. Gudipally P.R., Sharma G.K. (2022), ‘Premenstrual Syndrome’ In: StatPearls. Treasure Island (FL): StatPearls Publishing

2. Reid R.L. (2017), ‘Premenstrual dysphoric disorder (formerly premenstrual syndrome)’. In: Feingold K.R, Anawalt B., Blackman M.R., et al., eds. Endotext. South Dartmouth (MA): MDText.com, Inc

3. Eisenlohr-Moul T., Divine M., Schmalenberger K., et al. (2022), ‘Prevalence of lifetime self-injurious thoughts and behaviors in a global sample of 599 patients reporting prospectively confirmed diagnosis with premenstrual dysphoric disorder’, BMC Psychiatry, 2022;22(1):199, doi:10.1186/s12888-022-03851-0