PMS, Hormones, and The Female Brain

Why Female Pain Is Not Taken As Seriously via alexandrasacksmd.com

7 min readApr 5, 2018

This week, I had the opportunity to speak on NPR’s The Takeaway for their new series Taking Pains with Women’s Health. I had been listening along to the important topics they were covering, like how women are too often still viewed as “hysterical” when they present to doctors with symptoms of pain and how women of color are still treated with discrimination in medical settings- a topic highlighted this year in an impactful Grey’s Anatomy episode and in conversations sparked by Serena William’s bravely sharing of her hospital experience. What an excited surprise when I bumped into host Duarte Geraldino, an alumni of a residency program I’m currently doing at TED Talks, and he invited me to join the series to speak about my work on matrescence, and how the emotional experience of women around natural physical transitions like pregnancy is too often ignored by the medical community.

Please take 8 minutes and listen to The Takeaway segment, and if you’re really in a rush skip to the end to listen to the stories that women called in to share- they brought me to tears. I’m inspired and moved that more women and media are finding empowerment and relief after learning about matrescence, and appreciative of other journalists at Romper who have been continuing conversations about my public health mission: to transform the way our culture understands postpartum depression and the mother/baby bond, we need to first educate about the natural phase of matrescence.

On The Takeaway, I spoke about the latest research on how pregnancy impacts the female brain. In my work as a reproductive psychiatrist, I’m also interested in how hormones may be impacting women’s moods at other times in life as well. Many women come to see me to discuss whether or not their mood or anxiety is fluctuating with their menstrual cycle. I’ve come to appreciate how much more education is needed around Pre Menstrual Syndrome (PMS) and Pre Menstrual Dysphoric Disorder (PMDD) so was thrilled when reporter Hannah Smothers called me a few weeks ago to discuss this topic for Cosmopolitan Magazine.

What’s the difference between PMS and PMDD?

PMS is a syndrome that is more common than PMDD. Like PMDD, to make a diagnosis of PMS, your doctor will recommend that you track your symptoms for at least two to three months of your menstrual cycle. For both PMS and PMDD, symptoms will show up the week before you start your period (“luteal phase”) and resolve a few days after menstruation begins. Your symptoms should be absent at other times in the month in the “follicular phase” of your menstrual cycle (if they last throughout the whole month, they are likely being caused by another condition, not PMDD.) PMS is a milder condition that requires only one significant symptom, and it may only be physical (like bloating.) PMDD is a more severe condition that requires five significant symptoms, and at least one of them must be emotional (like mood swings.)

PMDD symptoms will be severe enough to cause distress or interfere with your usual functioning (work, school, hobbies, socializing.) Also, if you have a separate psychiatric condition aside from PMDD (such as Major Depressive Disorder, Panic Disorder, Substance Disorder) separate medical condition (such as Endometriosis, Fibroids, Thyroid Disorder or Irritable Bowel Syndrome), or are experiencing side effects of a medication you’re taking (including a birth control pill) your doctor will want to make sure that your monthly symptoms are not explained by an exacerbation of that other condition/medication, and will take a thorough medical history and do a physical exam as part of the workup and to make sure there isn’t any other condition/medication causing these symptoms.

To Diagnose PMDD:

One or more of the following emotional symptoms are required:
Mood Swings (your mood has sudden and intense changes, you may feel suddenly sad or tearful, you may feel more sensitive to rejection from others)
Increased conflict with others (irritability or anger that causes trouble in your relationships.)
Low Mood (depressed mood, feelings of hopelessness, or self-deprecating thoughts.)
Anxiety (worrying, tension, feeling on edge.)

One or more of the following behavioral/physical symptoms are required:

Decreased interest in usual activities
Change in energy
Difficulty concentrating
Fatigue
Change in appetite
Feeling out of control
Sleep problems
Cramps and bloating
Breast tenderness
Headaches
Joint or muscle pain
Hot flashes

PMDD diagnosis requires at least one emotional symptom and one or more of the physical symptoms listed above to reach a total of 5 or more symptoms combined. Symptoms need to be documented for at least 2 menstrual cycles, cause significant distress or interference with work, school, usual social activities, or relationships with others, and are not explained by another medical or psychiatric disorder or medication.

What Causes PMDD?

Science has yet to confirm the exact cause of PMDD. Most researchers think that it is caused by a reaction to hormone changes in the menstrual cycle that may impact serotonin levels (this is a chemical that your brain cells use to regulate mood, attention, sleep, pain and many other emotional, physical and behavioral experiences.)

The hormones of your menstrual cycle and your brain are likely connected by a system in your body called the hypothalamic-pituitary-gonadal axis. Through this system, fluctuations in the hormones produced by your ovaries (aka, your “gonads”) impact changes in your brain in the areas called the hypothalamus and pituitary.

Studies suggest that most women with PMDD do not have unusually high or low levels of hormones like estrogen or progesterone, or any specific problems with their ovaries. Instead, the symptoms of PMDD seem to be linked to your body and brain being super sensitive to normal hormonal fluctuations of the menstrual cycle.

It wasn’t until 2013 that the diagnosis of PMDD was established as an official psychiatric diagnosis in the Diagnostic and Statistical Manual of Mental Disorders V, giving it greater legitimacy to help in support and treatment for the millions of women worldwide suffering from the condition.

3–8% of menstruating women meet diagnostic criteria for PMDD. The prevalence shows that the rates, symptoms and severity are the same across countries and cultures worldwide.

More than half of menstruating women overall experience at least some premenstrual symptoms, but only 10% seek help and treatment from their doctors.

Thought there have been recent advances in research, many PMDD patients do not experience a 100% relief from the current treatment options. More research is needed to further advance our understanding of the exact cause of PMDD, the different possible subtypes, and additional treatments that have high benefit and low side effects.

How to best talk to your doctor about PMDD.

You may want to come prepared to your doctor’s visit having tracked two months of your menstrual cycles using a daily ratings chart. Even if you don’t meet criteria for PMDD, this chart can help you and your doctor determine if you’re suffering from another Menstrual Related Mood Disorder (MRMD) like PMS, or another medical condition that is being exacerbated menstrually. If you’re suffering and want to meet with your doctor before going through a month or two of symptom tracking, make the appointment and discuss the best approach with your provider.

How to treat PMDD

When discussing a treatment plan with your doctor, you should consider the specific symptoms you want to target, your medical history, other treatments you’ve tried, and the side effects of different treatment options. Treatments range from medications to vitamins/supplements, to psychological and lifestyle approaches for both the physical and psychological symptoms.

Studies have shown that these are the most effective medical treatments for PMDD:

Antidepressants in the SSRI class (includes medications like Prozac, Paxil, Zoloft, Lexapro and Celexa.) Your doctor may recommend that you take this antidepressant every day (this is how Major Depression is treated.) But some patients with PMDD may decided to take an antidepressant only during the days in the month when they experience symptoms, or a low dose every day and a higher dose during those targeted days.
Oral Contraceptive pills that contain drospirenone (includes medications like Yasmin, Yaz,). Unlike other birth control pills that focus mostly on estrogen, these pills also target the hormone progesterone. They also work to block the effects of testosterone that naturally occurs in the female body (which may help reduce acne and aggression) and targets another hormone that works as a diuretic (making you urinate, which may reduce the body’s water retention that targets bloating.) The general principle of using Oral Contraceptives for PMDD is to regulate your body’s natural fluctuations of hormones (because people suffering from PMDD may be more sensitive to these fluctuations.) One possible side effect of these drugs is that they may increase the risk of developing a blood clot more than other birth control options, so your doctor should take a detailed medical history and discuss this risk with you.

Other common options with less effective data but still may be helpful:

Other Antidepressants in the SNRI class (includes Effexor) and other antianxiety medications.
Other types of Oral Contraceptive pills (these can be tried, though studies have not shown that they are as helpful in treating PMDD as the drospirenone containing oral contraceptives.)
Calcium supplements (this is the most effective vitamin/supplement for treating PMDD.
Supplements like Chasteberry (V. agnus castus) and low doses of Vitamen B6. 5)
Psychological approaches: Talk therapies such as Cognitive Behavioral Therapy (CBT, a focused treatment that targets negative thoughts and behaviors) may be helpful.
Lifestyle approaches: exercise and decreasing alcohol, caffeine, and sugar intake may be helpful. Some studies have shown that eating complex carbohydrates (Oatmeal, brown rice, quinoa, sweet potatoes, beans, peas and lentils) may reduce symptoms.
Other treatment options with more serious side effects/risks are considered if those approaches aren’t effective.