PMS/PMDD

Research sheds light on Premenstrual Syndrome and Premenstrual Dysphoric Disorder

PMS/PMDD caught my attention as a young physician when it was used in the defense of a woman charged with murder in England in the early 1980s, successfully. Over the decades research has shifted from estrogen and progesterone to neurotransmitters and receptors. It really is in your head.

PMS occurs in 90% of women with 20-30% reporting significant negative impact on quality of life. PMDD by strict criteria affects 5-8% of women. The symptoms occur after ovulation and can range from a few days to two weeks. Symptoms resolve after the onset of the period.

Symptoms of PMS/PMDD include:

• Anger and irritability, feeling overwhelmed and out of control
• Depressed mood, feeling hopeless, dark thoughts
• Anxiety, feeling “keyed up” or “on edge”
• Difficulty concentrating and lacking interest in normal activities or work 
• Lack of energy, joint and muscle aches
• Either insomnia or hypersomnia
• Increased appetite, food cravings
• Physical symptoms such as breast pain, muscle aches, bloating, weight gain, 

The combination of symptoms varies from one woman to the next and thought to be related to individual neurobiology.

Because PMS/PMDD is a post ovulation problem scientist first thought it was due to decline in estrogen(E) and/or progesterone(P). Studies on E or P supplementation did not report any benefit. In many cases, E and P made PMS/PMDD worse. Oral contraceptives(OCP) produce mixed results. Some women improve and some are worse.

The most effective therapy to date has been with selective serotonin reuptake inhibitors (SSRI). Nothing is 100% effective because everyone is a little different. 

There are many studies on using supplements, natural herbs and complementary and alternative treatment. Some have shown consistent benefits, others not. I want to share scientific research to help you.

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Holistic approaches

Some of the first research on PMS/PMDD involved dietary supplements. These studies have shown inconsistent or limited benefit. It does not hurt to try them.

• Calcium 600 mg twice daily
• Vitamin B6 50 mg twice daily
• Vitamin E 400 IU daily
• Magnesium 200 mg daily
• L-tryptophan 6 g daily from ovulation to the third day of the period
• Neptune Krill Oil 250-500 mg daily
• Soy Isoflavone 68 mg/day

Herbal Medicine

Chasteberry – Numerous placebo-controlled trials demonstrate a benefit compared to placebo. It stimulates certain nerve receptors in the brain. The studies are mostly from Europe and report on a specific extract that may not be available from the OTC products sold in America. There were two studies comparing Chasteberry to SSRI and both showed SSRI more effective.

Saffron – A placebo-controlled trial concluded Saffron 15 mg twice daily improved PMS scores after three cycles.

St John’s Wart – Has been reported to improve PMS symptoms in open reports but no placebo-controlled trials have been reported

CBD - Cannabidiol has been shown to reduce irritability, anxiety, global impression of change, stress, and subjective severity scores when compared to pretreatment assessments but not depression

Ginkgo Biloba – did not improve PMS symptoms compared to placebo

Evening Primrose oil – did not improve PMS symptoms compared to placebo

Complementary and other treatments

Most of the studies are small in number and short in duration. That means more studies are necessary to truly know if any of these approaches work. None of them are harmful and there is nothing wrong with trying any of them. Some may not be available locally.

Qi therapy – showed benefit in a small, randomized study

Massage – showed benefit in a small, randomized study

Reflexology – showed benefit in a small, randomized study

Chiropractic manipulation – showed benefit in a small, randomized study

Biofeedback - showed benefit in a small, randomized study

Yoga – showed benefit in a small noncontrolled study

Guided imagery – showed benefit in a small noncontrolled study

Photic stimulation – showed benefit in a small noncontrolled study

Acupuncture - showed benefit in a small noncontrolled study

Bright Light therapy – Has shown a small benefit in several trials

Lifestyle modifications and cognitive therapy

Studies have shown improvement in PMS/PMDD when women participate in group sessions emphasizing diet, exercise, environment modification and positive self-thoughts. Cognitive therapy has also been shown to improve scores on PMS/PMDD profiles and appears to improve outcomes when used with medication, complementary therapy or lifestyle improvements over the same intervention without cognitive therapy.

Prescription medication

SSRI - Extensive research indicates SSRIs are highly effective in treating PMS/PMDD. Because PMS/PMDD is limited to the last half of the cycles and the serotonin deficit is a temporary physiologic state there is no need for continuous use or gradual withdrawal. You can start taking them when symptoms start and stop once the period starts. Unlike biochemical depression, SSRIs are almost immediate in helping and do not require several weeks to see results.

Alprazolam – Studies have shown 0.25 mg once or twice daily after ovulation is effective, especially for tension and irritability. If taken for more than a week there is a need to taper for a couple of days after the period starts.

Buspirone – has also shown to be effective like Alprazolam

Bromocriptine – may be helpful for breast tenderness

Spironolactone – has data to support it helps bloating

Nonsteroidal anti-inflammatory Drugs – can be helpful for cramps, joint and muscle aches

Oral contraceptives – have shown mixed results with some women reporting improvement and others feeling worse. One OCP containing drospirenone has been given a PMS indication by the FDA.

Pituitary agents – are compounds that inhibit the pituitary gland from stimulating the ovary, so ovulation stops. Some are very potent and lower estrogen into the menopause range which trades one problem for another with hot flashes, night sweats and mood swings. They are expensive and used in very limited circumstances.

Surgery

Removing the ovaries and placing a woman on continuous estrogen will eliminate PMS/PMDD. Hysterectomy would also be necessary as Progesterone could aggravate central nervous system receptors and cause PMS/PMDD symptoms. The American College of Obstetricians and Gynecologists recommends a trial of pituitary suppression prior to removing the ovaries to gauge effectiveness.

Personalized Medicine

My approach to treating PMS/PMDD is to personalize the science to the patients needs. There are several ways to help. Every woman has different symptoms and severity. The treatment is tailored to their specific needs and feelings.

Diagnostic Criteria for Premenstrual Dysphoric Disorder

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

• In the majority of menstrual cycles, at least five symptoms must be present in the final week before the onset of menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week post menses. 
• One (or more) of the following symptoms must be present: 
  • Marked affective lability (eg, mood swings; feeling suddenly sad or tearful, or increased sensitivity to rejection). 
  • Marked irritability or anger or increased interpersonal conflicts. 
  • Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts. 
  • Marked anxiety, tension, and/or feelings of being keyed up or on edge. 
• One (or more) of the following symptoms must additionally be present, to reach a total of five symptoms when combined with symptoms from Criterion B above. 
  • Decreased interest in usual activities (eg, work, school, friends, hobbies). 
  • Subjective difficulty in concentration. 
  • Lethargy, easy fatigability, or marked lack of energy. 
  • Marked change in appetite; overeating; or specific food cravings. 
  • Hypersomnia or insomnia. 
  • A sense of being overwhelmed or out of control. 
  • Physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of “bloating,” or weight gain. 
• Note: The symptoms in Criteria A–C must have been met for most menstrual cycles that occurred in the preceding year. 
• The symptoms are associated with clinically significant distress or interference with work, school, usual social activities, or relationships with others (eg, avoidance of social activities; decreased productivity and efficiency at work, school, or home). 
• The disturbance is not merely an exacerbation of the symptoms of another disorder, such as major depressive disorder, panic disorder, persistent depressive disorder (dysthymia), or a personality disorder (although it may co-occur with any of these disorders). 
• Criteria A should be confirmed by prospective daily ratings during at least two symptomatic cycles. (Note: The diagnosis may be made provisionally prior to this confirmation.) 
• The symptoms are not attributable to the physiologic effects of a substance (eg, a drug of abuse, a medication, other treatment) or another medical condition (eg, hyperthyroidism).