Do you sometimes wonder why you feel like a diﬀerent person every month right before your period starts? If so, you’re not alone. Premenstrual symptoms most commonly include physical discomforts such as bloating, fatigue, headaches, and breast tenderness, or mood changes like irritability, sadness, or angry outbursts. It’s normal to experience these symptoms, but you may not actually be suffering from premenstrual syndrome (PMS). Let’s take a look at what causes premenstrual symptoms, what exactly constitutes PMS, and which treatment options might be right for you.
Why Do I Feel This Way?
There is a lot that we don’t know about what causes premenstrual symptoms. We do know that they are likely related to hormone fluctuations which naturally occur throughout the menstrual cycle. Typically, symptoms begin in the “luteal phase” of the cycle, which is the time after ovulation and before the onset of menstrual bleeding; in other words, the 2 weeks before the period starts. They are usually consistent from month to month, as the hormone fluctuations follow the same pattern during each cycle.
Estradiol (your most important form of estrogen) rises steadily in the period before ovulation (also referred to as the follicular phase) and then peaks sharply and drops abruptly at ovulation. It then has a more gradual rise and smaller peak in the luteal phase and drops again at the onset of menses.
Progesterone is the more likely culprit as its levels tend to mirror the timing of symptoms. It remains low during the follicular phase but starts to rise after ovulation and peaks in the middle of the luteal phase, just when symptoms are also peaking. Progesterone levels then start to decrease just before the onset of bleeding and are low throughout menses. That’s most likely why women often feel better after their periods begin.
What’s My Diagnosis?
Fortunately for most women, premenstrual symptoms are mild. While women commonly refer to the experience as “PMS’ing,” technically only 5-8% have the moderate to severe form of symptoms called premenstrual syndrome (PMS) or the most severe form called premenstrual dysphoric disorder (PMDD).
Premenstrual Syndrome (PMS)
The American College of Obstetricians and Gynecologists (ACOG) defines PMS as the presence of at least one symptom causing “economic or social dysfunction” during the 5 days prior to menses which occurs for at least 3 consecutive menstrual cycles. These symptoms can be aﬀective (i.e. mood-related) such as mood swings, sadness, tearfulness, irritability, depression, anxiety, and sensitivity to rejection; or they can be physical, like bloating, headaches, fatigue, breast soreness, hot flashes, dizziness, and headaches. (Cramps, while a very common symptom, are technically a separate medical problem called dysmenorrhea.). So in order to meet the medical definition of PMS, you have to have at least one of those symptoms that is severe enough to cause you to miss work or school or to cause major disruption in your daily routine or significant conflict in interpersonal relationships.
Premenstrual Dysphoric Disorder (PMDD)
Well, then what’s PMDD? Dysphoria means a generalized state of dissatisfaction or unhappiness, a general term for an abnormal mood. PMDD consists mainly of aﬀective or mood-related symptoms. The diagnostic criteria for PMDD are stricter than PMS. PMDD requires the presence of at least one of the following: mood swings, sudden sadness, sensitivity to rejection, anger, irritability, feeling of hopelessness, depressed mood, self-critical thoughts, tension, or anxiety. It also requires at least 5 symptoms: diﬃculty concentrating, change in appetite/food cravings, diminished interest in usual activities, decreased energy, feeling overwhelmed or out of control, sleeping too much or not enough, breast tenderness, bloating, or joint/muscle aches. Furthermore, symptoms must have been present during most menstrual cycles for at least a year, usually occurring during the week prior to menses and resolving within a few days after the onset of menses. Lastly, these symptoms must cause significant disruption in usual activities (school, work, social or family life).
Inexplicably, the hormone levels of women who suﬀer from PMS and PMDD are no diﬀerent from those of women who don’t. So, we don’t know why some women have PMS/PMDD and their unaﬀected counterparts do not.
Do I Need Testing?
In short, no. There are no tests or labs used to diagnose PMS and PMDD because even if you have one of these disorders, your hormone levels will be normal. However, in some cases, a thyroid test might be helpful since thyroid disorders sometimes cause mood abnormalities. Your doctor can decide if you need any bloodwork, but most women do not.
What Non-prescription Treatment Options Are Available?
If you’re like most women and your symptoms are mild, you can probably treat them with over-the-counter (OTC) medications such as NSAIDs (nonsteroidal anti-inflammatory drugs), including Advil, Motrin, Aleve and their generics; Tylenol, Midol, or Pamprin can also help.
Exercise is an often a forgotten but highly eﬀective treatment for both pain and mood disorders. Exercise causes the release of endorphins, which are chemicals that relieve pain, decrease appetite, and modulate moods. Endorphins may even lead to a sense of euphoria. If you’re feeling rotten because your period is approaching (or has already arrived), you don’t have to do vigorous exercise if you don’t feel up to it. Yoga, Pilates, and simple stretching can be beneficial too.
Don’t forget to eat healthy. Binging on greasy, salty, or heavy foods will only increase your sensation of bloating and lead to further fluid retention. Also, be sure to drink plenty of water which will help reduce bloating and fluid retention. Acupuncture and massage may provide some benefits too.
Keep a Diary of Your Symptoms to Share with Your Doctor
If you’ve tried these things and they’re not helping enough, talk to your doctor. He or she will ask you about your symptoms and when they occur. The most helpful thing you can do is bring a symptom diary to your appointment. For a few months, write down what symptoms you’re experiencing and when. Many period tracking apps for smart phones allow you to record symptoms, or you can always use an old-fashioned paper and pen. It’s important to also record when your periods occur so the timing of symptoms can be correlated.
Tracking your symptoms will help your doctor when considering whether you have PMS, PMDD or something else like generalized anxiety, depression, other mood disorders, a thyroid disorder, or even perimenopause. It’s also important to consider that substance abuse can mimic these diagnoses, so you should be honest with your doctor about your alcohol or drug use.
What Prescription Treatments Are Available?
Whether you have PMS, PMDD, or less severe premenstrual symptoms, you may benefit from a prescription treatment.
Birth Control Options
If you’re sexually active and would like to prevent pregnancy, the simplest and most eﬀective approach is a combined hormonal contraception, which refers to birth control methods that contain both an estrogen and a progesterone. These include most birth control pills, the patch, and the vaginal ring. Other birth control methods such as the shot (Depo-Provera), the implant (Nexplanon), and hormonal IUDs (Mirena, Kyleena, Liletta, and Skyla) contain only progesterone and may not be as eﬀective at controlling all of your premenstrual symptoms. More specifically, some of the most eﬀective medications are birth control pills that contain drospirenone (a specific type of progesterone). These include Yaz, Yasmin, Beyaz, and their generics (Ocella, Gianvi, and others).
Your doctor also may want to make sure he or she is prescribing a monophasic treatment, which means the hormone doses are the same every day. Another consideration is a pill with a shorter placebo course (4 sugar pills instead of the usual 7). All these options use the rationale of suppressing ovulation and maintaining a steady hormone level.
Options For Women Who Don’t Wish to Prevent Pregnancy
For women who don’t wish to prevent pregnancy, the most eﬀective treatment is a class of antidepressants called SSRIs. The most used and widely studied drugs include Prozac or Serafem (fluoxetine), Zoloft (sertraline), Celexa (citalopram), and Lexapro (escitalopram). When taken for PMDD, these drugs can be dosed continuously (taken every day) or intermittently. Intermittent use entails taking the medication only during the luteal phase, usually starting around day 14 of the cycle or when symptoms begin and stopping around the time the period starts or a couple of days after.
It’s important to note that intermittent dosing won’t be fully eﬀective for those who have some mild symptoms before ovulation, but in general, both dosing regimens are equally eﬀective. Intermittent use carries the advantage of having fewer side eﬀects and lower cost.
You Don’t Have to Suﬀer!
Whether your premenstrual symptoms are mild, severe, or somewhere in between, there are many ways to manage them. Talk to your doctor about a management plan that is tailored for you.