We break down the symptoms and differences, when to seek help and how to treat your symptoms.
If you struggle with symptoms that you think are linked to your menstrual cycle, it’s important to understand what this could mean, when to speak to a healthcare professional and the available treatment options.
You may notice these symptoms occur within the two weeks before a period and these are called premenstrual symptoms.
Typical premenstrual symptoms
If you think you may have premenstrual symptoms, you are likely to experience some of the following:
- Depressed mood, hopelessness or a lack of pleasure in the things you’d normally enjoy
- Anxiety, tension or panic attacks
- Mood swings, tearfulness or a sensitivity to rejection
- Irritability, anger or getting into arguments more often
- Tiredness or low energy
- ‘Brain fog’, difficulty thinking clearly or a lack of concentration
- Food cravings or overeating
- Difficulty sleeping or sleeping too much
- Feeling overwhelmed or out of control
- Physical symptoms (e.g. headaches, bloating, breast tenderness or joint pain)
- Suicidal thoughts or thoughts of disappearing.
There are other symptoms that you may notice with the timing of your menstrual cycle, and it is important to be aware of what is happening with your body. It is a good idea to keep a menstrual diary where you can monitor your symptoms related to your cycle.
Symptoms occur following ovulation and last anywhere from a few days to a couple of weeks but begin to improve around the time the period starts and fully resolve within a few days.
Both PMS and PMDD can lead to breakdown in relationships and interfere with normal daily activities.
Premenstrual syndrome
Premenstrual syndrome (PMS) is a term used to describe physical, emotional and psychological symptoms that occur within the two weeks before your period starts. They usually go away once your period begins or shortly after.
PMS is very common, affecting up to 40% of women and assigned female at birth (AFAB) individuals. Symptoms vary between mild to severe.
Premenstrual dysphoric disorder
If your symptoms are more severe and have a significant negative impact on your everyday life, it could be premenstrual dysphoric disorder (PMDD). PMDD is thought to affect 3-8% of women and AFAB individuals. It is a severe form of PMS that significantly affects daily life, causing distressing physical, emotional and psychological symptoms.
Both PMS and PMDD can lead to breakdown in relationships and interfere with normal daily activities.
Although we do not know the exact cause of PMS and PMDD, the hormonal changes in a menstrual cycle are important. Those with premenstrual symptoms tend to be more sensitive to hormonal fluctuations, particularly after ovulation in the menstrual cycle (luteal phase). This explains why symptoms tend to occur at that time.
Seeking help
If you identify with some of these symptoms, then it’s important to help yourself.
- Keep a symptom diary
To understand what is happening to your body, it is a good idea to keep a diary of your symptoms and timings with your menstrual cycle. If you need to seek medical support with your PMS or PMDD, your healthcare professional will need to understand what you’re experiencing and when. Recording symptoms alongside your menstrual cycle provides information to show your healthcare provider the cyclical pattern. It is recommended to keep a daily record for at least two menstrual cycles.
2. Get some support
Seek help if you are struggling with your symptoms. Speak to family and friends about how you’re feeling, consider your mental load (we have some articles on that, just search in Get informed). If you’re looking for more information and support on premenstrual disorders, The International Association for Premenstrual Disorders (IAPMD) has free one-to-one support and resources, and the National Association for Premenstrual Syndromes (NAPS) has useful information, too.
If you seek medical advice, you may require blood testing to rule out other potential causes, such as a thyroid disorder. However, there is no blood test to diagnose PMS or PMDD and the symptom diary will be a very useful tool to help with your diagnosis.
You may want to look for advice from your GP, women’s health specialist, psychologist, dietician or complementary therapist depending on which symptoms are most affecting you.
3. Agree a treatment plan that you are happy with
Your healthcare provider may recommend several treatment options, which should be personalised to you. However, it can be a case of trial and error to find out what works best. If you do not find relief through the treatments offered initially, you may be referred to a gynaecologist or other specialist for further advice.
Help yourself
There are many things you can do to help manage your symptoms, whether or not you receive a diagnosis.
Lifestyle
Experts recommend a nutrient-rich diet high in fibre and complex carbohydrates (plant-based whole foods). Minimise saturated fat, processed carbohydrates, caffeine and alcohol, and engage in regular exercise and stress management techniques eg yoga, meditation.
Complementary therapies
Evidence for complementary therapies is limited. The most researched and recommended to try is Agnus Castus at 20-40mg/day. Please note that Agnus Castus should not be taken alongside hormonal contraception or HRT.
Other options include Vitamin B6 at 2mg per day, Magnesium, Calcium and Vitamin D, Soy products or Red Clover, St John’s Wort and Evening Primrose Oil. There is no clear evidence that any of these options work, but you may wish to try supplements if lacking in your diet. Note that St Johns’ Wort interacts with medications, so do check with a healthcare provider before starting.
Cognitive Behavioural Therapy
Cognitive behavioural therapy (CBT) has been shown to be effective for reducing premenstrual symptoms and is particularly useful for psychological symptoms in PMDD. It can be used with or without medication and has shown to benefit long-term improvement.
SSRIs
The SSRI family of antidepressants, eg citalopram or escitalopram, taken either continuously or in the second half of the menstrual cycle (the luteal phase) has been shown to reduce psychological symptoms. Again, trial and error may be needed to find the right type of medication and dosage for you.
Hormonal treatments
The combined contraceptive pill is commonly used to treat PMS as it prevents ovulation and suppresses the natural hormonal cycle. However, it can have limited benefit for some and it is a case of trial and error to see if it works for you. If trying a combined hormonal pill, one containing drospirenone (eg Yasmin) may be better, taking the pill continuously without a break.
The drospirenone only contraceptive pill (Slynd) is an alternative for those who cannot take combined hormonal contraceptives. It also works by preventing ovulation and suppressing natural hormonal cycles. Again, this should be taken continuously without breaks.
Oestrogen patches at high doses along with a progestogen intrauterine device (coil) is often recommended. The progestogen is more localised in the womb and the oestrogen aims to suppress natural hormonal fluctuations. Those not wanting a coil could consider micronised progesterone capsules, which is similar to our own body’s natural progesterone and may be better tolerated.
If these do not work, a specialist may be able to offer the following, but these require specialist counselling to understand the severity of these options:
- Injections or oral tablets called GnRH analogues to switch off ovarian activity and induce menopause. This stops natural hormonal cycles and fluctuations, requiring additional HRT to replace your own hormones.
- Hysterectomy and removal of the Fallopian tubes and ovaries, with careful choice of HRT post-operatively. Removal of the ovaries induces menopause, instantly removing the natural hormonal changes. Because it severely lowers your own hormones, you would require HRT to add back hormones for bone and heart health. This option is for treatment resistant PMDD and would only be offered as a last resort.
Impact of perimenopause
Remember that premenstrual symptoms can become worse and erratic when perimenopause occurs, this is due to the erratic hormonal fluctuations with menstrual cycles becoming more irregular. As there is a sensitivity to hormonal changes already, this can often make this phase in life more difficult. Make sure you seek advice during perimenopause on how to best manage your symptoms. Continue to track your symptoms, seek support and give yourself a break when you are experiencing premenstrual symptoms.
The article was originally written by Dr Jane Davis and Dr Hannah Short, it has been reviewed and revised by Dr Wendy Knoops.
