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Severe Premenstrual Symptoms (PMS)

November 18, 2022

Premenstrual symptoms (PMS) are described as the physical and emotional symptoms that occur during the luteal phase of the menstrual cycle- the two weeks from ovulation until menstruation begins. Physical symptoms may include breast tenderness, bloating, pelvic cramping, headaches, and fatigue. Emotional symptoms may include feeling more sensitive or reactive, depressed mood, anxiety, irritability, and anger. Eight percent of women have a debilitating syndrome called Premenstrual Dysphoric Disorder (PMDD), where their mood and functioning are stable for the first part of their cycle but deteriorate as they get closer to the onset of menstruation. Often when the period starts (or 1-2 days later), it feels “as if a light switch has been flipped” and the PMS symptoms disappear. PMDD is diagnosed when there is a clear worsening in mood only during the luteal phase and when this pattern has been confirmed by mood charting for at least two months. More commonly, women have a premenstrual exacerbation (PME) of an underlying untreated (or under-treated) mental health issue like anxiety or depression; the symptoms fluctuate throughout the cycle but get significantly worse for the 1-2 weeks prior to period onset. There is also emerging data showing that people who have a diagnosis of ADHD (Attention Deficit Hyperactivity Disorder) may notice a worsening of their symptoms in the weeks leading up to menstruation. 

After having a baby, menstruation may only restart once breastfeeding slows down, or once breastfeeding has stopped completely, but sometimes the menstrual cycle can resume fairly quickly and without warning. Once menstruation restarts postpartum, people often have surprisingly heavy, long-lasting periods and worse mood and anxiety symptoms before menstruation. Similar symptoms may happen when women begin the menopause transition with even more unpredictability, ranging from shortened cycles to missed cycles. The physical symptoms during these times of menstrual changes cannot be understated: bloating, cramping, back pain, sore breasts, insomnia, and fatigue. And the emotional symptoms associated with resumed menstruation can be crippling, especially during the luteal phase. During this phase, postpartum women may have “really, really bad PMS”— the worst irritability, anger, sadness, and anxiety they have ever felt— even if they never had PMS before. Sometimes, women feel suicidal during this phase. Once their period starts, they suddenly feel lighter, more tolerant, calmer, and back to themselves. When severe PMS lasts for a few days, it can be frustrating and an inconvenience. When it lasts for 1-2 weeks, it can have a significant impact on work, relationships, pleasurable activities, and overall functioning.

There are several things to consider when treating bad PMS. The first thing is to ensure that there are no underlying medical issues, like endometriosis or a thyroid disorder which can cause excessive bleeding. It’s also important to make sure iron levels are normal since anemia (low iron)  may be associated with fatigue and mood issues. Painful PMS and period cramps can be treated with over-the-counter pain medication and it’s always important to maintain good sleep, adequate nutrition, and limit caffeine and alcohol use during the PMS period. Mindfulness meditation and Cognitive Behavioural Therapy (CBT) are other non-medication ways to manage severe PMS. Often women feel better simply by improving their sleep hygiene during the luteal phase– using mindfulness techniques, decreasing screen time before bed, or using Melatonin or a low-dose prescribed sleep aid during this phase. 

If mood, anxiety, irritability or worsened ADHD start interfering with how someone functions during the days-to-weeks leading up to a period, it is recommended to see a primary care provider to discuss medications, such as antidepressants, to more robustly address these symptoms. Sometimes adding an antidepressant or increasing the dose of an existing mental health medication can be helpful just for the 1-2 weeks of bad PMS days— this is called “intermittent dosing”. But first, it is important to assess whether emotional changes are only happening during the weeks leading up to menstruation(PMDD) or if it’s an underlying worsening of an ongoing mood and anxiety disorder or ADHD (PME), which may require continuous dosing of an antidepressant or ADHD medication. The best way to determine this is to closely track symptoms against menstrual cycles for two consecutive months. 

Some MDs prescribe hormonal treatments, such as oral contraceptives (“the pill”), an IUD, or menopause hormone therapy to treat PMDD. This may be very helpful to some people. But it is important to note that some women notice a worsening of their mental health when they use hormonal therapies. So, it is important to closely monitor mental health symptoms when taking this type of treatment. 

If you think your PMS is interfering with your functioning, please speak to an MD specialist to discuss which treatment option would be best for you and stop the needless suffering!

Written By:

Dr. Bev Young

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