Jules walks into the office, sits down and starts to cry. Then she apologizes for crying and tells me, “I can’t live like this anymore, I’m just not myself”. When we get to talking about what she means, she cries some more and expresses that she feels taken over by aliens for many days of each month. She is irritable, distracted, tired, overwhelmed and feels anxious without any apparent reason.
Is she alone? No! Premenstrual syndrome (PMS), affects 20-40% of premenopausal women and can be really severe in 2-10%. Many women even experience worsening PMS symptoms in perimenopause. While it is unclear why a particular woman is affected some hypotheses include decreased serotonin during the weeks leading up to menses or a particular sensitivity to estrogen and progesterone experienced by some women and not others. We know that a reduction in brain serotonin leads to poor impulse control, anxiety, depressed mood, irritability, anger and increased cravings for carbohydrate foods (like chocolate, pasta and breads). We know that women with a susceptibility to depression or a family history of bad PMS are at greater risk. Also women who are taught to repress anger or have a need for control in their lives will end up with greater PMS symptoms.
While we may all may feel a little irritable leading up to menses, the definition includes 1 emotional and 1 physical symptom, (bloating, breast tenderness etc.), present for 3 consecutive months that interferes with daily life. It is important to differentiate the timing of PMS symptoms from the more persistent symptoms of a psychiatric disorder that are present for more days of the month and not related to the monthly cycle. While your healthcare provider may decide to do some lab work, the diagnosis is, mostly, made by a diary of the symptoms over several months.
Jules is offered a step-wise approach starting with reassurance that she is not going crazy and that help is available. If she is able to eat small, frequent, healthy meals and eliminate salt, sugar, chocolate, caffeine and alcohol she may find symptoms improve. Just understanding the process is sometimes enough and women who wish to avoid medications will often implement healthy lifestyle changes including exercise, stress reduction techniques (yoga, meditation, tai chi) and open dialogue at home for a more supportive family unit. Sometimes Mommy just needs a “time-out”!
For those interested in an integrative approach there has been some progress with nutritional supplementation, (to include vitamin B6, vitamin E, Calcium, Magnesium and replacement of all dietary deficiencies to recommended daily allowance levels). To date there is minimal evidence for Evening Primrose Oil, Ginkgo or St. John’s Wort but massage, reflexology, acupuncture and bright light therapy may provide some relief. Yoga and Qigong (a version of TaiChi) have been shown to help by releasing the “good” or “relaxing” hormones our bodies crave to combat stress.
When needed, medical management should be initiated to improve quality of life and provide support until other lifestyle measures can be implemented. Jules decided to start on an anti-depressant in the category of Serotonin and Norepinephrine Re-uptake Inhibitors (SNRI) and found immediate relief. Some birth control pills and other hormonal treatments have been proven safe and effective for PMS due to their hormone stabilizing effects.
The most important step is to seek help and to realize that you are not alone.