Understanding PMS and PMDD

Many women have experienced some form of emotional or physical symptoms a few days prior to the onset of their period. For most, these symptoms can include mood swings, irritability, breast tenderness, fatigue, bloating and headaches. Now although these symptoms can be considered  “normal” when they are mild, some women unfortunately experience more severe symptoms that can be debilitating. In other words, if your symptoms interfere with your daily life on a regular monthly basis, this is NOT normal. Unfortunately, since society, social media and even your doctor may disregard your symptoms as “just PMS”, it can often be difficult to get the treatment and care you deserve. The reality is, PMS is NOT normal and it is important we discuss what PMS is, why it can be hard to diagnose it and a few important factors we have learned about how PMS should be evaluated and treated.

So let’s dive in.

Premenstrual Syndrome (PMS), is particularly difficult to officially diagnose because there is actually no lab test or imaging test we can order to diagnose your PMS. PMS is unlike other known conditions like PCOS or even iron deficiency anemia. With these types of diseases, we have particular set guidelines that allow us to confirm your diagnosis and make it easy to evaluate when treatment is implemented and how well it’s working.

When it comes to PMS, on the other hand, there is more to our evaluation that is required. We must make sure that you truly have PMS and your symptoms aren’t related to another underlying condition. One myth I hear so often in the wellness space is that PMS is caused by a “hormonal imbalance” and that we need to “treat your hormones” in order to improve your symptoms. But this is actually false. In fact, PMS, and in more severe cases PMDD, actually happens because our body develops an inappropriate response to our own hormones. In other words, your hormones are doing exactly what they are supposed to be doing but your body creates an “intolerance” or “sensitivity” to these normal hormonal fluctuations. This is particularly important to understand because if we were to evaluate hormone levels in a patient with PMS, her lab results may look exactly the same as someone who does not experience PMS.

Instead, the women with PMS, are inappropriately responding to a normal hormonal pathway. This inappropriate response isn’t just experienced by the endocrine system, but her brain and her nervous system, which often explains the mood swings, irritability and pain often associated with PMS. This is often why even doctors can struggle with the diagnosis of PMS and PMDD because the condition is extremely subjective and we have limited objective measurements to help with our diagnosis. This is also why many women with PMS and PMDD can feel dismissed by their doctor and just told “it’s probably PMS”. Instead if a woman is experiencing PMS-like symptoms, it is our responsibility as doctors to dig a little deeper. It is also important to be cautious when you hear “wellness or hormone experts' ' online telling you that you need to order this fancy lab test, or fancy “hormone balancing” supplement to fix your symptoms. This should be a huge RED FLAG!

If you don’t ovulate, you likely don’t have PMS

This may surprise you but the reality is PMS is associated with an intolerance or sensitivity to ovulation activity. Without ovulatory activity (aka if you aren’t ovulating), chances are your symptoms are NOT due to PMS. This is important when evaluating your symptoms because if you are not ovulating, chances are,  you don’t have PMS and it’s important that we investigate what else could be causing your symptoms. This also applies to medications, like birth control, that suppress ovulation. 

Again, birth control works by suppressing ovulation, so if you are experiencing symptoms or not feeling well while on birth control, chances are this isn’t PMS. I know, shocking right?

The reason this is so important to mention is because women are too often dismissed because of their symptoms and just told (by the internet or by their doctor) that it’s “probably PMS” rather than truly evaluating what the cause of their symptoms truly are. At NMD Wellness of Scottsdale, we are extremely passionate about educating patients about this particular concept because if we start treating your symptoms assuming you have PMS but we don’t  take the time to rule out other causes of your symptoms, our treatments are likely not going to be successful. And chances are, if you are reading this article, it’s because you too have experienced limited improvement in your symptoms even with the use of certain medications and/or supplements. This also impacts the lifestyle and dietary recommendations we provide our patients and is why following someone online who calls themselves a “hormone expert” providing everyone with PMS/PMDD the exact same diet and lifestyle recommendations often falls short in terms of your results.

It’s time we really look at how we can provide women with PMS more personalized care and stop assuming “it’s just PMS”.

How to Diagnose PMS/PMDD

When it comes to PMS, symptoms must occur in ovulatory cycles. Again, this means, you must ovulate in order to be diagnosed with PMS. Symptoms must occur for a minimum of two consecutive cycles and they must only occur during the luteal phase of your cycle (aka after ovulation and before your period). They should not happen during your period or before ovulation. They should cause significant distress or symptoms. So, if you feel like you fight with your husband every single month at the exact same time or you notice severe breast tenderness every month before your period, these can be symptoms of PMS. Now again, you MUST ovulate in order for your symptoms to be associated with a true diagnosis of PMS. That being said, some women will experience PMS-like symptoms and do not ovulate. A great example of this is women who feel horrible even on the pill. They may experience PMS-like symptoms, but this isn’t truly PMS. This is extremely valuable to understand because again our treatment options will vary based on the actual root cause.

PMDD, otherwise known as premenstrual dysphoric disorder, is a much more severe form of PMS. Unfortunately, since both society, and even sometimes doctors, are known to dismiss PMS and PMS-like symptoms. Many women with PMDD often go months, if not years, without a proper diagnosis. This can delay their treatment and significantly impact their quality of life. Women with PMDD are not only experiencing severe impairment in family life, social life and their ability to work, but they are at a significant higher risk for suicide due to their symptoms. In fact, according to researchers (Pilver 2012), there is a significantly higher risk of non-fatal suicide behaviors in women with PMDD. Suicide attempts can be seen in up to 15% of women with PMDD. (Cunningham 2009).  Part of the reason many of these women are at higher risk of suicide is because they are often dismissed by their doctor, told “it’s not that bad '' or that their “symptoms are in their head”. They are often given limited guidance and support when it comes to treatment options.

Blood work that IS helpful 

Now as I mentioned, testing your hormones or even doing a pelvic ultrasound does not help us diagnose PMS. That being said, we need to make sure to rule out other possible causes of your symptoms and this is where it can be helpful to order blood work. According to the interdisciplinary consensus created on the management of premenstrual disorders in Switzerland (2016), it is recommend to evaluate the following labs: 

  • Thyroid Stimulating Hormone (TSH) 
  • Cortisol 
  • Follicle Stimulating Hormone (FSH) 
  • Estradiol (active form of estrogen) 
    • Should be evaluated on cycle day 3-5 of your cycle. Remember cycle day 1 is the first NOT the last day of your period. 
  • Prolactin 

How to Help your Doctor Diagnosis PMDD 

As we mentioned, it can often take women months, if not years, to be probably diagnosed with PMDD. If you are struggling with PMS or PMS-like symptoms, keeping track of your symptoms can be extremely beneficial and helpful for your doctor and can even speed up the process of diagnosis and, most importantly, treatment. Now although most of us track our periods with some app, calendar or notes in our phone,  the DRSP, otherwise known as Daily Record of Severity of Problems, is an essential assessment tool we can use to help establish the diagnosis of PMDD. So make sure if you're tracking your symptoms using a period tracker that your tracker uses the DRSP questionnaire. One of our favorite apps is Me v. PMDD.

Tracking your symptoms is extremely important and in order to help your doctor make the proper diagnosis, you will need to track your symptoms EVERYDAY for at least two cycles. In other words, if you are currently only tracking your symptoms when you feel bad or right before your period, this isn’t enough to help your doctor diagnose PMDD. We also know that according to studies, it can be hard for women to recall the dates and severity of their symptoms in the past. So, if you are worried that you may be experiencing PMDD, start tracking your symptoms today and track them each and every day for at least two consecutive cycles.

Is PMDD caused by a progesterone deficiency? 

Although you might have heard that low progesterone is the cause of PMDD, researchers are not convinced. In fact, the use of progesterone in women with PMDD may not improve their symptoms and, in some cases, could make symptoms worse. Some of the studies that evaluated progesterone levels in women with PMDD showed women had low levels of progesterone in the luteal phase, while others studies showed levels to be elevated. What does this mean for you? Chances are, unfortunately, supplementing with progesterone likely won’t help your PMDD symptoms and could even make your symptoms worse. Instead, researchers have theorized that it isn’t low progesterone that is contributing to PMDD symptoms. Instead, researchers believe the production of a neuro-hormone, known as allopregnanolone may be associated with PMDD. Allopregnanolone is produced from progesterone and normally has a calming effect on the brain. Unfortunately, in women with PMDD, it appears that allopregnanolone has almost the opposite effect on the brain, and impacts our stress response. This may help explain why patients with PMDD often presents with such severe psychiatric and behavioral changes.

Is “Estrogen Dominance” the cause of PMDD? 

The term “estrogen dominance” is more so a marketing tool and not an official diagnosis. So again, if a “hormone expert” or social influencer says your symptoms are caused by “estrogen dominance” —- RUN AWAY! Estrogen dominance is NOT a formal diagnosis and should not be listed as the cause of your symptoms. That being said, researchers have been interested in the role estrogen specifically plays on women with PMDD. They have learned  that estrogen, specifically fluctuations in estrogen, may play an important role in PMDD. Because PMDD symptoms occur in the luteal phase and, not in any other part of the cycle, researchers have theorized that low levels of estrogen in the luteal phase may be triggering PMDD. In fact, when women with PMDD experience low estrogen levels, their symptoms often get worse. This is extremely insightful because rather than assuming we need to lower estrogen levels, treatments that increase estrogen, especially during the luteal phase, may be more beneficial.

“I’m considering a hysterectomy because my symptoms are so bad!”

For many women with PMDD, their symptoms have become so extremely debilitating that they may have even considered the option of a hysterectomy. Again, if you aren’t ovulating, PMDD symptoms should resolve, so for many women who have experienced PMS, PMS-like or PMDD symptoms that have become debilitating, they may assume a hysterectomy is their only option. But, before you consider a hysterectomy for your symptoms, it is extremely important that we make sure your symptoms are actually caused by PMDD and not another underlying condition. This is important because not only is a hysterectomy an invasive procedure, but if your symptoms aren’t caused by PMDD, that hysterectomy may not improve your symptoms. Prior to a hysterectomy, it is often recommended that women try using GnRH analogues (like Lupron) to evaluate whether their symptoms get better or worse. If they show a positive improvement in symptoms with Lupron, this can help us determine if a hysterectomy would likely improve their symptoms and, most importantly, their quality of life. 

About the Author: Meet Dr. ZenAlissia Zenhausern- Pfeiffer, NMD, FABNE, (commonly known by her patients as Dr. Zen), is a licensed naturopathic doctor board certified in naturopathic endocrinology and the founder of NMD Wellness of Scottsdale, a premier naturopathic medical practice that focuses on helping women to take a proactive approach to their hormone and fertility health. Dr. Zen has been featured as a lead expert in Forbes, Shape Magazine, and Instyle and is deeply passionate about bridging the gap between traditional and natural medicine in the world of fertility. She works with a variety of hormone related issues including PCOS, endometriosis and unexplained infertility. Her goal is to help more women get back into the driver’s seat of their own health to make lasting transformational changes to their health to bring more cute and adorable babies into this world. Read More About Dr. Zen...