Promoting menstrual wellbeing

Premenstrual Syndromes and Premenstrual Dysphoric Disorder

Premenstrual syndromes are a collection of physical and mental symptoms that occur in the luteal or secretory phase of the menstrual cycle, between ovulation and start of menstruation.

Premenstrual syndrome (PMS)

Some women are more sensitive to the hormonal changes that occur during this time and can lead to uncomfortable or distressing symptoms that can include:

  • mood swings
  • feeling depressed, anxious or irritable
  • tiredness and fatigue
  • sleep disturbance
  • headaches
  • appetite changes
  • bloating
  • acne and greasy hair
  • breast changes
  • loss of libido.

The experience of symptoms is extremely individual and may vary enormously from month to month. Symptoms usually resolve with the onset of menses.

Most women will experience some degree of PMS but between two and four in 100 women get severe PMS that prevents them from fulfilling their daily activities, affecting work, relationships, intimacy and the enjoyment of life. PMS can start at any time in a woman's reproductive life and may also worsen in the perimenopausal phase.

Premenstrual Dysphoric Disorder (PMDD)

PMDD is a hormone-based mood disorder. It is a severe form of PMS, affecting an estimated 5.5% of women. It can occur at any time in a woman's reproductive life with symptoms often worsening over time and sometimes worsening around reproductive events such as menarche, pregnancy, birth, miscarriage, and perimenopause. It is a complex cellular condition characterised by disabling symptoms of poor mental health and for some, physical symptoms, all occurring within the luteal phase each month. It is frequently under recognised and under diagnosed.

  • anxiety and panic attacks
  • suicidal thoughts
  • extreme mood swings
  • uncontrollable anger 
  • sleep issues such as insomnia or hypersomnia (sleeping too much)
  • headaches, joint pain and bloating.

Podcast: Laura Murphy - Premenstrual Dysphoric Disorder

Please find below a short podcast from Laura Murphy, Director of Education and Awareness at the International Association For Premenstrual Disorders (IAPMD).

Diagnosis

There is currently no blood or saliva test to diagnose PMDD. It is not a hormone imbalance. Nurses should take a thorough history and ask about the impact of symptoms. Recording a symptom diary over at least two consecutive menstrual cycles which can help identify a pattern and aid diagnosis. This can be used to identify patterns, plan interventions and evaluate treatment. Symptoms usually occur in the luteal phase with PMDD. Symptoms occurring through out the cycle but increasing in the luteal phase are not indicative of PMDD and other causes may need to be investigated.

Management

This should be individualised to each woman. There is no one size fits all for treatment and women should be supported during this ‘trial and error’ process. 

Lifestyle measures include:

  • exercise to release 'feel good' endorphins and aid rest and relaxation 
  • healthy balanced diet to optimise nutrition and stabilise blood sugars. Increasing foods rich in may help boost mood
  • stress reduction activities such as pilates, yoga or mindfulness 
  • ensuring seven hours quality sleep
  • smoking cessation and the reduction of alcohol and caffeine consumption.

Psychological support

Cognitive Behavioural Therapy (CBT) is a talking therapy that may be effective in enabling women to find new ways of managing symptoms so they have less of an impact on their life.

Complementary therapies

There is little evidence-based work to show if these therapies are effective, but some women find them of benefit. Supplements of calcium, vitamin D, Agnus Castus, Ginkgo and evening primrose oil for breast tenderness may be helpful.

Treatment options

Non-Hormonal options

Antidepressants – Selective serotonin reuptake inhibitors (SSRIs) or serotonin-noradrenaline re-uptake inhibitors (SNRIs) taken intermittently during the premenstrual phase or continuously can be effective. A trial of at least 3 months is recommended. Women should be fully advised of potential side effects.

Hormonal options

The use of hormones can be useful in suppressing ovulation to avoid cyclical changes.

  • Combined hormonal contraception in the form of oral pills, transdermal patches or vaginal rings can be used in extended regimens or used continuously to suppress ovulation, provided that the woman meets the medical eligibility criteria to use them safely. As PMDD is a sensitivity to hormone fluctuations, hormonal treatments can be difficult to start and women should be made aware of this prior to commencing treatment.
  • There is little evidence that women may benefit from the insertion of Levonorgestrel intrauterine system, as its prime action does not consistently supress ovulation and many women with PMDD are progesterone intolerant.
  • GnRH analogues as a nasal spray or injection cause a temporary menopause to stop periods. They are usually used for 6 months but this can be extended if combined with HRT to protect bone mineral density and to mitigate other risk factors.
  • Referral to a gynaecologist for specialist advice on treatments may be necessary.

Surgical treatment

Surgery is the last line in treatments for those with severe PMS/PMDD, and are resistant to all medical treatments and lifestyle interventions. A bilateral salpingo oophorectomy or total hysterectomy are not reversible, and all other options should be explored first.

A trial of GnRH analogues for three to six months before a hysterectomy will help to determine how effective surgery may be and to see what HRT will be suitable.

Further resources