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Premenstrual syndrome and menopause

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This booklet has been written by Dr Louise Newson, GP, menopause specialist and founder of the

Newson Health and Wellbeing Centre in Stratford-upon-Avon, England.

For more information on Dr Newson visit www.menopausedoctor.co.uk

Contents

Types of PMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Diagnosing PMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Impact, causes and symptoms of PMS . . . . . . . . . . . . . . . . . . . . . . . . . 5

Treatments for mild to moderate PMS . . . . . . . . . . . . . . . . . . . . . . 7-9

Treatments for moderate to severe PMS . . . . . . . . . . . . . . . . . . . 9-10

PMS, perimenopause and menopause . . . . . . . . . . . . . . . . . . . . . . . . 11

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What is Premenstrual syndrome/PMS?

Premenstrual syndrome (also known as PMS) is when women who have periodsexperience distressing symptoms in the days or even weeks leading up to starting theirperiod. PMS encompasses a vast array of psychological symptoms such as depression,anxiety, irritability, loss of confidence and mood swings. There are also physical symptoms,such as bloatedness and breast tenderness.

PMS is identified when symptoms occur - and have a negative impact - during the lutealphase of your menstrual cycle. The luteal phase occurs between ovulation (normally mid-cycle, around day 14) and starting your period (usually around day 28). Although theaverage length of the menstrual cycle is 28 days, it can vary greatly between women andyou may find the length of your cycle varies from month to month.

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Types of PMS

Many women notice their premenstrualsymptoms, but they are not really affectedby them in any significant way. This wouldnot be considered as a premenstrualdisorder as such, merely a typicalphysiological process. Unfortunately, formany other women the symptoms thatoccur in the premenstrual part of theircycles do have a negative effect on theirlives and relationships.

There are several types of premenstrualdisorders (PMD) and they are classifiedinto two groups: ‘core’ premenstrualdisorders and ‘variant’ premenstrualdisorders. The most commonlyencountered and widely recognised typesof PMS are the core premenstrualdisorders.

Core PMDsWomen with premenstrual disordershave symptoms that are severe enough toaffect daily functioning, interfere withwork, school performance orinterpersonal relationships. The symptomsoccur and recur in ovulatory cycles.Symptoms must be present during the

luteal phase and improve when you startyour period. You should then have asymptom-free week after your period.

Variant PMDs There are also PMDs that do not meetthe criteria for core PMDs. These arecalled ‘variant’ PMDs and examples ofthese include when you experience PMSsymptoms but do not have periods (forvarious medical reasons), when you havePMS symptoms that are triggered byprogestogen treatments or when youhave an existing medical condition that isexacerbated in the premenstrual phase.

Premenstrual dysphoric disorder(PMDD)This term is becoming increasingly usedand is an extreme version of a corepremenstrual disorder ; there are strictcriteria for diagnosing PMDD. Certainsymptoms must be present, and thisalways includes mood. The symptomsmust occur in the luteal phase and mustbe severe enough to disrupt dailyfunctioning.

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Diagnosing PMS

It is the timing of symptoms and the degreeof impact on daily activity that supports adiagnosis of PMS, rather than merely thetypes of symptoms themselves. Identifyingthe timing of the symptoms is crucial asthere are no blood tests to confirm PMS;keeping a symptom diary is the mostreliable method of diagnosis. You shouldkeep the diary over the length of two cyclesas a minimum and write in it as it happensrather than relying on your memory a weekor two later.

There are charts or questionnairesdeveloped for this purpose. The DRSPtool (Daily Record of Severity of Problems) is a questionnaire that is widely used by doctors; The NationalAssociation for Premenstrual Syndrome(NAPS) has a chart that can bedownloaded (www.pms.org.uk) and theIAPMD also has a symptom tracker(https://iapmd.org/symptom-tracker) torecord your symptoms over the month.Alternatively, some women find using aperiod tracking app useful for loggingsymptoms and monitoring how they

change over the course of a cycle (such asbalance-app.com)

Using such tools will accurately reflect whatdays symptoms occur, which days they areabsent, the days of menstruation and theduration of the menstrual cycle. It providesyour GP with an evidence base from whichto both diagnose and treat the PMS. Thisinformation should be established andshared with your GP before any treatmentis commenced.

If a symptom diary is inconclusive, there isan alternative way of diagnosing PMS andthat is to ‘shut off ’ the ovaries by usingmedication. GnRH (gonadotropin releasinghormone) analogues are a group of drugsthat are modified versions of a naturallyoccurring hormone in the body, which helpto control the menstrual cycle. Shuttingdown the body’s production of estrogenand progestogen for three months, by usinga GnRH analogue, will stop the menstrualcycle occurring and should in theory stopPMS symptoms. If symptoms do not stopthen other medical or psychiatric causesshould be investigated.

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Causes of PMS

Although the precise causes of PMS areyet to be identified – there may be agenetic susceptibility for some women -there is compelling evidence thatsymptoms are directly related to thefluctuation of hormone levels in themonthly cycle. PMS is not seen in younggirls who are yet to start their periods, inpregnancy, or after the menopause inmost women. (Women with a history ofsevere PMS/PMDD may still be affected

by their hormones, postmenopause, andtime is often needed to find the right HRTregimen for these women).

PMS  appears to begin, or increase inseverity,  at times of marked hormonalchange such as in puberty (even beforethe first period happens), starting orstopping the oral contraceptive pill,after  pregnancy, and during theperimenopause and menopause.

Symptoms of PMS

PMS is characterised by a number ofsymptoms (over 150 have been identified)and they are usually grouped intopsychological and behavioural, and physicalsymptoms.

Common psychological and behaviouralsymptoms are mood swings, depression,tiredness, fatigue or lethargy, anxiety,feeling out of control, irritability, aggression,anger, disordered sleep, and food cravings.

Common physical symptoms are breast tenderness (mastalgia), bloating,clumsiness, and headaches.

Most women will experience only a fewof these symptoms – one or two may bedominant - and each symptom can varyin severity during a cycle, and from onecycle to another. New symptoms maypresent at any time during a woman’sexperience of PMS.

PMS symptoms may be experiencedcontinuously from ovulation tomenstruation, for just the 7 days beforemenstruation, at ovulation for 3 or 4 days,and/or just prior to menstruation. Somewomen do not experience relief fromsymptoms until the day of the period’sheaviest flow.

Impact of PMS

PMS can occur in any woman during herchild-bearing years. It is estimated that asmany as 30% of women experiencemoderate to severe PMS and 5-8% ofthese women suffer with very severe PMSor PMDD. This means that for 5 millionwomen in the UK, PMS is having asignificant and detrimental effect on theirquality of life, if left untreated.

PMS can affect not only the individualwoman but her whole network ofrelationships – partners, children, relatives,friends and work colleagues. Thefluctuating nature of symptoms can beunsettling for all involved.

Treatments for PMS

There are different levels of managementfor PMS, depending on the severity ofsymptoms and how a woman hasresponded to previous treatments. Thefirst line approach most GPs will adopt isto try one or more of the following: lifestyle changes and exercise, vitamin B6 supplements, the combined oralcontraceptive pill, Cognitive BehaviouralTherapy (CBT), and a low-dose SSRI(antidepressant).

Lifestyle changes Making healthy changes to your lifestyle canbe beneficial if you experience milder PMSsymptoms. This includes reducing stress,limiting alcohol and caffeine, and cuttingdown or stopping smoking. Alcohol maycontribute to anxiety symptoms andhormone imbalance - it is best consumedin moderation. High caffeine consumptionhas been associated with an increasedincidence of PMS, and it may make breasttenderness worse for some women.Studies have shown that smokers are morelikely to develop PMS and the more severeform, PMDD.

Important lifestyle changes also involveimproving your diet and getting the rightamount and type of exercise:

DietThere are several changes to your diet thatcan help symptoms of PMS, starting withcutting down excess salt and sugar. Whiterefined carbohydrates such as pizza andwhite bread cause a rapid release of bloodglucose - which may affect mood swingsand cravings, as well as contributing to

weight gain. Changing to carbohydrates that releases glucose more slowly (lowglycaemic index/GI carbohydrates) such aswholegrain bread, brown or basmati rice,pulses, beans or sweet potatoes and havingplenty of low GI vegetables such as salador greens, can be beneficial. Avoiding meatin the 7 - 10 days before your menstrualcycle may help to reduce the painassociated with PMS.

The essential fats in oily fish, such as salmon, mackerel and sardines, or in plant-based foods such as chia seeds,edamame, or kidney beans, may improvePMS symptoms. It is recommended thatyou eat foods high in Omega 3 oils two times a week or in the form of aquality fish oil supplement or algae-basedEPA/DHA. Green vegetables are rich infibre, magnesium and folic acid and areimportant for hormone balance, foods richin B vitamins, particularly B1 and B2, suchas cereals, legumes and nuts, and leafyvegetables can help with PMS symptoms.Studies have also shown that womenwhose diet is rich in calcium and vitaminD  are less likely to suffer from PMS. Inaddition to dairy products, calcium can befound in green vegetables like cabbage, kale and broccoli, as well as nuts and seeds,and vitamin D is made by the skin inresponse to sunlight. During autumn andwinter months it is recommended that youtake a vitamin D supplement.

ExerciseIf you experience fatigue and mood swingsin the days leading up to your period,regular aerobic exercise may lessen these

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Treatments for mild to moderate PMS

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symptoms. Anything that boosts your heartrate is considered aerobic exercise. Briskwalking, running, biking, and swimming areall good choices. Exercise helps improveyour mood by boosting endorphins -chemicals produced by the body to helprelieve stress and pain. Yoga  is anotheractivity that might help with symptoms suchas bloating, it can also help reduce stressand improve your energy levels and mood.

Combined oral contraceptive pill (COCP)There are various ways to artificially modifythe hormone levels in your body; the mostcommon hormonal treatment for PMS isto use the combined oral contraceptive pill(widely known as ‘the pill’). Because the pillworks to stop ovulation happening, there isnot the typical rise and fall in hormonelevels in the luteal phase that can triggerPMS.

Studies have shown that COCPs containingdrospirenone reduce the severity of PMSsymptoms, especially when the pill is takencontinuously right through the month -rather than having a 7-day break to bleed.Research has shown that for women whotook this type of contraception every dayfor every month, their mood, headache andpelvic pain scores improved.

For some women however, the COCPmay bring on PMS symptoms if they havea particular sensitivity to progestogen, this may also happen with contraceptiveinjections or some types of HRT. Womencan be affected by both a corepremenstrual disorder and also experiencePMS symptoms that are triggered byprogestogen treatments.

Cognitive Behavioural Therapy (CBT)For women that have severe PMS, the useof CBT is widely recognised as beneficialand should be tried before otherpharmaceutical and surgical interventions.

In simple terms, CBT is talking therapybased on the idea that how we think, feeland act all interacts with each other.Studies have shown it to be of the samebenefit in reducing depression, anxiety andbehavioural problems as antidepressantmedication. Women who had CBT werebetter able to maintain the improvementsafter the course was over compared towomen who were given antidepressantsfor the same length of time.

Use of low dose SSRIs (antidepressants)Serotonin is a ‘messenger’ chemical thatcarries signals between nerve cells in thebrain. It is thought to be a positive influenceon mood, emotion and sleep. SSRIs(selective serotonin reuptake inhibitors) arethe most commonly used type ofantidepressant and work by increasingserotonin levels in the brain.

Women that suffer with PMS have beenshown to have low levels of serotonin intheir blood and these levels can varythroughout their cycle. SSRIs are often usedin the first instance as a treatment optionfor severe PMS and they can help not onlyyour psychological symptoms but yourphysical premenstrual symptoms as well.

In particular, citalopram and sertraline havebeen shown to be beneficial; you may havethem prescribed for just the premenstrual(luteal) phase of your cycle or be advisedto take them continuously throughout themonth.

If taking SSRI for PMS, improvement canoften be noticed within a matter of days.This is in contrast to taking the samemedication for depression, as symptomsmay not improve for 4-6 weeks afterstarting the medication.

There can be side effects with SSRIs suchas nausea, insomnia, fatigue and a reduction

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in your sex drive. When a decision is madeto stop taking them, SSRIs that are taken on a continuous basis (rather than just in the premenstrual phase) should bediscontinued gradually, to avoid withdrawalsymptoms.

If there is any chance of you becomingpregnant, the use of SSRIs is notrecommended.

Complementary TherapiesThere is some evidence that calcium,vitamin D and Vitex (also known aschasteberry) can help alleviate symptomsof PMS. Other studies have shown mixedresults about the benefits of reflexology,vitamin B, magnesium, Isoflavones, and St.John’s Wort for reducing PMS symptoms.

Treatments for moderate to severe PMS

If none of the above treatments are foundto be of benefit, there are further optionsthat can be explored with your GP, theseinclude additional hormonal and non-hormonal medications and - for the mostsevere cases - surgery can be considered.

Hormonal treatments:Estrogen gel, patches and implantsMedications that stabilise hormone levelsduring the luteal phase of the cycle can helpreduce the occurrence of PMS. In a normalluteal phase, estrogen (estradiol) dropssharply just before ovulation and then risesand falls again in the subsequent 14 daysrunning up to the next period.Progesterone levels show an even greaterrise and fall in the luteal phase. It is believedthat as these medications stop ovulationoccurring, these sharp fluctuations thattrigger PMS will not occur, thereforetreatments are focussed on evening out thebalance and levels of these hormones.

Introducing estrogen (estradiol) into thebody - via a patch, gel or with an implant -has been found to improve both physicaland psychological PMS symptoms and canbe used as a treatment for those with moresevere symptoms, when first line optionshave been tried with little benefit. Thiswould usually mean a referral to a specialist

in PMS, or a GP with a special interest inthe subject.

It is important to note that although theaim of this type of estrogen therapy is tostop ovulation happening, it has not beenproven as a reliable contraceptive, soalternative methods of contraceptionshould be used if a pregnancy is notdesired.

Another important note is that usingestrogen therapy on its own (via a patch,gel or implant) can adversely affect thelining of the uterus (womb). Cells canovergrow making the lining abnormallythick which can cause a small risk of cancer.You can prevent this from happening byusing a progesterone treatment; for thisreason, your doctor should always discussthe use of a progesterone whenrecommending estrogen treatments (if you still have a womb). Micronisedprogesterone or the Mirena IUS (a type of coil) is the favoured treatment option tocombat the adverse effects of estrogen on the lining of your womb. The Mirena has the additional advantage of providingcontraception, should you need it.

Discontinuation of treatment could allow areturn of premenstrual symptoms. A

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reliable long-term treatment is thereforeessential for women with moderate tosevere forms of PMS and should beseriously considered when weighing uptreatment options.

If you are wanting to take estrogen (andprogesterone) in the long term for PMSmanagement, you should be advised thatthere is uncertainty over the long-termeffects of this therapy, therefore decisionsshould be made on an individual basis,taking into account the risks and benefits.

There is no evidence to suggest that treating PMS with progesteronetreatments alone will be of any benefit;some menopause specialists haveobserved, anecdotally however, that for a small minority of women progestogenon its own can be beneficial.

GnRH analoguesGnRH analogues are medications that‘shut off ’ the ovaries altogether and are highly effective in treating severe PMS. This type of treatment would usually be reserved for women with the most severe symptoms and is not recommended routinely. Thesemedications are usually started in aspecialist clinic.

When treating women with severe PMSusing GnRH analogues for more than 6months, ‘add-back’ hormone therapyshould be used in the form of continuouscombined HRT or tibolone, to preventassociated risks and improve futurehealth.

Women on long-term treatment shouldhave regular measurement of their bone

density (bone strength) to monitor forsigns of bone weakness and osteoporosis,this is usually by having a DEXA (or DXA)scan.

SurgeryFor women who have very severe PMSor PMDD, a final option - after othertreatments have failed - is to considerhaving surgery to remove both ovaries(bilateral oophorectomy) and/or womb(hysterectomy). This should only bediscussed after a trial of GnRH analogueshas been done and indicated that surgerywill be beneficial and replacementhormone therapy will be well tolerated.

As this surgery involves total removal ofthe ovarian cycle it can be very effectivein treating PMS, even though a heightenedsensitivity to hormonal changes will alwaysremain.

For women under 50 years, that havesurgery to remove the ovaries and thewhole womb, taking replacementestrogen is recommended to protecttheir future health; they do not need to take progesterone. Women who havejust their ovaries removed, still need totake progesterone.

Older women can also benefit fromtaking HRT after this type of surgery.

Consideration should also be given to replacing testosterone, (which theovaries produce) as a sudden lack oftestosterone can affect your levels ofenergy, mental focus and your interest inand pleasure from sex.

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PMS, perimenopause and menopause

In theory, when the menopause occurs,PMS will cease, along with the monthly period. However, during theperimenopause (the time leading up tothe last period and a year afterwards)PMS symptoms are often heightened, due to fluctuating hormones. As womenapproach the perimenopause – for mostwomen this is in their mid to late forties– hormone fluctuations become moreexaggerated as the ovaries begin to slowdown the production of eggs. Both PMS and menopause symptoms can affect a woman’s wellbeing and quality of life at this time.

The symptoms of PMS can be similar to those experienced during themenopause. However, it is possible todifferentiate between the two as PMSsymptoms will stop or improve once aperiod has finished, whereas they may bepresent at any time of the month or becontinuous during the perimenopause.

Studies have shown that PMS sufferers are twice as likely to experience  hotflushes  and mood swings in theirperimenopause, than women who do not have a history of PMS. If you havebeen troubled by PMS throughout yourlife, this may be a predictor that you will experience unwanted symptomsduring your perimenopause. Alternatively,women who may never have experiencednoticeable PMS in the past may start

struggling with PMS symptoms when theyare in their mid to late forties as theirovary function slows down and hormonelevels change.

Treatments for PMS in theperimenopause are the same as thosealready described. If perimenopause isdiagnosed, then treatments for PMS will be discussed alongside decisionsaround the use of Hormone ReplacementTherapy (HRT) for perimenopausalsymptoms. This usually involves takingreplacement estrogen, as well asprogesterone to protect the lining of thewomb (if it hasn’t been removed bysurgery).

PMS symptoms will usually cease whenwomen become postmenopausal -typically one to two years after their lastever period. On average this is around the age of 51-52 years. This is becausehormone levels begin to even outthroughout the month and become much calmer, eventually settling downcompletely. However, as there are healthrisks of having low hormone levels (suchas an increased risk of developing heartdisease and osteoporosis in the future),many women continue to take HRT in thelong term, with no adverse effects.

PMS, perimenopause and menopause

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The team at Newson Health are passionate about improving awareness of safeprescribing of HRT to ladies at all stages of the perimenopause and menopause

and also offering holistic treatments for the menopause.

Dr Louise Newson has written and developed the websitewww.menopausedoctor.co.uk

This website contains evidence-based, non-biased information about theperimenopause and the menopause. She created this website to empower women withinformation about their perimenopause and menopause and to inform them about the

treatments available.

Her aim is for women to have more knowledge and confidence to approach their ownGP to ask for help.

Louise also wants healthcare professionals to access this website and read importantguidelines and articles so that their experience and knowledge of the menopause

improves and they can, in turn, help many more women.

Louise is also the director of the not-for-profit company Newson Health Research and Education.

Email: info@newsonhealth.co.uk | Web: www.newsonhealth.co.uk

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