Premenstrual syndrome and menopause

1 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

2 What is Premenstrual syndrome/PMS?

Premenstrual syndrome (also known as PMS) is when women who have periods experience distressing symptoms in the days or even weeks leading up to starting their period. 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 luteal phase 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 the average length of the menstrual cycle is 28 days, it can vary greatly between women and you may find the length of your cycle varies from month to month.

3 Types of PMS

Many women notice their premenstrual luteal phase and improve when you start symptoms, but they are not really affected your period. You should then have a by them in any significant way. This would symptom-free week after your period. not be considered as a premenstrual disorder as such, merely a typical Variant PMDs physiological process. Unfortunately, for There are also PMDs that do not meet many other women the symptoms that the criteria for core PMDs. These are occur in the premenstrual part of their called ‘variant’ PMDs and examples of cycles do have a negative effect on their these include when you experience PMS lives and relationships. symptoms but do not have periods (for various medical reasons), when you have There are several types of premenstrual PMS symptoms that are triggered by disorders (PMD) and they are classified progestogen treatments or when you into two groups: ‘core’ premenstrual have an existing medical condition that is disorders and ‘variant’ premenstrual exacerbated in the premenstrual phase. disorders. The most commonly encountered and widely recognised types Premenstrual dysphoric disorder of PMS are the core premenstrual (PMDD) disorders. This term is becoming increasingly used and is an extreme version of a core Core PMDs premenstrual disorder; there are strict Women with premenstrual disorders criteria for diagnosing PMDD. Certain have symptoms that are severe enough to symptoms must be present, and this affect daily functioning, interfere with always includes mood. The symptoms work, school performance or must occur in the luteal phase and must interpersonal relationships. The symptoms be severe enough to disrupt daily occur and recur in ovulatory cycles. functioning. Symptoms must be present during the

4 Diagnosing PMS

It is the timing of symptoms and the degree change over the course of a cycle (such as of impact on daily activity that supports a balance-app.com) diagnosis of PMS, rather than merely the types of symptoms themselves. Identifying Using such tools will accurately reflect what the timing of the symptoms is crucial as days symptoms occur, which days they are there are no blood tests to confirm PMS; absent, the days of menstruation and the keeping a symptom diary is the most duration of the menstrual cycle. It provides reliable method of diagnosis. You should your GP with an evidence base from which keep the diary over the length of two cycles to both diagnose and treat the PMS. This as a minimum and write in it as it happens information should be established and rather than relying on your memory a week shared with your GP before any treatment or two later. is commenced.

There are charts or questionnaires If a symptom diary is inconclusive, there is developed for this purpose. The DRSP an alternative way of diagnosing PMS and tool (Daily Record of Severity of that is to ‘shut off’ the ovaries by using Problems) is a questionnaire that is medication. GnRH (gonadotropin releasing widely used by doctors; The National hormone) analogues are a group of drugs Association for Premenstrual Syndrome that are modified versions of a naturally (NAPS) has a chart that can be occurring hormone in the body, which help downloaded (www.pms.org.uk) and the to control the menstrual cycle. Shutting IAPMD also has a symptom tracker down the body’s production of estrogen (https://iapmd.org/symptom-tracker) to and progestogen for three months, by using record your symptoms over the month. a GnRH analogue, will stop the menstrual Alternatively, some women find using a cycle occurring and should in theory stop period tracking app useful for logging PMS symptoms. If symptoms do not stop symptoms and monitoring how they then other medical or psychiatric causes should be investigated.

5 Impact of PMS

PMS can occur in any woman during her PMS can affect not only the individual child-bearing years. It is estimated that as woman but her whole network of many as 30% of women experience relationships – partners, children, relatives, moderate to severe PMS and 5-8% of friends and work colleagues. The these women suffer with very severe PMS fluctuating nature of symptoms can be or PMDD. This means that for 5 million unsettling for all involved. women in the UK, PMS is having a significant and detrimental effect on their quality of life, if left untreated.

Causes of PMS

Although the precise causes of PMS are by their hormones, postmenopause, and yet to be identified – there may be a time is often needed to find the right HRT genetic susceptibility for some women - regimen for these women). there is compelling evidence that symptoms are directly related to the PMS appears to begin, or increase in fluctuation of hormone levels in the severity, at times of marked hormonal monthly cycle. PMS is not seen in young change such as in puberty (even before girls who are yet to start their periods, in the first period happens), starting or pregnancy, or after the menopause in stopping the oral contraceptive pill, most women. (Women with a history of after pregnancy, and during the severe PMS/PMDD may still be affected perimenopause and menopause.

Symptoms of PMS

PMS is characterised by a number of Most women will experience only a few symptoms (over 150 have been identified) of these symptoms – one or two may be and they are usually grouped into dominant - and each symptom can vary psychological and behavioural, and physical in severity during a cycle, and from one symptoms. cycle to another. New symptoms may present at any time during a woman’s Common psychological and behavioural experience of PMS. symptoms are mood swings, depression, tiredness, fatigue or lethargy, anxiety, PMS symptoms may be experienced feeling out of control, irritability, aggression, continuously from ovulation to anger, disordered sleep, and food cravings. menstruation, for just the 7 days before menstruation, at ovulation for 3 or 4 days, Common physical symptoms are and/or just prior to menstruation. Some breast tenderness (mastalgia), bloating, women do not experience relief from clumsiness, and headaches. symptoms until the day of the period’s heaviest flow.

6 Treatments for PMS

Treatments for mild to moderate PMS

There are different levels of management weight gain. Changing to carbohydrates for PMS, depending on the severity of that releases glucose more slowly (low symptoms and how a woman has glycaemic index/GI carbohydrates) such as responded to previous treatments. The wholegrain bread, brown or basmati rice, first line approach most GPs will adopt is pulses, beans or sweet potatoes and having to try one or more of the following: plenty of low GI vegetables such as salad lifestyle changes and exercise, vitamin or greens, can be beneficial. Avoiding meat B6 supplements, the combined oral in the 7 - 10 days before your menstrual contraceptive pill, Cognitive Behavioural cycle may help to reduce the pain Therapy (CBT), and a low-dose SSRI associated with PMS. (antidepressant). The essential fats in oily fish, such as Lifestyle changes salmon, mackerel and sardines, or in Making healthy changes to your lifestyle can plant-based foods such as chia seeds, be beneficial if you experience milder PMS edamame, or kidney beans, may improve symptoms. This includes reducing stress, PMS symptoms. It is recommended that limiting alcohol and caffeine, and cutting you eat foods high in Omega 3 oils down or stopping smoking. Alcohol may two times a week or in the form of a contribute to anxiety symptoms and quality fish oil supplement or algae-based hormone imbalance - it is best consumed EPA/DHA. Green vegetables are rich in in moderation. High caffeine consumption fibre, magnesium and folic acid and are has been associated with an increased important for hormone balance, foods rich incidence of PMS, and it may make breast in B vitamins, particularly B1 and B2, such tenderness worse for some women. as cereals, legumes and nuts, and leafy Studies have shown that smokers are more vegetables can help with PMS symptoms. likely to develop PMS and the more severe Studies have also shown that women form, PMDD. whose diet is rich in calcium and vitamin D are less likely to suffer from PMS. In Important lifestyle changes also involve addition to dairy products, calcium can be improving your diet and getting the right found in green vegetables like cabbage, amount and type of exercise: kale and broccoli, as well as nuts and seeds, and vitamin D is made by the skin in Diet response to sunlight. During autumn and There are several changes to your diet that winter months it is recommended that you can help symptoms of PMS, starting with take a vitamin D supplement. cutting down excess salt and sugar. White refined carbohydrates such as pizza and Exercise white bread cause a rapid release of blood If you experience fatigue and mood swings glucose - which may affect mood swings in the days leading up to your period, and cravings, as well as contributing to regular aerobic exercise may lessen these

7 symptoms. Anything that boosts your heart In simple terms, CBT is talking therapy rate is considered aerobic exercise. Brisk based on the idea that how we think, feel walking, running, biking, and swimming are and act all interacts with each other. all good choices. Exercise helps improve Studies have shown it to be of the same your mood by boosting endorphins - benefit in reducing depression, anxiety and chemicals produced by the body to help behavioural problems as antidepressant relieve stress and pain. Yoga is another medication. Women who had CBT were activity that might help with symptoms such better able to maintain the improvements as bloating, it can also help reduce stress after the course was over compared to and improve your energy levels and mood. women who were given antidepressants for the same length of time. Combined oral contraceptive pill (COCP) There are various ways to artificially modify Use of low dose SSRIs (antidepressants) the hormone levels in your body; the most Serotonin is a ‘messenger’ chemical that common hormonal treatment for PMS is carries signals between nerve cells in the to use the combined oral contraceptive pill brain. It is thought to be a positive influence (widely known as ‘the pill’). Because the pill on mood, emotion and sleep. SSRIs works to stop ovulation happening, there is (selective serotonin reuptake inhibitors) are not the typical rise and fall in hormone the most commonly used type of levels in the luteal phase that can trigger antidepressant and work by increasing PMS. serotonin levels in the brain.

Studies have shown that COCPs containing Women that suffer with PMS have been drospirenone reduce the severity of PMS shown to have low levels of serotonin in symptoms, especially when the pill is taken their blood and these levels can vary continuously right through the month - throughout their cycle. SSRIs are often used rather than having a 7-day break to bleed. in the first instance as a treatment option Research has shown that for women who for severe PMS and they can help not only took this type of contraception every day your psychological symptoms but your for every month, their mood, headache and physical premenstrual symptoms as well. pelvic pain scores improved. In particular, citalopram and sertraline have For some women however, the COCP been shown to be beneficial; you may have may bring on PMS symptoms if they have them prescribed for just the premenstrual a particular sensitivity to progestogen, (luteal) phase of your cycle or be advised this may also happen with contraceptive to take them continuously throughout the injections or some types of HRT. Women month. can be affected by both a core premenstrual disorder and also experience If taking SSRI for PMS, improvement can PMS symptoms that are triggered by often be noticed within a matter of days. progestogen treatments. This is in contrast to taking the same medication for depression, as symptoms Cognitive Behavioural Therapy (CBT) may not improve for 4-6 weeks after For women that have severe PMS, the use starting the medication. of CBT is widely recognised as beneficial and should be tried before other There can be side effects with SSRIs such pharmaceutical and surgical interventions. as nausea, insomnia, fatigue and a reduction

8 in your sex drive. When a decision is made Complementary Therapies to stop taking them, SSRIs that are taken There is some evidence that calcium, on a continuous basis (rather than just in vitamin D and Vitex (also known as the premenstrual phase) should be chasteberry) can help alleviate symptoms discontinued gradually, to avoid withdrawal of PMS. Other studies have shown mixed symptoms. results about the benefits of reflexology, vitamin B, magnesium, Isoflavones, and St. If there is any chance of you becoming John’s Wort for reducing PMS symptoms. pregnant, the use of SSRIs is not recommended.

Treatments for moderate to severe PMS

If none of the above treatments are found in PMS, or a GP with a special interest in to be of benefit, there are further options the subject. that can be explored with your GP, these include additional hormonal and non- It is important to note that although the hormonal medications and - for the most aim of this type of estrogen therapy is to severe cases - surgery can be considered. stop ovulation happening, it has not been proven as a reliable contraceptive, so Hormonal treatments: alternative methods of contraception Estrogen gel, patches and implants should be used if a pregnancy is not Medications that stabilise hormone levels desired. during the luteal phase of the cycle can help reduce the occurrence of PMS. In a normal Another important note is that using luteal phase, estrogen (estradiol) drops estrogen therapy on its own (via a patch, sharply just before ovulation and then rises gel or implant) can adversely affect the and falls again in the subsequent 14 days lining of the uterus (womb). Cells can running up to the next period. overgrow making the lining abnormally Progesterone levels show an even greater thick which can cause a small risk of cancer. rise and fall in the luteal phase. It is believed You can prevent this from happening by that as these medications stop ovulation using a progesterone treatment; for this occurring, these sharp fluctuations that reason, your doctor should always discuss trigger PMS will not occur, therefore the use of a progesterone when treatments are focussed on evening out the recommending estrogen treatments (if balance and levels of these hormones. you still have a womb). Micronised progesterone or the Mirena IUS (a type Introducing estrogen (estradiol) into the of coil) is the favoured treatment option to body - via a patch, gel or with an implant - combat the adverse effects of estrogen has been found to improve both physical on the lining of your womb. The Mirena and psychological PMS symptoms and can has the additional advantage of providing be used as a treatment for those with more contraception, should you need it. severe symptoms, when first line options have been tried with little benefit. This Discontinuation of treatment could allow a would usually mean a referral to a specialist return of premenstrual symptoms. A

9 reliable long-term treatment is therefore density (bone strength) to monitor for essential for women with moderate to signs of bone weakness and osteoporosis, severe forms of PMS and should be this is usually by having a DEXA (or DXA) seriously considered when weighing up scan. treatment options. Surgery If you are wanting to take estrogen (and For women who have very severe PMS progesterone) in the long term for PMS or PMDD, a final option - after other management, you should be advised that treatments have failed - is to consider there is uncertainty over the long-term having surgery to remove both ovaries effects of this therapy, therefore decisions (bilateral oophorectomy) and/or womb should be made on an individual basis, (hysterectomy). This should only be taking into account the risks and benefits. discussed after a trial of GnRH analogues has been done and indicated that surgery There is no evidence to suggest will be beneficial and replacement that treating PMS with progesterone hormone therapy will be well tolerated. treatments alone will be of any benefit; some menopause specialists have As this surgery involves total removal of observed, anecdotally however, that for the ovarian cycle it can be very effective a small minority of women progestogen in treating PMS, even though a heightened on its own can be beneficial. sensitivity to hormonal changes will always remain. GnRH analogues GnRH analogues are medications that For women under 50 years, that have ‘shut off’ the ovaries altogether and surgery to remove the ovaries and the are highly effective in treating severe whole womb, taking replacement PMS. This type of treatment would estrogen is recommended to protect usually be reserved for women with their future health; they do not need the most severe symptoms and is to take progesterone. Women who have not recommended routinely. These just their ovaries removed, still need to medications are usually started in a take progesterone. specialist clinic. Older women can also benefit from When treating women with severe PMS taking HRT after this type of surgery. using GnRH analogues for more than 6 months, ‘add-back’ hormone therapy Consideration should also be given should be used in the form of continuous to replacing testosterone, (which the combined HRT or tibolone, to prevent ovaries produce) as a sudden lack of associated risks and improve future testosterone can affect your levels of health. energy, mental focus and your interest in and pleasure from sex. Women on long-term treatment should have regular measurement of their bone

10 PMS, perimenopause and menopause

In theory, when the menopause occurs, struggling with PMS symptoms when they PMS will cease, along with the are in their mid to late forties as their monthly period. However, during the ovary function slows down and hormone perimenopause (the time leading up to levels change. the last period and a year afterwards) PMS symptoms are often heightened, Treatments for PMS in the due to fluctuating hormones. As women perimenopause are the same as those approach the perimenopause – for most already described. If perimenopause is women this is in their mid to late forties diagnosed, then treatments for PMS – hormone fluctuations become more will be discussed alongside decisions exaggerated as the ovaries begin to slow around the use of Hormone Replacement down the production of eggs. Both Therapy (HRT) for perimenopausal PMS and menopause symptoms can symptoms. This usually involves taking affect a woman’s wellbeing and quality replacement estrogen, as well as of life at this time. progesterone to protect the lining of the womb (if it hasn’t been removed by The symptoms of PMS can be similar surgery). to those experienced during the menopause. However, it is possible to PMS symptoms will usually cease when differentiate between the two as PMS women become postmenopausal - symptoms will stop or improve once a typically one to two years after their last period has finished, whereas they may be ever period. On average this is around present at any time of the month or be the age of 51-52 years. This is because continuous during the perimenopause. hormone levels begin to even out throughout the month and become Studies have shown that PMS sufferers much calmer, eventually settling down are twice as likely to experience hot completely. However, as there are health flushes and mood swings in their risks of having low hormone levels (such perimenopause, than women who do as an increased risk of developing heart not have a history of PMS. If you have disease and osteoporosis in the future), been troubled by PMS throughout your many women continue to take HRT in the life, this may be a predictor that you long term, with no adverse effects. will experience unwanted symptoms during your perimenopause. Alternatively, women who may never have experienced noticeable PMS in the past may start

11 The team at Newson Health are passionate about improving awareness of safe prescribing 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 website www.menopausedoctor.co.uk

This website contains evidence-based, non-biased information about the perimenopause and the menopause. She created this website to empower women with information 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 own GP to ask for help.

Louise also wants healthcare professionals to access this website and read important guidelines 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.

© Newson Health Limited 2020 All intellectual property rights in the content and materials in this booklet are owned by Newson Health Limited. Materials, images and other content may not be copied without the express prior written permission or licence of Newson Health Limited.

Email: [email protected] | Web: www.newsonhealth.co.uk

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