PMS, PMDD and menopause

The impact of hormones on PMS and PMDD, plus managing symptoms

• Symptoms of premenstrual syndrome (PMS) include feeling overwhelmed, tearful, anxious or angry in the run up to your period
• Some women experience a very severe form of PMS known as premenstrual dysphoric disorder (PMDD)
• Hormone fluctuations during perimenopause can worsen symptoms of PMS and PMDD

What is PMS?

PMS covers a wide range of physical and emotional symptoms that you may experience before your periods. The most common of these are mood swings, feeling low in your mood, anxious or irritable, tiredness or trouble sleeping, bloating or tummy pain, breast tenderness, headaches, skin breakouts, greasier hair and changes in appetite and sex drive. The symptoms are the same as symptoms of perimenopause and menopause.

These symptoms are usually due to changes in hormone levels – especially progesterone and oestradiol – during the second half (luteal phase) of your cycle.

The timing of symptoms is important to make a diagnosis of PMS and PMDD, says Newson Health GP and Menopause Specialist Dr Hannah Ward. ‘About 90% of women will experience some PMS symptoms,’ she says. ‘They can vary a lot, and for about a third of women, they will interfere with their daily activities. To be PMS, the symptoms must occur in the luteal phase and resolve within a few days of your period starting.’

RELATED: All about progesterone: PMS, PMDD, postnatal depression and menopause

What is premenstrual dysphoric disorder (PMDD)?

PMDD is a severe form of PMS, which is thought to affect around 5% of women [1]. The symptoms are similar to PMS but much more intense and have a much greater negative impact on the life of those affected.

Definitions vary slightly, but the most commonly used is the Diagnostic and Statistical Manual of Mental Disorders, which says a woman must experience at least five out of 11 distinct psychological premenstrual symptoms, one of which must include mood [2]. Other symptoms on the list include marked anxiety, lethargy and decreased interest in usual activities.

These five symptoms should be present in the two weeks before your periods and start to improve within a couple of days of your periods starting, and be minimal in the week after your period.

One of the symptoms can be suicide ideation: an international study found that a third (34%) of 2,689 women affected by PMDD who completed a questionnaire said they had attempted suicide [3].

‘PMDD can be very severe but it is often not acknowledged,’ says Dr Hannah. ‘Often women will discuss it with their doctor who may dismiss the symptoms as they are not aware of PMDD and don’t realise how bad it can be.’

RELATED: What is reproductive depression factsheet

How will perimenopause affect my PMS or PMDD?

Unfortunately, perimenopause – when your hormone levels start to decline ahead of your periods stopping – can make your PMS or PMDD worse.

‘Symptoms are often more severe around times of hormonal change – so puberty, after having a baby and perimenopause are key times for this,’ Dr Hannah says. ‘Women who have not had PMS before can develop it, and if a woman had PMS before, they tend to get similar symptoms they have always had, but they are more severe, particularly the emotional and psychological ones.’

The amount of time that you experience the symptoms can also increase as your cycle becomes more erratic and starts to change. As you may not be regularly releasing an egg (ovulating), the symptoms can spread throughout your cycle as the changes in hormones start to fluctuate.

RELATED: All about progesterone: PMS, PMDD, postnatal depression and menopause

What can I do to help manage my symptoms?

It is worthwhile keeping a dairy of your symptoms and menstrual cycle for a month or even a few months, if possible. The free period tracker on the balance app is a good option for this, and the National Association of Premenstrual Syndrome (NAPS) also has an online menstrual diary.

Guidance for healthcare professionals says women with PMS should be advised on ways to improve diet and sleep, increase exercise, stop smoking, reduce alcohol intake and reduce stress. These lifestyle changes, particularly increasing movement, can have a beneficial impact, Dr Hannah says.

You can read more about creating long lasting food habits for better health and exercising during the perimenopause and menopause.

However, these lifestyle measures should not be regarded as a substitution for treatment – which is often with hormones.

RELATED: Premenstrual syndrome and the menopause booklet

What about treatment options?

As PMS and PMDD are usually caused by changes in hormones, replacing the missing hormones with the right dose and type can really improve symptoms. Sometimes hormones are given in a way to suppress your changing hormone levels, so you have a constant level of hormones in your body each day.

RELATED: Managing menopause beyond HRT

Many women with PMS and PMDD are prescribed the contraceptive pill. However, although the contraception stops ovulation, it contains synthetic types of oestrogen and progestogen, which have different effects in your body than natural (body identical) hormones.

This means that synthetic hormones can lead to side effects occurring, such as low mood, anxiety, reduced libido and low energy, and also are associated with risks including blood clots and increased breast cancer risk over time.

‘For women who are perimenopausal, HRT will often bring other useful benefits and help with other menopausal symptoms that the pill won’t,’ says Dr Ward. ‘It will also help protect your future risk of osteoporosis and cardiovascular disease.

If you have severe PMS or PMDD leading to depression, you may also be prescribed a type of antidepressant called a selective serotonin reuptake inhibitor (SSRI). SSRIs are useful for some women, and they work better with HRT. ‘You can take both, and often antidepressants work better when someone takes HRT as well,’ she says.

The RCOG and NAPS guidance agree that HRT, through an oestrogen skin patch combined with cyclical progestogen, is a good way to manage the physical and psychological symptoms of severe PMS.

And it’s worth pointing out that often women will be prescribed oestrogen or progesterone separately, and some women’s symptoms will improve with (body identical) progesterone alone.

Progesterone is produced following ovulation and for most women it has calming, anti-anxiety (anxiolytic) properties when it acts on the GABA receptors in the brain. But some women are particularly sensitive to progesterone, known as progesterone intolerance, and the hormone can have a paradoxical effect of worsening mood and anxiety.

RELATED: Progesterone intolerance

In the last week of your cycle, known as the late luteal phase, progesterone levels drop off rapidly and this fall in progesterone may well be one of the underlying causes of PMS and PMDD. This theory was originally suggested by Dr Katharina Dalton, author of a number of books on PMS including the PMS Bible and Once a Month.

Using high doses of body identical progesterone in the form of Cyclogest 400mg vaginal pessaries twice (or sometimes more) daily may improve symptoms more than oral progesterone for some women.

RELATED: Cyclogest: what you need to know

‘It can be a journey to find exactly the right combination of medication that will work for you,’ says Dr Hannah. ‘Expect to have to be persistent, as sadly many doctors don’t know enough about this. If the first treatment doesn’t work, go back and tell the GP that you need something else. Ask to be referred to a PMS specialist if you’re not getting the help you need.’

Some women also benefit from testosterone if they have symptoms of testosterone deficiency and their blood test shows low testosterone.  

RELATED: The importance of testosterone for women

What if my PMDD still can’t be controlled well?

For the most severe cases, the surgical removal of your womb and your ovaries is an option, but this should only be considered after all other options have been unsuccessful. Removal of your womb and ovaries will trigger what is known as a surgical menopause.

As the hormones, oestradiol, progesterone and testosterone are made in your brain as well as your ovaries, some women find they still experience symptoms after this operation.

Most women are under the age of 51 years when they have surgery to remove their ovaries; their body’s requirements for hormones is greater compared to that of older women going through menopause naturally, so it is important to consider taking hormones until at least the usual age of menopause for the long-term health benefits. Most women take HRT for ever as the benefits usually outweigh any risks.

RELATED: Surgical menopause: Dr Rebecca Lewis & Dr Louise Newson

It’s important that treatment is individualised, and your healthcare team work with you to take into account your medical history, symptoms and preferences.

What about when I reach menopause?

The good news is when you reach menopause – officially 12 months after your last period – your PMS symptoms will likely resolve. This is often as your hormone levels are not fluctuating.

However, you may find that you experience menopause symptoms, which can include low mood, hot flushes, night sweats, joint aches and pains and vaginal dryness. HRT will replace your hormones, ease symptoms and provide long-term health benefits.

RELATED: Perimenopause, menopause and HRT: everything you need to know

Resources

Premenstrual Disorders, Timing of Menopause, and Severity of Vasomotor Symptoms

References

1. Gudipally P.R., Sharma G.K. (2022), ‘Premenstrual Syndrome’ [Updated 2023 Jul 17]. In: StatPearls. Treasure Island (FL): StatPearls Publishing

2. Reid R.L. (2017), ‘Premenstrual dysphoric disorder (formerly premenstrual syndrome)’. In: Feingold K.R, Anawalt B., Blackman M.R., et al., eds. Endotext. South Dartmouth (MA): MDText.com, Inc

3. Eisenlohr-Moul T., Divine M., Schmalenberger K., et al. (2022), ‘Prevalence of lifetime self-injurious thoughts and behaviors in a global sample of 599 patients reporting prospectively confirmed diagnosis with premenstrual dysphoric disorder’, BMC Psychiatry, 22(1):199, doi:10.1186/s12888-022-03851-0