PMS and PMDD
It’s like having a Terrible Twin
At Drummartin Clinic we have had many positive outcomes treating refractory PMS and PMDD – including in those who have already unsuccessfully tried artificial menopause.
We work towards finding the ‘root cause’ as much as possible. It is important, though, that while searching for causes you do not abandon your current ‘symptomatic’ treatment until you are fully better and have discussed the changes with your GP or psychiatrist.
PMS/PMDD – PODCAST
40 Year old Female with PMS/ Premenstrual Dysphoric Disorder (PMDD)
(Summer 2020)
40 Year old Female with PMS/ Premenstrual Dysphoric Disorder (PMDD)
Something tells me this story may be a bit long winded and perhaps even too deep, however take what you like from it and more than anything I would like it to help others. I think writing this in itself will be a therapeutic journey.
This shall be my first time in 25 years writing about my journey….
Since I was about 15 I have been under a veil of nothingness,’ it’s the only way I can describe it’. I was a very happy child and my parents said I was always very confident and would light up a room when I entered. I do remember being very happy as a child but I was always very sensitive to other people and their problems and really I was too young to understand struggles and life’s up and downs. Things happened as they do, that I would describe as traumas in my life.
I didn’t know that then.
My parents broke up when I was 8 and my baby brother was only after being born, I had a 5 year old sister and an 11 year old sister. While my Mam was in hospital with severe post natal depression and couldn’t even hold her head up or speak, my Dad had an affair.
I won’t go into details but I knew the woman very well and she pretended she was my friend and helped look after me when Mam was in hospital and let me help out in her restaurant. I didn’t know then but when Mam got out of hospital she realised what was happening and because I was mature for my age and we were so close she spoke to me like an adult and friend and therefore made me aware of everything that was happening.
I don’t blame her she just needed someone to talk to but I was told many years after that my ears were too young to hear. To make a long story short they got back together. My word fell apart from there really.
My older sister met her boyfriend when she was 15 and he became part of the family. He was 6 years older than me, when I was 16 he I suppose the term these days is ‘groomed me’ and I didn’t know how to stop it happening and it continued for a couple of years (no need for details but let’s just say he did a lot of wrong things and nobody in my family knew (I blamed myself for letting it happen and to this day I find it hard to realise he took advantage of my youth and inexperience and my good nature).
It wasn’t until he started giving my younger sister attention and she thankfully came to me, that I told my Mam and Dad what was happening, I couldn’t bare the thoughts of her getting hurt and taken advantage of, I had the strength to speak up for her but not myself.
College started and I had trouble fitting in because I had an abortion the summer before I started (a local boyfriend) and another one 3 years later (a drunken night a man took advantage of me).
I drank way too much all through my college years and drink and drugs made me feel warm and loved. I always wanted to feel wanted and loved and I got it from relationships and one night stands.
Of course that was only damaging me even more and more because it didn’t fill the hole.
My Mam brought me to counsellors over the college years because I used to come home some weekends and just cry and cry. If I drank coming up to my periods I used to get really aggressive and I used to self harm to punish myself for everything I did and felt.
I didn’t make the connection between my PMS and my moods until I was in my 20’s. My Mam and Dad even started making the link. I would become a totally different person for the week before my period and yet again I would try and numb it with drink.
I was prescribed anti-depressants by my GP in my mid-20’s and tried lots of different ones but they only took some of the edge off and numbed all my senses and emotions. I met a psychologist every week for 2 full years when I was in my late 20’s and he was amazing. He helped me deal with everything that had happened up to that point and helped me understand what I had gone through and I felt for the first time I had dealt with the skeletons in my closet.
I thought that would fix me but time moved on and I continued to not be me, it’s so frightening and alien like to feel how I felt on and off for years to come. Everyone else was happy and I couldn’t feel anything. From the outside I was happy, confident and managed 6 years of college and had registered as a nurse. I was a people person and people found me warm and fun to be with and I was never short of a boyfriend or friends but I just wasn’t me deep inside. I was so confused and wanted to be normal.
I met my now husband when I was 29 and we got engaged and married within 2 years. I was very up and down and 10 days to 2 weeks before my period I was agitated and aggressive and depressed. After I had my first daughter my hormones hit rock bottom and I was miserable but I struggled on. At some stage after I had my 2nd daughter and hit rock bottom again I went on my GP’s advice to see a psychologist. He spent 2 hours taking my history and diagnosed me with dystimia and double depression and started me on 200mg of sertraline (around 8 years ago).
Since then I improved somewhat but as I got older my PMT continued to get worse and worse. I would wake up after being me to being depressed, agitated and aggressive and not me. My husband and I would fight and I would storm off in the car and imagine driving into something just to turn off the lights inside me. I would often be walking down the street and want to walk in front of a car just so I could take a break from living and go to hospital for a while, all sounds so ridiculous but that’s how I felt. I would walk and cry, walk and cry for days and then things would get better until the following month.
Before I met Dr. Magovern I had my ovaries shut down with an injection with a view to having a hysterectomy to see if it would help but when it came to it the side effects from the loss of ovary function frightened me away from proceeding with the surgery. I felt like I aged 10 years in 3 months, it wasn’t a nice feeling (hot sweats, dry skin, dry eyes, hair falling out, weight gain) to mention a few. Of course weight gain has been a constant struggle all my life due to comfort eating and sugar cravings for 2 weeks out of every month and then I would stop bleeding and eat healthily and exercise and feel great until the next cycle.
I did some of my own research in 2019 and came across Dr.Magovern’s clinic in Goatstown on the internet. I discussed it with my husband and parents and they agreed it was worth a try because they suffered along with me all over the years and wanted me to find an answer. I made my first appointment and my husband drove me to Drummartin Clinic in October 2019.
That initial consultation I spent hours with Dr. Magovern and for the first time ever somebody understood me and asked all the right questions. He really listened and allowed me say everything I needed to say no matter how strange or confusing it sounded. Each question led to another and I realised that what I had been experiencing was real and that there was a reason for it.
It started with an in-depth consultation and I came home with a number of investigations to be carried out prior to returning to the clinic including bloods, urine and saliva tests. On return to the clinic I had a number of specialist blood tests and received an intravenous nutrient therapy called Myers cocktail to kick start my treatment.
Once the clinic had received all my investigation results including hormone measurements I commenced supplements and hormone replacement therapy. Over the next 6 months my treatment was monitored and my symptoms and changes discussed in depth. Some supplements were added and hormones increased gradually.
My last consultation with Dr. Magovern was Friday 24th of July and my first words to him was “ I haven’t experienced any changes in mood or character for my last 2 periods” bleeding just started and I turned to my husband and said I’m bleeding and felt normal all month. Either my husband or I could believe it.
My relationship with my husband was affected in so many ways and for years he knew the day I started PMT like a light switch had been pressed. He could see the cloud over me, I couldn’t speak properly without mixing up my words, I got clumsy, forgetful, lost interest in hygiene, brushing my teeth was an effort, agitated, and aggressive I always felt like crying but the sertraline doesn’t allow me to cry much anymore, it dulls all emotions, good and bad. He saw it in me for 2 weeks out of every month. It wasn’t fair on him or my daughters. Between the anti-depressants and low moods I had no libido and had lost all interest.
Today I can honestly say for the first time ever that I am starting to feel level now for the whole month, there isn’t that constant roller coaster every month. I am more content and free. I am feeling things again and my sex drive is definitely returning. I can enjoy it again (it’s not an annoyance or chore, I can let myself relax and enjoy it like I did in my 20’s)
I know my treatment is still being tweaked and I still have some symptoms to deal with but most of them are physical symptoms now, like night sweats and heavy bleeding and even if I was told I had to live with them I would be more than happy to minus all the emotional and psychological torment I have suffered for the past 20 years. However Dr. Magovern is continuing to monitor my progress and is constantly reaching for the stars.
I would like to finish by referring to Vincent Van Gough’s Starry Night painting. It depicts the view from the east-facing window of his asylum. In the aftermath of his breakdown that resulted in the mutilation of his left ear Van Gough admitted himself to this lunatic asylum.
He could see this beautiful image after his torment and my own Starry Night is also emerging with all its beauty, emotion and colour. When that fog is there every month it’s impossible to see any stars but they are truly starting to shine now and I can identify with Dr.Magovern’s idea of “Reaching for the Stars”. The next step is weaning off my anti-depressants, don’t get me wrong there is a time and a place for them and I needed them but they weren’t the answer in the end.
- Estimates of significant PMS vary from 12.6% to 31% of menstruating women. According to studies approximately 20% of reproductive age women have moderate to severe PMS.
Premenstrual dysphoric disorder?
- PMDD is estimated to affect 5% to 8% of menstruating women. The average age of onset of PMDD is 26 years
The key differentiator between Premenstrual Syndrome (PMS) and PMDD is
- Severity of symptoms.
- Premenstrual syndrome (PMS) sufferers have less severe symptoms.
- Premenstrual dysphoric disorder (PMDD) sufferers have much more severe symptoms which are significantly more life-disrupting.
- With PMDD there will usually be significant effects on relationships with partners, children, work colleagues etc.
Do not underestimate the disruption potentially associated with Premenstrual Syndrome (PMS) – it may still cause quite a degree of disruption especially if a woman is on a ‘bad’ month symptom-wise.
Standard medical thinking states that the causes of Premenstrual Syndrome (PMS) and PMDD are not well-understood and that hormone level changes lead to changes in the levels of key neurotransmitters (serotonin, dopamine, noradrenaline and GABA). It really does not go much deeper than that.
- Variation in age of symptom onset.
- A significant number say : “the PMS began with my first period” – this is despite the average age of onset of PMS/PMDD in medical literature as 26 years
- Some women report puberty as a huge mood ‘watershed’
- They will report feeling totally ‘carefree’ before puberty but then experiencing a relatively abrupt transition to a huge increase in day-to-day anxiety with a daily low mood pretty well as soon as their periods began
- In real life a significant number of women with Premenstrual Syndrome (PMS) or PMDD will already have day-to-day anxiety or low mood
- They will experience a huge ramp up of symptoms in the 1 to 2 weeks before their period. Then, as the period arrives, they return to the ‘lower’ level of everyday anxiety which troubles them.
- If someone tells me “I just could not take the contraceptive pill – it made me ‘psycho’ ” or words to that effect, I suspect that abnormally elevated free copper levels may be in the diagnostic mix.
- In severe PMS and PMDD I frequently hear:
- “I spend the first week of my cycle period apologising to x……….” Partners, family members, work colleagues, friends any or all get a mention.
- A significant number of PMS/PMDD sufferers also suffer from SAD and other mood disorders.
In a Scandinavian medical study of 40 women suffering from premenstrual syndrome (PMS) and 20 control (i.e. non-PMS-sufferers) it was discovered that in the PMS sufferer:
- Mean average plasma copper was higher,
- Mean average plasma zinc was lower
- Mean average plasma magnesium was lower
- Zinc/ copper ratio was lower (i.e. significantly less zinc relative to copper)
It also was observed that
- After ovulation i.e. week 3 and week 4 of the cycle, magnesium and zinc levels were significantly lower in the PMS group compared to non-PMS sufferers – this of course is the time when symptoms appear.
Summary
- Elevated copper, reduced zinc levels, reduced magnesium and a reduced zinc/copper ratio may play a role in the causation of PMS.
- Rule out other similar diagnoses
- Make sure the patient is not suffering from an anxiety disorder, depression, a thyroid abnormality or something else which may partially mimic symptoms of Premenstrual Syndrome (PMS) or PMDD.
- It is considered that measuring hormone levels is not helpful (I disagree strongly)
- Keep a symptom diary for a minimum of two months, ideally three months
- This is very helpful to doctors and patients in making a diagnosis.
- Call the first day of your period “day one”
- Fill in on a spreadsheet the symptoms which occur on each of the days of your cycle
- If you are someone who has a 28 day cycle on day 28, record 28 days and then start again next day on the first day of your next period in a new column(see below). This enables patterns to be spotted.
Diary re:your cycle, for the full month: sleep, well being etc. Put in Excel sheet, do it day by day.
|
Day of cycle (1st day of period = day 1) |
Cycle 1
Symptoms, How you feel, sleep, energy, mood, pain, menstrual flow, breast pain, etc. etc |
Cycle 2
Symptoms, How you feel, sleep, energy, mood, pain, menstrual flow, breast pain, etc. etc |
Cycle 3
Symptoms, How you feel, sleep, energy, mood, pain, menstrual flow, breast pain, etc. etc |
| Day 1 | |||
| Day 2 | |||
| Day 3 | |||
| ….………….. | ………………… | ||
|
Day 28 – 35 or more depending on cycle length |
|||
| MOVE TO NEXT CYCLE COLUMN | Period commences | Period commences |
|
The standard treatments for PMS and PMDD include
- Antidepressants particularly SSRIs,
- Non-steroidal anti-inflammatory medicines if needed to help with cramping and breast discomfort,
- Diuretics if needed to treat fluid retention
and - hormonal contraceptives.
- Exercise and salt restriction also are important.
Premenstrual dysphoric disorder
- If very severe e.g. suicidal ideation, PMDD must be considered a medical emergency
- Is not something to be trifled with.
- It is important to follow the advice of your GP or psychiatrist.
In 2016 I had a professionally life changing experience when I attended a four day training seminar for doctors and psychiatrists in the US
- I became aware of the work of Dr William Walsh of the Walsh Research Institute in Chicago on brain biochemistry.
- I took the seminar again in 2017 because the information was just so fantastically useful in my practice
- I suddenly understood why some patients could not tolerate the birth control pill or tolerate hormone replacement
- in my experience the intolerance of oestrogen tends to be much more severe than intolerance of progesterone
- I became aware of the potential role of elevated free copper in premenstrual syndrome/PMDD
- Elevated free copper may also play a role in postnatal mood disorder
- Copper of itself is not a ‘baddie’: We all need the right amount of free copper. Too much free copper may be a problem.
- If the free copper gets too high
- it may result in too much noradrenaline (anxiety and sleep problems) and also
- too little dopamine (lack of focus) and the result is a strung out, tired and irritable woman.
- A group of substances called the metallothionines play an important role in copper regulation within the body i.e. maintaining copper levels within an optimal physiological window so that copper levels are not too high and not too low. Other members of the metallothionine family also have a role in taste which explains why
- Some individuals are very attracted to strong flavours e.g. salt and spicy in particular because their sense of taste is diminished due to low metallothionine levels.
- Increase in oestrogen (e.g. or hormone replacement whether bioidentical or pharmaceutical) in vulnerable individuals
- can drive free copper levels upwards causing anxiety and PMS/PMDD type symptoms
- During the human female life-cycle there are three times in particular when copper levels may go out of balance – they all are times when oestrogen levels may be in a state of flux
- at puberty/onset of periods
- during and after pregnancy
- during perimenopause
- This also threw more light for me on postnatal anxiety /postnatal mood disorders.
Methylation chemistry is important to consider when diagnosing and treating p.m. S/PMDD since methylation critically important to the functioning of the human body
- without adequate methylation, there will be reduced serotonin and melatonin availability
- Reduced serotonin and melatonin availability may make itself known through symptoms which may include
- low mood, irritability,
- sleep issues
- carbohydrate cravings
- Seasonal affective disorder – typically the person who just feels their energy drain on dark days
Methylation is critically important
- To detoxification in the liver i.e. how the body breaks down foreign substances and also its native chemicals which have passed their usefulness
My diagnosis and treatment strategy for PMS/ PMDD is based on trying to look at the ‘big’ picture diagnostically
It is important that the patient completes a detailed pre-consultation questionnaire
- Outlining everything from past medical history to allergies to social history because, when someone has a complex medical problem there is a lot to do in a one-hour consultation period!
- The pattern of PMS/PMDD – this needs to be assessed individually because there is no one-size-fits-all treatment
- Most but not by any means all women with severe PMS will report the aggressive type of PMS
- There also are relative oestrogen-deficient types [see below] of PMS/ PMDD
- It is important to also carry put a general laboratory screen of ‘routine’ blood tests
- Measuring oestrogen and progesterone both early and late in the cycle is important in my opinion
- Days 2-5 (that is during the menstrual bleed)
- Day 18-21 depending on cycle length
- It is important to pay attention to copper levels, methylation status and also to consider the possibility of pyrrole disorder
Oestrogen deficiency in PMS
Some women who suffer from PMS may have a deficiency of oestrogen, This may or may not be in addition to a deficiency of progesterone. Cyclically oestrogen-deficient women may report a mixture of
- fatigue and low mood especially in the premenstrual week
- pre-menstrual constipation and carbohydrate cravings
- vaginal dryness, ‘brain fog’, night sweats and significant fatigue during the menstrual period
- May report report being “fatigued, slowed and overwhelmed” pre-menstrually
- may report feeling faint premenstrually – especially first thing in the morning
- these women in particular may become weak if inappropriately prescribed progesterone on its own.
I emphasize the treatment of PMS or PMDD
- is not just a matter of simply prescribing generous amounts of supplementary progesterone pre-menstrually
- Too much progesterone relative to oestrogen may affect the patient adversely
Other issues not to be neglected include:
- Attending to magnesium status,
- Optimising digestion and gut bacteria (70% of serotonin is manufactured in the bowel)
- Awareness and possible manipulation of neurotransmitter/brain chemistry levels.
- Other general measures to reduce the overall level of inflammation in the patient’s body
Breast soreness in the medical history
- may point to an iodine imbalance
While one of my mantras is that I continually say :” there are no magic bullets” but,in my experience, given cooperation between doctor and patient it is usually possible to achieve a good outcome for patients experiencing menstrual cycle related mood disorders.
Personally I do not prescribed antidepressants for PMS are PMDD but, if patients already are on them I will build treatment plan around the medicines which they are already taking.
At the core of this approach is an attention to detail which looks at: levels of oestrogen and progesterone at different parts of the menstrual cycle, calculation of free copper levels, awareness of zinc and magnesium, assessment of methylation chemistry, the gut micro biome, the patients brain chemistry, overall level of inflammation and digestive processes.
It is an approach which utilises both medical history, ongoing symptom monitoring and laboratory testing as three pillars of a detailed diagnostic approach which, in my experience, frequently gives excellent results. Personally I do not prescribe antidepressant for the purpose of treating PMS or PMDD but will happily work alongside your GP or psychiatrist to look at all the other factors which may be involved in menstrual cycle related mood disorders.
In this article you will find interesting, additional information Premenstrual dysphoric disorder (PMDD)