premenstrual treatment - pms treatment in dublin

Kill My Terrible Twin

It was a November morning in 2011. It was a first consultation with a new patient. We shook hands and sat down.

I asked the question which I always address to a new patient:  “If I had a magic wand: what  would you like me to do?”

“Kill my Terrible Twin” she replied.

34 years old married physiotherapist, mother of two children. Mary described significant period-related mood problems from “as far back as I can remember – I cannot recall a time when I was without it. The symptoms became much worse since I was  29 or 30.” The problem now was getting worse and worse.

The full range of standard PMDD treatment options  had been tried including anti-depressants and  pharmaceutically-induced menopause. The only treatment option left was a total hysterectomy. Total hysterectomy was an awful prospect for a young Mum only 34-years-old who really was only just setting out on life and parenthood.

In my experience there are other possible ways to assess, diagnose and treat PMS and PMDD  – whether it is mild PMS/PMDD or severe – without necessarily having to resort to hysterectomy.

  • Estimates of significant PMSvary: 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 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. PMDD there will usually be significant  effects on relationships with partners, children, work colleagues etc..

Do not underestimate the disruption potentially associated with 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 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 the medical literature is 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 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 Scandanavian 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 sufferers
  • 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  and may play a role in the causation of PMS and, presumably, by extension in
  • 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 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, wellbeing 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, brest pain, etc. etc

Cycle 2

Symptoms, How you feel, sleep, energy, mood, pain,  menstrual flow, brest pain, etc. etc

Cycle 3

Symptoms, How you feel, sleep, energy, mood, pain,  menstrual flow, brest 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.