All About PMDD: Is it my hormones, my brain, or both?

PMDD, or premenstrual dysphoric disorder, has been gaining a lot more attention over the past couple years. Many women have been finding that their monthly PMS (pre-menstrual syndrome) symptoms are a lot more severe than they should be, eventually leading them to a PMDD diagnosis. In this article I’ll be taking you on a deep dive on what PMDD is exactly, its signs and symptoms, what causes the condition, and potential treatment options. My hope is this deeper insight can better help you understand your body and reach the best treatment options for you.

So what is PMDD and how do you know if you have it?

PMDD is a severe and often debilitating form of PMS. PMS is like a spectrum, ranging from mild to most severe forms. Mild PMS where you feel a bit more sensitive for example and notice a couple changes before your period is normal. But severe symptoms that significantly disrupt your quality of life is where PMDD usually falls, placing it on the highest upper end of that PMS spectrum. PMDD is characterized by a range of physical and behavioral/psychological symptoms that occur in the week or two before your period and disappear a few days after the start of the menstrual period. These symptoms can feel like they significantly impact your daily life and relationships.

In PMDD the psychological symptoms especially are the most severe and often include: anger, irritability, feeling “out of control”, paranoid, depressed mood, anxiety, moodiness, crying spells, emotionally very sensitive, and a lack of interest in things you usually enjoy.

Some physical symptoms may include: sleep troubles (can’t sleep or sleep a lot), very fatigued, breast tenderness & pain, swelling of hands/feet/other areas, appetite changes, hot flashes, bloating, constipation, nausea, pelvic heaviness/pressure, backache, acne, heart palpitations, headaches, and often times quite painful period cramps.

I will say many of these physical symptoms are also related to other gynecologic conditions like endometriosis, uterine fibroids, or ovarian cysts, to name a few. So, it’s important to see a gynecologist that will rule out and exclude all other diagnoses before just labeling you with “PMDD”. As you can see PMDD symptoms can be vast and therefore the room for making a diagnosis is quite large. Your provider should be mindful to rule other conditions out before jumping to a PMDD diagnosis. Make sure to advocate for that, especially if you also have many physical symptoms. Also keep in mind that PMDD is a severe form of PMS, so even if you don’t fall under a “PMDD diagnosis” you may still very well have disruptive PMS symptoms, and that’s not ok to just chalk up as “that’s normal so live with it” either. Since PMDD is a variation of PMS, the points discussed in this article are applicable to both PMS and PMDD.

Because of the vastness of this topic, I will focus this blog article on the psychological/mental health symptoms in PMDD. There will be later blogs to come and some linked below on the physical symptoms.

What causes the psychological symptoms in PMDD?

Now that we know what PMDD looks like, it begs the question, why do some women have PMDD whereas other women barely notice any PMS symptoms at all?? To answer that question let’s look at the hypotheses around what causes PMDD.

Scientists have differed on what exactly causes PMDD, but over decades of research the winning hypothesis has been the “neurotransmitter-hormone” hypothesis. But it gets more complicated. The neurotransmitter hypothesis is also associated with inflammation from the immune system and stress hormones related to your hypothalamic-pituitary-adrenal axis, linking all these systems together! You’re probably wondering, what does all this jargon even mean?! Let’s break it down, starting with the neurotransmitter hypothesis. 

Neurotransmitter Hypothesis:

The neurotransmitter hypothesis suggests that PMDD is caused by the interaction between neurotransmitters, such as serotonin, norepinephrine, and GABA, and your hormones, specifically estrogen and progesterone. What this hypothesis is saying is it’s not that your estrogen and progesterone levels are out of range and causing changes in your neurotransmitters, but rather women with PMDD have nervous systems that are more sensitive to their hormones. Let’s take this example, hypothetically let’s say Sarah’s estrogen levels are 80 and her progesterone levels are 5. Every month for 1-2 weeks before her period Sarah experiences significant psychological symptoms like anger, depression, and frequent crying that significantly disrupt her life. And let’s say Laila has the same lab values as Sarah, estrogen at 80 and progesterone at 5, but Laila has zero symptoms and no issues before her period at all!! That is the essence of the neurotransmitter hypothesis. It’s not that your hormones are out of the normal range, but rather your brain and nervous system react to your hormone levels more sensitively than someone else. This sensitivity may be due to genetic factors, environmental exposures, and other underlying mechanisms that are not yet fully understood.

So, what do we know?

We know that estrogen and progesterone do impact which neurotransmitters are made and how long they last in the brain, and in PMDD these effects are amplified. In various studies, estrogen has been shown to ramp up the production of serotonin, dopamine, and other neurotransmitters like epinephrine. That may sound like a good thing but too much production of these neurotransmitters can give you a “wired” or “on edge” feeling, as though you are constantly activated and easily triggered. On the other hand, progesterone has been linked to an increase in GABA production. GABA is a neurotransmitter that helps with relaxation, so too little of it can leave you feeling anxious. But again, too much of it can also result in depression or anxiety.

How is PMDD treated?

As you can see, estrogen or progesterone fluctuating in either direction can skew the neurotransmitters that swim around in your brain. Again, bearing in mind that your estrogen and progesterone levels aren’t “out of range”, so when we say we should support hormone health in PMDD that can look like, for example, making sure we remove estrogen-like chemicals from the environment that may be mimicking estrogen in your body and tipping the scale. Or making sure that you have a helathy gut microbiome (gut microbes) that metabolize and absorb your hormones in a proper manner.

In addition to addressing those hormonal aspects, addressing your neurotransmitter health directly is also key. With my patients struggling with PMDD we always include herbs and nutrients that help to buffer the neurotransmitter and hormonal fluctuations happening each month. We’ve had lots of success with that combination approach, making sure both hormone and brain health are targeted. This is also why you often see that SSRI medications (mood stabilizing medication) and/or birth control pills are often prescribed together to patients with PMDD. The SSRIs are targeting the neurotransmitter component and birth control pills are targeting the hormonal fluctuations, so both are addressing the brain and hormonal health pieces as well. The only difference is 1) these medications come with side effects or risks that may not align with your health goals or values and 2) the moment you stop the medications the symptoms typically come back. A big part of that is because the root causes behind brain and hormonal health (listed in more detail at the end of the article) aren’t being addressed fully with these medications, they serve to provide that relief in the moment they are used. Now don’t get me wrong, at times when we’re in a dark place or crisis we need those medications to pick us up and bridge us over to lifestyle and natural approaches when possible. I just want you to know that they’re not your only option.

In addition, unfortunately, these medications also have increased risks associated with them the longer they are used. SSRIs for instance increase the risk of suicidal thoughts for some individuals the longer they are used and the side effects of SSRI withdrawal can be debilitating. As for birth control, there is the small but existing risk of blood clots, migraines, blood pressure issues, and the risk of nutritional insufficiencies mostly in the B vitamins. For example, birth control pills have been shown to lower vitamin B6 levels, especially if taken for a longer period of time. Ironically B6 has been shown to help with the psychological symptoms in PMDD, so you wouldn’t want it decreased.

For these reasons and many others, I find that it can often be preferred to use natural alternatives that don’t carry many of those risks. Of course, there’s always a time and place for SSRI medications and birth control pills and sometimes they may be necessary or the best choice, I just want to emphasize that they are not the only choice. Also, the choice doesn’t have to be either or, all these nutrients can be safe options to augment the treatments you’re already doing. Here are a couple examples of nutrients you can give a try to relieve some of those PMDD symptoms:

  • A combination of magnesium, vitamin B6, and calcium has become more widely used for PMDD treatment, so much so that it’s a PMDD treatment recommendation on John Hopkins’ hospital website. I often include all three of these alongside omega-3s as well for patients with PMDD, here’s how each one is used:
    • Magnesium – Magnesium can greatly help with period cramps and pain and has been shown in clinical trials to help with mood regulation as well. Check out my “Magnesium for Period Cramps Relief” blog for exact dosing instructions and how to use magnesium. Magnesium has specifically been shown to help with PMS-related anxiety when combining it with vitamin B6. Make sure to consult with your doctor before using magnesium if you’re on blood pressure medication!
    • Vitamin B6 – also a great option for helping with those mood-related symptoms. It’s helpful at a dose of 100 mg/day. Don’t exceed this dose. Doses that are multiple times higher than 100 mg/day over a long period of time can cause neurological toxicity.
    • Calcium – calcium has also been shown in various studies to reduce mood symptoms related to monthly menstrual cycles. The dose used is 1,200 mg per day.
    • Omega-3s – Omega-3s have been studied extensively in depression, anxiety, and other mental health conditions. Omega-3s are an essential nutrient and a building block for brain cells (makes up cell membranes), so your brain health suffers without them. Many Americans don’t get enough omega-3s. If you’re not eating 2 servings of fatty fish per week then you don’t meet your minimum omega-3 needs. I recommend any of my patients with PMDD or mood-related conditions to add in omega-3s. The dose I often recommend is between 3000-4000 mg per day for mood stability / brain health. I am very particular on the brands of omegas I recommend because omega-3s oxidize easily, meaning they essentially “rot” quickly on the shelf if they are not formulated properly. I explain this in more detail in this video.
  • As always, make sure to consult with your medical provider before starting any supplements, especially if you’re on any medications or have any medical conditions.
  • It’s important to note that many of these supplements have been shown to be most effective when used for a couple months. Meaning, each month you use the supplements the more effective they are. Most studies show that peak efficacy is at month 3 (i.e., after 3 months of using the supplements is when participants noted the best results).

​Some examples of quite effective herbal therapies that have been studied in numerous clinical trials include St. John’s wort, vitex/chaste tree berry, ashwagandha, reishi mushroom, motherwort, to name a few. For each of my patients I always include some or all of the above nutrient recommendations alongside a few herbal recommendations. All my recommendations are customized to the individual’s needs depending on which symptoms are present. However, alongside any supplements, I always make sure we work on addressing root causes behind why that person may be experiencing more sensitivity from their hormones. This allows us to wean off some of the supplements over time and just keep a select few that are the most helpful. Some of those root causes include:

  • Detoxification of exogenous estrogens or estrogen-like (i.e., endocrine disrupting) chemicals from the environment (chemicals in products that mimic estrogen in the body)
  • Making sure gut health is optimized with well-formed easy to pass daily bowel movements and proper fiber intake (estrogen partly leaves through the stool!)
  • Making sure liver health and detoxification is addressed (estrogen gets detoxified through your liver too)
  • Supporting the brain with both micronutrients and phytonutrients it needs from foods
  • Addressing stress through the hypothalamic-pituitary-adrenal axis and inflammation from the immune system (I didn’t get to discuss these here, but they are related to other hypotheses about PMDD causes – more to come on this in a later blog!)

In summary, to properly address PMDD it’s best to target both hormonal and brain health. If you or someone you know is struggling with PMDD, know that you are not alone and that there are effective treatment options available, whether that is naturally or through pharmaceuticals. Make sure your provider makes you feel heard, validated, and supports you in finding the best options for you. As I always like to say – your treatment plan should make you feel empowered.

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