Premenstrual Syndrome (PMS)

In this episode, Sexual Health Physician, Dr Tonia Mezzini, tells us all about PMS. She will talk us through what is common and what is not, how to diagnose and how GPs can help manage PMS.

  • Transcript
    Please note this is a machine generated transcription and may contain some errors.
    *As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.

    *We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
    If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.

    Dr Tonia Mezzini is a Sexual Health Physician committed to improving women’s health. Tonia has a special interest in menopause and hormonal concerns, vulval pain and skin conditions, gender-affirming hormone therapy, complex contraceptive choices and more.

    Question 1
    The topic of today’s discussion is premenstrual syndrome.
    Tonia, can you describe for our listeners what premenstrual syndrome (PMS) technically is?

    So, premenstrual syndrome, or sometimes it’s called premenstrual tension is a range of symptoms that women report in the second half or what we refer to with the luteal phase of their menstrual cycle. And it can, it’s quite common. As many as 75 to 95% of women will report these ranges of both physical and psychological difficulties in the week or two weeks before their period. It can include symptoms like low mood, depression, tearfulness, sadness, being irritable, cranky, um, increased anxiety, difficulty, making decisions, difficulty concentrating, being more forgetful, low libido to some of the more physical symptoms which can be missed out your breast pain, weight, gain fluid retention, nausea, headaches, migraines. It’s quite an extensive list of what we call effective and sematic complaints. It’s I think the price that we pay for being able to bring children into the world and for being able to multitask well, at least three out of four weeks of the month, it is something that affects, as I said, many women, but only about five to 10% of women reports to be symptoms. And a similar number will present for, for help usually to their primary care practitioner. The GP is their first line of quest for help.


    Question 2

    What is the worst-case scenario for PMS?
    So, the worst case scenario is, is something we call premenstrual dysphoric disorder. So this is PMs, bigger, uglier, meaner sister. Um, it’s actually a DSM-5 diagnosis. And what this refers to is those physical and somatic symptoms that significantly impact on a woman’s ability to function. So, these, these are the kind of mood disturbances and physical complaints that make it difficult to work, to function in your family, to have relationships, to be able to study, you know, women will report that they need to take time off work. They need to isolate from their family. Um, and these sorts of symptoms cause significant distress. We need to make sure though that they’re not Judah, another medical problem. They’re not due to the effects of other drugs. Um, and we need to screen for other underlying mental health conditions as well because there’s often an overlap. Um, and that differential diagnosis that we need to consider.

    Question 3
    Is there anything that predisposes someone to having worse premenstrual syndrome?

    Well, that’s a really interesting question. That’s certainly the focus. There’s a lot of research over the last five to 10 years. We used to think that it was just fluctuating hormones, but our understanding has become more nuanced over time. And the current evidence points to an enhanced sensitivity to progesterone. So, progesterone is one of the hormones that fluctuates in that luteal phase of the cycle, but it’s not just the fluctuation of the hormones. It’s the underlying serotonin deficiency. So, it’s the interplay between hormones and neurotransmitters that we think is where the predisposition and the pathology can lie. We also think that there’s a dysregulation of Pedesta around metabolism and how that affects other neurotransmitters, not just serotonin, but also the gabber system, and also potentially low levels of endogenous opioids in women who eat, tend to experience particularly more physical symptoms in their luteal phase of the cycle. When you talk to women about their experience with PMs, they will often report a family history of the difficulty. So, they’ll say that their mum had difficulties, or their sisters have difficulties. And again, that relates to those inherited neurotransmitter pathways and hormonal sensitivities, which we’re starting to appreciate more.

    Question 4

    What can a GP do for a patient presenting with PMS?
    What we also need to consider in this question though, is when women present with premenstrual symptoms, is, is this a valid way for them to seek mental health support or is it a cry for help around intimate partner violence? Is it a question of profound fatigue? Women are often trying to juggle their work, their families, caring for young children, caring for older relatives and doing so with very little sleep and chronic fatigue, you know, sleep deprivation can absolutely present with similar sorts of symptoms. So while we consider the hormonal and the neurotransmitter pathways, we also need to consider the broader bio-psycho-social picture of where the woman is and why she’s presenting with this particular problem at this particular point in time.

    Well, like all potentially complex problems, we need to start at the beginning and break it down into chunks. And I think one of the challenges for GPS is that I often need to do this over two or three consults that don’t have the luxury that I have of, you know, 45 minutes per presentation. Um, so the first thing to do is to ask the woman to chart her menstrual cycle with the details of her physical and psychological concern, not just on a phone or an app, um, but actually written down on a piece of paper so that you can both look at it and see the patterns you’re looking for, a consistent pattern of symptoms across at least three cycles. It’s also important to remember. Women will often come in and say, you know, I need a blood test for my hormones. I think my hormone levels are balanced and all my levels are inherently unbalanced.

    They are cyclical. That is absolutely the nature of them. Um, but, and doing a blood test for estrogen, progesterone, testosterone, LH, and not helpful in diagnosing PMs because it’s, you know, a blood test of hormones is only ever a snapshot. The only time we’d advocate doing blood tests in this way is if we’re screening for polycystic ovarian syndrome or early or premature menopause. But it’s certainly important to remember to screen for things like fibroid dysfunction screening for anemia, low iron stores. And that can be very reassuring both for you and for the patient to know that you’ve covered off on excluding other physical problems that might be impacting on the presentation. And then it might be that in your second or third appointment, you spend some time screening for the broader context of mood disorders. So bipolar affective disorder, major depressive disorder, generalized anxiety disorder. And I’ve even seen some overlap with somatization disorder, complex PTSD and borderline personality disorder. So, it’s, it’s a big job to unravel, but it can be broken down into its component parts

    Question 5
    Is there anything that doesn’t work for PMS?

    Unfortunately, the list of things that doesn’t work for PMs or premenstrual dysphoric disorder is quite long. And that reflects the fact that there’ve been a number of things that have trialed that people have trolled, but the last couple of years have seen quite a few good quality systematic reviews, looking at the efficacy of various natural and alternative therapies and what we’ve found, doesn’t work it’s chase tree, which is a herb encode biloba, which is a herb, um, evening Primrose oil, homeopathy, calcium tablets, magnesium tablets, vitamin E multivitamins, reflexology chiropractic treatments by a feedback and extra doses of progesterone. This is probably the latest fashion trend is either; synthetical, bio-identical extra doses of progesterone. And I’m particularly concerned about those extra doses of Pedesta Rhone because of their association with increasing the risk of breast cancer. So just because the pedestrian is natural, um, doesn’t mean that it’s a useful therapeutic option. And we’ve outgrown that understanding about increasing the level of hormones that we provide to women as a way of treating pain there. So, I think if you’re seeing a practitioner and it’s advocating that, then it means they’re a little bit behind the time with their evidence

    Question 6
    Is PMS something you can truly cure? If not how common is reoccurrence?

    If we’re talking about cure, then probably the only way to cure the cyclical disease. Hormonal fluctuations are menopause and menopause present some of its own challenges. Um, that’s another pod talk in and of itself. Um, what we’re trying to do is to relieve the cyclical fluctuations, um, by managing hormones and then also managing the neurotransmitter pathways. So, the treatments that we offer to manage the symptoms depend on the woman’s preferences, their underlying health status, and also then the need for contraception impacts on our decision making here, as well as the severity of symptoms. So, someone who’s got, um, mild to moderate symptoms, sometimes an explanation of what’s going on, explaining what goes on in the normal menstrual cycle. And that this is quite common can absolutely be enough. It’s normalizing, validating. They realize they haven’t got any terrible underlying medical problem. They’re not going crazy. And that can be enough.

    The women who need oral contrast who need contraception, then if there’s no contraindications to the oral contraceptive pills, such as migraines with aura previous VTE, or, you know, they’re not current smokers, then we might look at starting an oral contraceptive pill and particularly an oral contraceptive pill with a four day, rather than a seven-day placebo break can be very useful to suppress ovulation. And sometimes we’ll actually run those oral contraceptive pills back-to-back. So, we skip the placebo pills entirely if that’s not sufficient, or if the woman doesn’t want to take the oral contraceptive pill or that’s not suitable then using SSRI medications either continuously or intermittently. So just in the luteal phase of the cycle can be very helpful. Sometimes if the PMs are more severe, then we’ll do both. We’ll actually use a continuous dose of an SSRI and a continuous dose of an oral contraceptive pill to suppress ovulation. And that can be, you know, the basis for starting a treatment plan.

    Question 7

    When should a GP refer?
    It always depends on the GPS level of comfort in expertise in managing these issues. Um, and all, all doctors, regardless of, you know, area of specialty will have subspecialty areas of interest. So I think it, it reflects on you as a practitioner, what you feel comfortable with managing and how much support you can get if things don’t go to plan, but certainly for most GPS, once you’ve tried an oral contraceptive pill and perhaps an SSRI, if that’s not helping things, then by the time that we start looking at more intensive treatments, like the GnRH agonist, such as Rolodex, um, with add back therapy, then I, that that would be the time that getting some specialist support would be really appropriate.

    Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on PMS

    I think first of all, it’s hugely important to validate and normalize that a woman’s concerned. So, explained sitting down with the chart and explaining what your menstrual cycle is, why the changes occur and the interplay between hormones and serotonin is immensely helpful. And absolutely that’s where we need to start. I think the second thing to always consider is to screen for other mental health issues, masquerading as a, as a hormone problem. So not just borderline personality disorder or generalized anxiety disorder, but also the bio-psychosocial picture of things like intimate partner violence, marital disharmony, fatigue of modern living and helping, helping women to thought out what is attributable to my cycle and my periods and what is part of a bigger picture. And then I think finally it’s really important that GPS and physicians avoid evidence-based treatment. They can do harm.

    And often the harm that they do is failing to provide an adequate solution to people. I often see people when they’ve seen two or three doctors or, and maybe a natural person chiropractor as well, and they are frustrated and worn out and the consequences of their mental health and physical problems not being attended to appropriately has had significant consequences for their life. And it, it saddens me seeing people continue to suffer unnecessarily when this is actually a problem we can manage. So, I think wasting, you know, I’m going to say wasting time with natural therapies is hugely problematic.

    Well, thank you very, very much for your insights today. And I’ve learned a lot..

    I think all men could do with learning a little bit about pre-menstrual tension and premenstrual syndrome. It might help them to be a little bit more understanding.

    70% is a big percentage of women who experience PMS. So, I totally agree. Thanks so much.

    Thank you

*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.