Treating PMDD without Medications

In an earlier post, we defined PMS and PMDD, and briefly discussed their etiology. Here, we will look into the treatment of PMS/PMDD. While there are many pharmacologic treatments of PMDD, non-pharmacologic approaches may often be considered first. Indeed, just like mild to moderate hypertension is often first treated with lifestyle modifications like exercise and a low-sodium diet, PMS/PMDD is often improved with the following lifestyle modifications:

• regular aerobic exercise 4-5 times a week
• good sleep hygiene, i.e., establishing a consistent sleep schedule 
• dietary changes: limiting alcohol, caffeine, salt, chocolate, red meat, and eating smaller, more frequent meals with complex carbohydrates 
• avoiding stressful activities/ situations during the premenstrual period 

These interventions can often be started in the 2 months (or 2 menstrual cycles) during which a patient is completing the daily symptom ratings needed to confirm a diagnosis of PMDD, and for some women, they may be enough to control their symptoms. 

We have had patients ask us about whether certain vitamins and dietary supplements (like vitamin B6, calcium, magnesium, chasteberry, soy) are helpful for PMS/ PMDD symptoms. For most of these supplements, there is no consistent evidence from research showing that they are are better than placebo, and some may carry risks:   

• vitamin B6; at high doses may lead to peripheral neuropathy and there is only low-quality evidence that it may help with PMDD symptoms, so it is not recommended
• calcium supplementation has benefits beyond those on mood symptoms, but high doses may increase the risk of heart disease 
• soy was found to have reduced physical symptoms but not mood symptoms in women with PMS/ PMDD
• chasteberry (vitex agnus-castus) may also be more helpful for the physical symptoms rather than mood symptoms of PMDD

Some other therapeutic modalities that have been considered in the treatment of PMDD include group or individual psychotherapy, acupuncture, yoga, and bright light therapy. There is little research evidence available for most of these treatments, but bright light therapy in particular has shown some promise, and psychotherapy has shown promise but with small effect sizes. 

Do I have PMS? PMDD?

Discussions of premenstrual syndrome (PMS) cannot ignore the fact that it's partly a social construct, used in popular culture to explain women's increased emotionality--whether it be sadness or anger or anxiety--when it's "that time of the month." But for some women, the symptoms are much more severe than what is typically portrayed. As one woman wrote, "Every month I battle a monster. I gird myself with a healthful diet and a couple of pills, but the personality switch comes, like a lamp switched on, three weeks into my menstrual cycle. If most women get a little bloated, a little cranky, maybe a little confused, I swell an entire dress size and try to ban my husband from any room I'm in. Deciding what to eat for dinner so overwhelms me that I've broken down crying in the frozen food aisle."

In the psychiatric community, PMS's severe manifestation is called premenstrual dysphoric disorder (PMDD). The diagnosis is made using the following criteria from the DSM-5: 

It's a bit wordy, so here's a brief summary: PMDD is diagnosed by 1) the presence of at least 5 symptoms in the luteal phase of the cycle (including at least 1 mood symptom like irritability or mood swings), 2) the symptoms must be confirmed by prospectively monitoring at least 2 cycles, and 3) the symptoms must interfere with the woman's work, relationships, or other activities.

The American College of Obstetrics and Gynecology has a slightly different way of describing this condition, using the phrase "moderate to severe PMS" (rather than PMDD) and the diagnostic criteria of at least one psychological or physical symptom that causes significant impairment and is confirmed by prospective ratings.  Approximately 5-8% of women with hormonal cycles would be classified as having moderate to severe PMS, or PMDD.

The etiology of PMDD is unclear. Given the cyclicity of symptoms, it's long been thought to be related to the ovarian cycle, a brief overview of which is below:

There are 2 main phases--the follicular phase, and the luteal phase. In the follicular phase, an egg follicle in the ovary prepares to release an egg; this phase terminates with ovulation. During the luteal phase, the corpus luteum develops from the ovarian follicle and produces progesterone and estrogen. As you can see from the chart, estrogen levels peak prior to ovulation (while there is a smaller peak during the luteal phase), and progesterone levels rise significantly during the luteal phase. It's thought that the fluctuations in hormone levels--rather than a hormonal imbalance--may trigger PMS or PMDD symptoms, and that some women are more sensitive to these fluctuations than others.

However, hormones like estrogen and progesterone are not the full story; in fact, research has shown that the neurotransmitter serotonin modulates, or dampens, the impact of sex steroids on behavior, while sex steroids also affect serotonin transmission in the brain. We will be discussing the treatment of PMDD in a later post.