(Snarl your answer) “JUST ONE! ME! HEY, BUDDY–YOU GOT SOME SORT OF PROBLEM WITH THAT?!”
Ah, PMS. Even if you don’t ever want a baby let’s see if we can fix things so you don’t have to put up with this crap for 30 years.
I can write about PMS, and over the years have helped many women deal with the emotional roller coaster and physical miseries of it, but I haven’t the vaguest idea what it feels like. From what I’ve heard, I’m pretty sure I’d prefer a couple hours of root canal, and when I think of the controversial rabbinic prayer thanking God for not having made the supplicant a woman I do believe it offers thanks for the inner peace of a PMS-free life.
Although dozens of symptoms are linked to PMS, there are basically three major themes: (1) a cornucopia of unpleasant physical sensations, (2) a smorgasbord of mood swings, and (3) both. Most women with PMS have both. Patients with PMS might begin by describing to me their breast tenderness, fatigue, or migraines and not mention emotional issues at all until I specifically inquire. To which the answer is invariably “Oh, yeah, of course, those.”
As you likely know, the culprit behind PMS misery is hormones, the monthly rise and fall of estrogen and progesterone. Every month, like it or not, estrogen gets your body ready to become pregnant. Immediately after you ovulate (release an egg), your estrogen levels start dropping at the same time a tsunami of progesterone turns your uterus into a comfy hidey-hole for a fertilized egg.
But if there is no fertilized egg, your whole system uncomfortably resets itself by rapidly lowering levels of both estrogen and progesterone, and the price of this is PMS. If an egg is fertilized and you’re pregnant, you’ll experience all sorts of new and surprising symptoms, but I guarantee you one of them won’t be PMS.
In case you weren’t paying attention in your high school health class, here’s what happens physically, and why you and your sisterhood feel differently every week of the month:
- After your period ends, estrogen quickly rises. You’ll feel sexy maybe. One study showed during this week waitresses earned more tips.
- Ten days later, a mega-surge of estrogen forces release of an egg.
- Assuming it’s not fertilized, a few days later (with estrogen falling and progesterone rising) you enter the realm of PMS and you feel like a completely different person.
- A few days after that, along with the falling estrogen your progesterone plummets as well. This triggers your uterus to shed the lining it had prepared for a fertilized egg.
This transformation is simply mystifying to men. Their sex hormone, testosterone, peaks around age 19, making them so horny they could enjoy sex with a hubcap. Then, for three or four decades, it remains at a steady level until around age 50 it begins to, well, dwindle.
PMS: the physical symptoms
Physical symptoms like breast tenderness, fluid retention, and feeling bloaty all occur because your estrogen is not falling quickly enough or low enough in relation to your progesterone. This is called estrogen-dominant PMS, in which estrogen levels are higher than those of progesterone, rather than the reverse. You’ll notice this mainly in your breasts because they’re loaded with hormone receptors, but there are many other symptoms as well.
If you want a list of all the symptoms associated with estrogen-dominant PMS, just unfold the torah-like package insert that accompanies a box of birth control pills (BCPs) and read the entire side effect list. That’s because BCPs contain estrogen.
PMS: the emotional symptoms
Linked to estrogen is serotonin, your feel-good, stress-buffering neurotransmitter. Envision a two-car roller coaster, estrogen up front, yanking along your serotonin. When estrogen is high, as it is during the first and second weeks of your cycle, serotonin is also high, your mood is good, and the world is all right.
Just for the record, when you’re pregnant your estrogen soars extra high (the source of morning sickness). Tagging behind, serotonin goes extra high as well and as a result, once your nausea is under control mood is generally very good throughout pregnancy. More than a few women have told me, “If I could just be pregnant all the time…I felt so good!”
So if you keep the two-car roller coaster image in mind, as your estrogen drops, so will your serotonin. Your stress-buffering system vanishes and you’re as emotionally vulnerable as an open wound. You might feel you could burst into tears if someone looked at you cross-eyed or you might become as aggressive as a preying mantis, ready to gnaw off your partner’s head.
PMS: physical and emotional symptoms and/or chronic conditions may worsen
Like the enormous list of side effects in the BCP package insert, there are so many symptoms linked to PMS that it would take another Health Tip to describe them all. But here’s a useful rule: any symptom, physical or emotional, that makes a regular appearance at about the same time every month (usually worse during the week your period is due) is likely caused by PMS.
If you’ve got any chronic medical problems, like migraines, irritable bowel syndrome, or fibromyalgia, these may also worsen during your PMS week. Any problem–from eczema to arthritis, weight gain to hair loss–if there’s a strong cyclic component, don’t start with a dermatologist or rheumatologist. Instead, first work on resolving your PMS.
By the way, if you’ve not been pregnant, file this paragraph away for future reference or not. The physiology behind postpartum depression (the “baby blues,” though that minimizes what can be a serious condition) is essentially a state of super-PMS. After delivery, your estrogen plummets like the first hill of a Great America roller coaster ride and right in its wake so does your feel-good serotonin. You’re exhausted, the baby arrived with no operating manual or help, and you seriously consider whether Bombay Sapphire would taint your breast milk.
Let’s talk treatment, conventional and non
Conventional medicine approaches PMS like this:
- For physical symptoms of PMS, the breast tenderness et.al., conventional doctors usually reach for a prescription pad and prescribe a combination BCP containing estrogen (to suppress ovulation and keep you from getting pregnant) and an abundance of a synthetic progesterone called drospirenone. This type of BCP literally turns off your own hormone system, forcing your body to obey the dictates of synthetics. Generally, these work for physical symptoms but they may not be effective for mood issues.
- For emotional PMS symptoms, renamed premenstrual dysphoric disorder (PMDD) by the pharmaceutical industry, the goal is to raise your happy-making serotonin. The most commonly prescribed med is Sarafem, which is nothing more than the antidepressant Prozac. Any drug in this SSRI family (which includes Zoloft, Celexa, Lexapro, and Paxil) will work just as well as Sarafem, but read the side effects list carefully before you find yourself needing a wardrobe a few sizes larger than you might like. Many women gain weight on SSRIs.
You can treat PMS’s physical and emotional symptoms using non-pharmaceutical products.
- Gentler approach to physical PMS symptoms. Here your goal is to balance your hormones and reduce the effect of excess estrogen. Start with the herb Vitex (chasteberry), one capsule daily, which works on your pituitary, the master gland of the endocrine system, to balance estrogen and progesterone. This may take two or three cycles. For faster relief, offset the estrogen excess by raising progesterone. You can accomplish this using progesterone cream, sold over the counter as Progonal, applying one-quarter teaspoonful twice daily to the thin skin on the underside of your wrist. Calculating how long your PMS symptoms actually last, use Progonal during the 7 to 10 days before the guesstimated first day of your period. Stop the Progonal when your period arrives. If you’re one of the unfortunates with long-duration PMS (you can rely on only one week per month feeling human), start the Progonal earlier in the month, perhaps as early as ten days after your last day of flow.
- Gentler approach to PMS mood issues. Increase your serotonin with St. John’s wort (450 mg twice daily). Some women do well limiting St. John’s wort to the same days they use Progonal, but if an undercurrent of depression dogs you throughout the month, take St. John’s wort every day.
- For women with really severe PMS (you know who you are), the gentler approaches may not cut it. Ask your doctor for a prescription for bioidentical progesterone capsules (“bioidentical” because the progesterone molecule is exactly the same as that of a human female). You’ll fill this prescription at a compounding pharmacy. Generally about 100 mg daily from midcycle to start of period works well. If the St. John’s wort isn’t handling your PMS Hell Week, you can try taking an SSRI antidepressant just a few days every month, typically from ovulation to flow. This shorter use of an SSRI may bypass the side effects.
Finally, all the gentler approaches to PMS will be enhanced if you also work with traditional Chinese medicine or homeopathy. Both can re-set your imbalances so you may not need to take anything for PMS from now through menopause.
Remember that your grandmother, if she’s still alive and kicking, doesn’t have PMS, and right there is light at the end of the tunnel.
Which reminds me. Do you know why the female black widow spider kills her mate after sex? So she doesn’t have to listen to him snore.
David Edelberg, MD