Commonly Overlooked Diagnoses: The Subtleties of PMS

Health Tips / Commonly Overlooked Diagnoses: The Subtleties of PMS
PMS

Several women’s health websites place the number of symptoms attributable to premenstrual syndrome (PMS) at 150. I personally think that’s an undercount. I really began to appreciate this some years ago when a young woman came to see me with recurring hives.

Out of the blue, she’d awaken from sleep covered in large red itchy welts. She was pretty miserable. She’d seen her primary care doc, a dermatologist, and an allergist and was told she had idiopathic urticaria, a diagnosis that translates to “you have hives and we don’t know why.” She was prescribed an array of antihistamines and steroid creams.

When I asked if her hives were constant, she first answered yes, but then paused, thought for a moment and said, “No, sometimes they’re better right after my period. Just for a week or so.”

With fingers flying, I searched the internet and found no shortage of articles linking PMS and hives and yet when I checked one of several PMS symptom lists hives wasn’t there.

Although dozens of symptoms are indeed linked to PMS, there are three major themes:
(1) A cornucopia of unpleasant physical sensations.
(2) A smorgasbord of mood swings.
(3) Both.

Most women with PMS have both. Often my patients with PMS begin by describing their breast tenderness, fatigue, or migraines and don’t 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 the rise and fall of your hormones, the monthly up/down cycles 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), if the egg gets fertilized a tsunami of progesterone turns your uterus into a comfy spot for the fertilized egg.

But if there is no fertilized egg, your whole system goes through the hormonal shifts anyway. Estrogen and progesterone both drop, and the price of this drop is PMS.

On the other hand, if the 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. With pregnancy, your estrogen level skyrockets and instead of PMS you have first-trimester morning sickness.

Hormones control feel-good serotonin
Your sex hormones control levels of the stress-buffering neurotransmitter serotonin, which drags behind estrogen like the second car of a two-car roller coaster. During the few days just before your period, estrogen goes quite low, your  serotonin stress buffer disappears, and you’ll burst into tears at a Hallmark movie trailer or attack your significant other with a stream of invective you didn’t know you were capable of, all the time saying to yourself “Why am I doing this? It isn’t me!”

You’re right. It’s your hormones.

However, there’s light at the end of the tunnel. After your period, your estrogen and serotonin begin to rise and you start feeling pretty good again. For this reason, most menstruating women feel their best during the week after their period. And then the whole thing starts over again.

Although we attribute premenstrual symptoms to the days just before menstruation (usually no more than four or five), for some women, having PMS for just four or five days would constitute a good month. This group starts having PMS symptoms within a week after the last day of their period, experiences a worsening at mid-cycle during ovulation, and has a couple of calm days after ovulation followed by serious and worsening PMS symptoms, making the 8 to 10 days before their periods start sheer hell.

Is your symptom PMS-related?
Young women pick up early on what constitutes PMS for them (and every woman is unique in this regard), but for someone who is puzzled about a symptom–emotional, physical, both, or a worsening of any chronic condition–the number one method to determine if a symptom has a PMS component is to track that symptom over two or three menstrual cycles.

If, for example, you get diarrhea the third week of every month, that’s PMS and don’t bother with a gastroenterologist. If you’ve been diagnosed with ulcerative colitis and it worsens during the third week of your cycle, that too is PMS.

Working diligently on your PMS will likely improve the overall status of your ulcerative colitis because the symptoms of virtually any chronic illness are worsened by stress. Because during PMS days your stress-buffering serotonin drops, you’re more vulnerable to stress and thus your symptom/illness worsens.

Personalized tracking is the single most important thing you can do toward making a PMS diagnosis and your first step toward getting relief. Just use any diary or calendar where you have space to write notes. Or check out this link to PMS trackers.

Believe me, you can track any symptom. The PMS biggies are pretty obvious (mood, bloating, breast tenderness). But many women get midcycle migraines, for example, that they don’t realize are connected to their hormones. Others see gastroenterologists for irritable bowel syndrome (IBS), dentists for temporomandibular joint (TMJ) problems, ear-nose-throat specialists for chronic sinusitis, dermatologists for rosacea, allergists for asthma symptoms,  rheumatologists for joint pain, and psychiatrists for bipolar disorder.

These same women will also endure unnecessary breast biopsies, uterine biopsies, colonoscopies, skin biopsies, and other procedures because the specialist doesn’t realize the symptom is related to PMS. One patient I know underwent totally unnecessary back surgery for her PMS-aggravated fibromyalgia.

Most women will hear “You’re tests are all normal,” followed by “Here, take this,” a prescription for something to suppress whatever symptom is troubling them.

Then one fine day, if they’re lucky, they’ll appreciate the cyclic nature of their symptoms and this becomes the game changer.

The cyclic nature of PMS symptoms
The very moment you learn your symptoms could be one or more of the hundreds caused by PMS and you set about working on them you become empowered. After two or three cycles you’ll notice a positive change and, not infrequently, complete resolution of your longstanding symptoms.

Or if you’re burdened with a chronic health condition–say migraines or an autoimmune disorder–at the very least you’ll experience significant improvement.

One word of advice about PMS. Don’t waste time and energy measuring your hormones since they change from day to day. You could have all the features of estrogen-dominant PMS (breast tenderness, fluid retention) and if your hormone levels are normal, you’d be told not to treat your symptoms as PMS.

But you are not the same as your lab test.

For longstanding symptoms, do the following
Track your symptoms. If they’re worse the same days of every month and better on other days and this pattern is consistent for a couple of cycles, you’ve got a PMS symptom, period. (Pun not intended.)

Basic treatment of PMS is straightforward. Your first steps are lifestyle and dietary changes and certain nutritional supplements. Read more about them here. If you have estrogen-dominant PMS (breast tenderness) add Progest Assist, a progesterone oil applied to your skin.

Functional medicine is an excellent resource for anything PMS. Remember PMS is not a disease, it’s a dysfunction. You don’t need your symptom suppressed by the big-gun prescription drugs of specialists. You need to learn why your hormones are off kilter. All of our functional medicine practitioners have a lot of experience here (Rachel Gates, APN, Caley Scott, ND, Parisa Samsami, DC, and Wendy Ploegstra, APN).

Also extremely effective are both Traditional Chinese Medicine (TCM) with Derek Becker or homeopathy with Dr. Sujatha Mannal. Click here to learn more about our practitioners.

Be well,
David Edelberg, MD

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