What is pre-menstrual syndrome (PMS)

Pre-menstrual syndrome or PMS is a physical and psychological disorder that causes a number of symptoms (both physical and psychological) that affect the physical and emotional well-being of women for a period of up to two weeks prior to menstruation.

While PMS can occur for up to two weeks prior to menstruation (usually just after ovulation), the worst symptoms seem to occur in the the week and days just before menstruation. PMS normally disappears (or is reduced significantly) once menstruation starts.

PMS was first classed as a medical disorder in 1953 by Dr Raymond Greene and Dr Katharina Dalton in a paper published in the British Medical Journal the same year.

Research shows that up to 90% of all women experience some level of PMS during their menstruating years and that around 40% of these women have PMS symptoms that disrupt their life in some major way.

Some women even report that any underlying medical disorders (allergies, asthma, irritable bowel syndrome) seem to get worse, or just much harder to manage during PMS.

Pre-menstrual dysphoric disorder (PMDD) has recently been identified as a type of PMS, but with much worse symptoms.

Facts about PMS

• PMS is very common in women and occurs in almost all women (about 90%)
• PMS can occur at any time, but is most common in women in their late 20’s to early 30’s and beyond
• PMS normally ends once menopause starts
• Some women find that having a baby makes PMS worse
• Some women find that having a baby relieves their PMS greatly
• PMS seems to get worse as women get older
• PMS is a very misdiagnosed and misunderstood medical disorder

Symptoms of pre-menstrual syndrome (PMS)

There are over 150 different symptoms that have been identified as being associated with PMS.

The symptoms of PMS can be divided into five sub-groups (and while most women generally have symptoms of 1-2 groups, some women experience all the symptoms from all groups):

PMS-A

This group of symptoms is characterised by anxiety (which may be due to a higher than normal ratio of oestrogen to progesterone)

• Nervous tension – anxiety, crying, irritability, mood swings, nervous tension

PMS-C

This group of symptoms is characterised by cravings (which could be due to an exaggerated response of insulin to carbohydrates and a probable magnesium deficiency too)

• Cravings – cravings for sweets, dizziness, fainting, fatigue, headache, increased appetite, palpitations, pounding heart

PMS-D

This group of symptoms is characterised by depression (which may be due to a lower than normal ratio of oestrogen to progesterone)

• Depression – “brain fog”, confusion, crying, depression, excessive sleep, forgetfulness, insomnia, lowered libido

PMS-H

This group of symptoms is characterised by hyper-hydration, an excess of fluid in various parts of the body (and this is due to an increased retention of sodium in the body)

• Fluid retention – abdominal bloating, swelling of legs, arms, fluid retention, breast swelling and tenderness, weight gain (more than 1.4kg)

PMS-P

This group of symptoms is characterised by pain in certain parts of the body

• cramps – pain or cramping in the lower back, lower abdominal, leg and any other body part
• reduced pain threshold – this is very noticeable during PMS

Interestingly, PMS symptoms are very similar to the symptoms of hypothyroidism.

In addition to this, studies have also shown that PMS symptoms also correlate to the effects of prolactin when it is injected into a healthy woman who does not experience PMS. This suggests that some women may be highly sensitive to their own prolactin levels or have higher than normal levels of prolactin in their blood.

Causes of pre-menstrual syndrome (PMS)

Medical experts generally think that it may be a woman’s response to her hormones (whether they are balanced or not), diet (there may be nutritional deficiencies), stress or lifestyle factors (there may be prolonged stress) that could be the underlying cause of PMS and as every woman is different, the level of PMS each woman experiences is also different.

While we do have some answers about pre-menstrual syndrome and know more about PMS than when it was first diagnosed over 50 years ago, the exact cause of PMS is sill not known.

While PMS is a recognised medical disorder, the underlying cause has not been really identified, but a variety of explanations have been given as to the reasons why PMS may occur.

Prevention of pre-menstrual syndrome (PMS)

Non-preventable risk factors

Pre-menstrual syndrome (PMS) may be unpreventable in certain circumstances:

• Abnormal hormones – studies show that when the ratio of eostrogen to progesterone is unbalanced, this can trigger symptoms of PMS, irrespective of whether the ratio is too low or too high. The correct levels of oestrogen (which increases energy) and progesterone (which acts as a depressant) are needed to maintain a proper balance and create harmony. Other studies have shown that PMS may be triggered by imbalances in other hormones – serotonin, adrenaline and androgen. In addition to this, an under active thyroid can also exacerbate symptoms of PMS
• Abnormal central nervous system function – some women have a central nervous system that simply does not function in a normal manner to the normal fluctuations of hormones during the monthly menstrual cycle and instead the central nervous system (CNS) instead behaves abnormally and causes the PMS symptoms. Current science does not know why some women’s CNS behaves abnormally and so do not know how to prevent PMS from this factor
• Blood glucose imbalances – an exaggerated insulin response to carbohydrates (glucose) is tied with associated symptoms of low blood glucose, cravings and increased appetite during PMS. Some experts think that this abnormal insulin response to glucose may be tied with higher than normal eostrogen levels, because this triggers more insulin insulin to be released into the blood, dropping glucose levels more than necessary and causing symptoms such as dizziness, increased appetite, headache and food cravings (especially for sweet foods, that have a high glycemic index (GI) and which can bring glucose levels back to normal very quickly). This may be the reason why some women experience intense cravings for sweet foods during PMS
• Genetics – studies show that women whose direct female relatives (mothers and grandmothers) had PMS will most likely experience it too and probably very similar symptoms too

Preventable risk factors

There may be ways to prevent PMS from occurring or at least preventing symptoms from becoming very severe:

• Exercise – a lot of research suggests that regular exercise can reduce the symptoms of PMS, by increasing levels of endorphins, the “feel good” hormones as well as increasing levels of serotonin, one of the hormones thought to be responsible for the mood problems during PMS. Exercise should be engaged on a regular basis, every day to be effective
• Reduce salt – excessive salt intake can lead to fluid retention symptoms such as breast tenderness and general fluid retention. The substance in salt that is responsible for the fluid retention is sodium. Sodium occurs naturally in all foods, but it is in a specific ration with potassium (a natural anti-diuretic) to prevent fluid retention problems. There is a lot of hidden sodium in processed or packaged foods, so avoiding these at least in the two weeks prior to menstruation may help to avoid the worst of the fluid retention symptoms during PMS
• Relaxation strategies – any type of relaxation strategy may help to reduce the emotional symptoms of PMS by increasing levels of serotonin. Some good relaxation therapies are: meditation, tai chi, yoga
• Stress and emotional problems – it is well known that stress can make any health condition feel (or be) worse, so it is no surprise that it can also makes PMS symptoms worse. While stress does not cause PMS, it can trigger symptoms. Stress affects the adrenal glands to produce the hormones noradrenaline, aldosterone, adrenaline and cortisol, which affect and regulate fluid balance in the body, mood, appetite and response to stress. Studies show that stress caused by emotional trauma, especially those that are ongoing, can disrupt balance of hormones in the body and trigger PMS. Many studies have shown that reducing stress through techniques such as yoga or meditation can significantly reduce symptoms of PMS
• Treat underlying nutritional deficiencies – imany experts believe that nutritional deficiencies could be the main reason that PMS occurs. It is thought that a diet high in processed foods, refined sugar, excess salt and lacking in fresh fruits, vegetables, legumes and foods high in omega 3 essential fatty acids (such as oily fish). Numerous studies have shown that calcium levels are greatly reduced in a high percentage of women with PMS, which means the body may not be using calcium properly during PMS and this could be causing a deficiency in this essential mineral, which could be further exacerbating symptoms. Studies also show a deficiency of vitamin B6 (pyridoxine) could be a contributing factor to the bloating symptoms. Other studies show that many women could be deficient in magnesium, a mineral that helps the muscles relax, which could be why many women binge on chocolate during PMS, as chocolate is high in magnesium. Yet other studies show the whole range of B vitamins may be deficit in women with PMS, as well as the essential fatty acids and especially gamma-linoleic acid (GLA) (which is the reason why naturopaths prescribe evening primrose oil for PMS as it is very high in GLA)

Complications of pre-menstrual syndrome (PMS)

The complications of PMS can occur if this disorder is unrecognised and untreated, which can cause an exacerbation of the symptoms and make life very difficult.

The two most severe complications that can occur in relation to untreated PMS symptoms are:

Anxiety

One of the most debilitating symptoms of PMS is anxiety, which can manifest as feelings of tension, agitation and general anxiety. Women with PMS tend to experience anxiety at a high level in the whole two weeks prior to menstruation, but even more so in the days just before the start of menstruation. If the PMS remains unrecognised and untreated, the anxiety symptoms can make the woman feel as though there is something very wrong with her mind because she is feeling so anxious and “on edge” without any apparent reason. If this goes on for some time, it can be severely debilitating and really disrupt a woman’s enjoyment of life. This is the reason why this disorder must be appropriately diagnosed and treated.

Depression

Women with PMS can experience very severe depression symptoms in the whole of the two weeks prior to menstruation and specifically even more so in the days running up to the start of menstruation. If the PMS remains unrecognised and untreated, then the depressive symptoms can make the woman feel as though there is something very wrong with her mind because she is feeling all those depressed, low mood feelings without any apparent reason. If this goes on for some time, it can be severely debilitating and disrupt a woman’s enjoyment of life. This is the reason why this disorder must be appropriately diagnosed and treated.

When to see a doctor about pre-menstrual syndrome (PMS)

If you experience any of the symptoms of PMS, especially if they only occur in the two weeks prior to menstruation you should visit your doctor to discuss your concerns. Your doctor will diagnose your symptoms or send you to a gynaecologist for further review.

If you already suspect you have PMS and have been tracking your symptoms with a PMS tracker for several months, you should present your symptoms to your doctor for diagnosis and appropriate treatment options – both conventional treatment (medication and/or hormones) or alternative/complementary treatment.

Diagnosis of pre-menstrual syndrome (PMS)

There are no tests to definitively diagnose PMS.

The only way that PMS can be determined is through observation. A woman who feels that she has symptoms of PMS (or even PMDD) through observation of the time and length of symptoms and whether or not there is a pattern to it that is related to the two weeks prior to menstruation (the luteal phase of menstruation).

It is advisable to create a menstruation diary and take note of all symptoms, severity and duration to determine exactly if the symptoms are due to PMS.

Use the PMS Tracker to accomplish this. Print it out and use it as your menstruation diary and take it to your doctor for discussion.

To determine if you have PMS, answer the questions below :

• In the two weeks prior to menstruation, do you feel anxious, moody, irritable and snap at people?
• In the two weeks prior to menstruation, do you feel depressed, confused, forgetful, cry a lot and withdraw from people?
• In the two weeks prior to menstruation, do you experience bloating (especially in your abdomen and breasts) and sore or tender breasts?
• In the two weeks prior to menstruation, do you get intense food cravings and have an increased appetite?
• In the two weeks prior to menstruation, do you find it difficult to sleep properly or experience headaches/migraines?

If you can answer yes to any of the above questions then it is most likely you have PMS, especially if the symptoms occur quite regularly (for most menstrual cycles).

Conventional treatment of pre-menstrual syndrome (PMS)

The conventional (western) medical approach to treating PMS is through the following.

Hormone therapy

These are used to regulate hormones by preventing ovulation and prevent or ease PMS symptoms:

• Contraceptive pill – this contains both oestrogen and progesterone in specific amounts. There are many variations of the Pill, with different amounts of each of the hormones oestrogen and progesterone. Today, most doctors prescribe a particular contraceptive pill called Yasmin with a special combination of hormones (drosperinone/ethinyl estradiol), as research has shown it can greatly assist in reducing the symptoms of PMS by suppressing ovulation, reducing fluid retention and countering the effects of testosterone. The other commonly prescribed contraceptive pill is YAZ, which is very low in oestrogen (lower than Yasmin)
• Danazol – this medication reduces the output of both follicle-stimulating hormone (FSH) and luteinising hormone (LH) and eostrogen, so it stops the menstrual cycle, which may help with some women’s PMS symptoms. If the menstrual cycle is ceased, then PMDD symptoms are also not going to occur. While Danazol is effective at reducing symptoms of PMS, it is only prescribed as a medication of extreme last resort, when other options are not viable, as it has really severe side effects (acne, cramps, depression, flushing, increased HDL (“bad”) cholesterol levels, increased male characteristics, reduced breast size, weight gain) and also cannot be prescribed for longer than six months
• GnRH agonists – Gonadotropin releasing hormone agonists (GnRH) are a type of medication that suppresses ovulation by stopping the production of oestrogen and progesterone. The GnRH agonists are effective at reducing symptoms of PMS, but they are only prescribed as a medication of last resort, when other options are not viable, as they have severe menopause-like side effects (in particular, hot flushes and night sweating) and they also cannot be prescribed for longer than six months
• Bromocriptine – this drug selectively targets one of the abnormal hormones (prolactin), but is not used very much these days as its side effects can cause a worsening and further imbalance of the hormones

These drugs all have side effects and they just treat the symptoms and not the actual cause of the PMS, so they do not really provide a major benefit for PMS long-term. This is the reason why many doctors these days are more inclined to suggest an alternative / complementary approach to treating PMS and only suggest medication as a last resort.

The contraceptive pill for example, should not be taken by women who smoke, who have had any type of blood clots or who have had any type of oestrogen-dominant female cancers. The other medications also have their own set of side effects and the risks should be discussed with your doctor.

Medications

The following medications are prescribed, either on their own or in a combination advised by your doctor, depending on symptoms:

• Fluid retention relief – to relieve symptoms associated with bloating in the breasts, abdomen and the whole body
  • Diuretics – both over-the-counter and prescription are used to relieve the fluid retention and breast tenderness symptoms associated with PMS by blocking the function of the hormone aldosterone. Examples are: Aldactone(not to be taken at night as they can cause disrupted sleep when they wake you with the need to urinate often)
• Prostaglandin inhibitors – to relieve inflammation
  • COX-2 Inhibitors – these medications are used to relieve menstrual cramping and premenstrual symptoms. Examples are: Celebrex (other Cox-2 inhibitors have been taken off the market due to significant side effects, including heart attack, stroke and possible death)
• Analgesics – to relieve pain and/or inflammation
  • Naproxen, ibuprofen, or mefenamic acid – these are non-steroidal anti-inflammatory medications which relieve premenstrual pain and reduce menstrual pain and bleeding. They work to reduce inflammation by reducing prostaglandin production. Examples are: Advil, Naprogesic, Nurofen, Ponstan
• Anti-depressants – these are recommended to be used just in the two weeks prior to menstruation, during PMS (or sometimes all month for some women) to reduce symptoms associated with depression. Today, there are a number of anti-depressant medications which are specifically tailored to be used for PMS
  • Benzodiazepines – are only recommended to be used for a few days prior to menstruation for anxiety symptoms, when other treatments have been ineffective. These medications depress the central nervous system, but they lose their effectiveness over time and can be very addictive. Examples are: Xanax
  • SSRIs – these medications work by helping the brain retain more serotonin, the neurotransmitter responsible for regulating mood and which may be low in women with PMS. These medications help to relieve depression, anxiety, irritability, aggression, and many physical symptoms of PMS. Examples are: Prozac, Sarafem, Paxil, Zoloft, Luvox, Celex

Alternative / complementary treatment of pre-menstrual syndrome (PMS)

For most women, a combination of the alternative treatments below will work to alleviate PMS symptoms, but in order for them to work, they must be used regularly and on an ongoing basis (especially the dietary changes) with commitment. To get a better understanding of what can help your PMS, see a qualified naturopath.

Herbs

There are a number of herbs which are routinely recommended for assisting with not only reducing symptoms but also to help balance hormones:

• Chamomile (matricaria chamomila) – an excellent herb for relaxing the whole body and is particularly useful for women whose PMS causes sensitivity, irritability, crying, timidity and feelings of inadequacy
• Chaste berry (agnus castus) – this is the berries of the chaste tree, indigenous to Southern Europe, the Mediterranean and Asia. The berries contain compounds which act on the pituitary gland, specifically on the production of luteinising hormone to influence progesterone levels during the second half of the menstrual cycle, which is when PMS occurs. Chaste berry is highly effective in treating menstrual irregularities, breast pain and premenstrual complaints
• Dandelion (taraxacum officinale) – is an excellent natural anti-diuretic which is well tolerated by most women, which makes it an excellent tonic for women that have PMS-H (fluid retention) symptoms. Dandelion also works on the liver to detoxify it from all toxins in general and excessive amounts of eostrogen in particular
• Dong quai (angelica polymorpha) – is a herb widely used for treating PMS as it has analgesic and sedative properties, which is good for treating PMS-A (anxiety) and PMS-P (pain). Note: excessive doses can cause uterine contractions and should be avoided in women who are trying to get pregnant
• Lavender (lavandula vera) – as an essential oil is beneficial for reducing nervous tension and to treat insomnia as it is a relaxant. Lavender can be applied in a number of ways – a few drops to the pillow, some drops to an oil burner, as a room spray or even a few drops on the skin (as long as it is the diluted form). Note: some people may be allergic to the oil if applied topically, so use with caution in this manner
• Lemon balm (melissa officinalis) – is a very soothing herb, which has mild muscle relaxant properties, so is beneficial for PMS-A (anxiety) symptoms, especially for insomnia as it helps to reduce the time to get to sleep and assists with a better quality of sleep. Lemon balm is very effective if stress has adversely affected the stomach and digestive system too
• St John’s wort (hypericum perforatum) – is a well known and much used herb to treat mild to moderate depression from any cause. It is widely used in many countries by doctors) as an alternative treatment to anti-depressant medications. St John’s wort helps to support the nervous system as a whole, which means it is helpful for all PMS symptoms, but it also has a sedative effect which means it is good for women with PMS-A (anxiety and insomnia) symptoms. Note: St John’s wort should never be used together with anti-depressant medications as this combination can produce serious health effects
• Valerian (valeriana officinalis) – is a herb that is widely used for its calming effects on the mind. It is especially useful for stress-related anxiety, tension and insomnia and for depression caused by stress or nervous tension. Studies show that valerian is an excellent non-addictive sleep aid, as it helps people fall asleep quite quickly and improves the quality of sleep. Valerian is useful for anxiety and stress, but lower doses needed to be used during the day for this purpose. Note: about 2%-5% of people experience the opposite effects when taking valerian – they become more alert, more awake, more wired up and do not calm down and relax if they take valerian, so try it at a smaller dose to be sure or try other herbs such as chamomile or lemon balm which are gentle and soothing

Vitamins

There are a number of vitamins especially beneficial for reducing PMS symptoms:

• Vitamin B1 – is very useful in supporting the nervous system, which may not be functioning as effectively as normal and may not be able to handle stress as well as it should
• Vitamin B2 – is very useful in supporting the nervous system, which may not be functioning as effectively as normal and may not be able to handle stress as well as it should
• Vitamin B3 – is very useful in supporting the nervous system, which may not be functioning as effectively as normal and may not be able to handle stress as well as it should
• Vitamin B5 – is very useful in supporting the nervous system, which may not be functioning as effectively as normal and may not be able to handle stress as well as it should
• Vitamin B6 – is involved in the synthesis of specific neurotransmitters that regulate mood and which may be at abnormal levels during PMS. Vitamin B6 helps to balance the amount of certain neurotransmitters, thereby reducing mood swings and depression and regulating mood during PMS
• Vitamin B12 – is very useful in supporting the nervous system, which may not be functioning as effectively as normal and may not be able to handle stress as well as it should
• Vitamin D – assists in the absorption of calcium and thereby gives relief to some of the symptoms associated with PMS which are related to a deficiency of calcium (excess of oestrogen)
• Vitamin E – the powerful antioxidant and free radical scavenger vitamin E, which helps to alleviate breast tenderness and pain symptoms associated with PMS

Minerals

There are a number of minerals especially beneficial for reducing PMS symptoms:

• Calcium – plays quite a big role in hormone regulation. It has been shown in various studies that the level of calcium drops in the two weeks preceding menstruation. Those studies showed that if calcium levels were increased at this time, many of the symptoms of PMS were reduced. Calcium supplements should be taken with Vitamin D and magnesium to ensure there are correct ratios of all three nutrients
• Chromium – is especially beneficial for regulating insulin levels in women with an exaggerated insulin response and reducing the cravings associated with PMS
• Magnesium – is important for hormone production and metabolism, as well as for the proper use of calcium and vitamin D. Magnesium deficiency during PMS is associated with decreased levels of dopamine (which is a neurotransmitter that helps to calm the brain) and an inability to synthesise linoleic acid properly. Studies show that magnesium deficiency is common in women with PMS. Chocolate, which contains magnesium, is a food often craved by women experiencing PMS, due to the body’s need for magnesium
• Zinc – acts as a hormone regulator due to its function with various enzyme processes in the body, so it is very useful for controlling PMS symptoms by balancing the hormones circulating in the body. In addition to this, zinc helps to metabolise linoleic acid properly (which is needed to produce the anti-inflammatory PGE1 prostaglandins that help reduce pain and fluid retention)

Other nutrients

There are a number of important nutrients which can be beneficial in helping reduce symptoms:

• DHA/EPA – these two omega-3 essential fatty acids are found mainly in fish oil and have excellent anti-inflammatory properties due to the excellent omega-3 fatty acids they contain. Fish oil which contains high levels of DHA/EPA are often prescribed for women with PMS to help with pain, depression and fluid retention especially
• Evening primrose oil – this supplement is especially beneficial for the PMS-P (pain) group, but it is also great for all women experiencing all types of PMS as it helps to reduce inflammation. Evening primrose oil is also great for women experiencing breast pain and tenderness, depression, irritability and fluid retention. The GLA (gamma-linolenic acid) in EPO (evening primrose oil) helps to regulates the hormone prolactin, which may be too high in some women, causing the symptoms of PMS
• Linoleic acid – is required to ensure proper synthesis and metabolism of PGE1, which is a specific anti-inflammatory prostaglandin that has been shown to assist women who have either PMS-H (fluid retention) or PMS-P (pain) type symptoms. One of the richest sources of gamma-linoleic acid (GLA) is evening primrose oil, which is why it is most often prescribed for women with PMS
• Tryptophan – is an essential amino acid which is the precursor of serotonin, a neurotransmitter in the brain that helps to normalise mood (it relaxes and calms the brain). Some scientists think that an imbalance in serotonin could be an underlying factor in women who experience the PMS-D (depression) and PMS-A (anxiety) symptoms, so supplementation of tryptophan may help to ease these type of symptoms
• Tyrosine – is a non-essential amino acid which is involved in the proper function of the thyroid, as well as adrenal and pituitary glands. Some scientists think that an imbalance in any of these glands, but especially the adrenal glands (which control how well we handle stress) could be one of the underlying factors of PMS and especially the PMS-A (anxiety) symptoms and tyrosine may be the key to this. In addition, an imbalance of the thyroid hormones can cause symptoms very similar to PMS and in fact, most women with severe PMS (or PMDD) seem to have some type of thyroid disorder – these two conditions seem to go hand-in-hand (although science is yet to prove why and solve the riddle of these disorders)

Dietary modifications

There are a number of dietary modifications that can be implemented to help reduce symptoms of PMS:

• Increase fibre intake – fibre binds with excess oestrogen in the blood to help get rid of it and help normalise levels of eostrogen, which reduces the symptoms associated with PMS-A (anxiety). Fibre also helps digestion, by ensuring there is no build-up of toxins or waste by removing them and reducing bloating
• Increase foods high in vitamin B6 – this mineral is really important in PMS as it is a precursor to serotonin, a neurotransmitter that is responsible for maintaining mood on an level (and happier) basis. Eating foods rich in vitamin B6 (and taking a supplement if necessary) can help to regulate serotonin levels, improve mood and may reduce anxiety and depression symptoms associated with PMS
• Increase intake of fish – oily fish contains the beneficial omega 3 essential fatty acids DHA/EPA, which have a proven anti-inflammatory effect on the body and are very useful in preventing pain, fluid retention and inflammation symptoms of PMS
• Increase intake of phytonutrients – (or phytochemicals) are responsible for flavor, color, and disease-resistance in plants (fruits, vegetables, whole grains and legumes). Most are antioxidants that benefit humans by enhancing immunity, strengthening heart and blood vessels and preventing tumors. They are also found in smaller amounts in nuts and seeds. Certain phytonutrients (namely phytoestrogens) can help to balance abnormal hormone levels that occur during PMS – and they are found mainly in: soya, flax seeds, wheat, rice, oats, barley, carrots, potatoes, apples, cherries, plums and parsley. Vegetable oils such as safflower, wheatgerm, corn, olive, linseed (flaxseed), peanut, soya and coconut oils also have some level of phytoestrogens
• Increase intake of sunflower seeds – which are rich in the essential fatty acid linoleic acid which helps to reduce symptoms of PMS by increasing the amount of the anti-inflammatory prostaglandin PGE1 and reduce pain and inflammation as well as fluid retention
• Increase intake of vegetables – vegetables contain so many vitamins and minerals which may be in deficit during PMS and so exacerbate PMS symptoms. Fruit and vegetables are also rich in potassium, which helps to regulate sodium levels in the body and prevent symptoms of fluid retention
• Limit caffeine – coffee, tea (except for most herbal teas), chocolate and some energy drinks all have caffeine, which can all over stimulate the brain and aggravate feelings of depression, irritability and anxiety as well as worsening breast tenderness and bloating, which are not beneficial during PMS, when calm and relaxation are required
• Limit processed foods – most processed foods are very high in saturated fat, sugar, salt, calories and have little nutritional benefit at any time, but have even less relevancy at PMS when foods high in nutrients are needed to help support the body and reduce symptoms
• Limit refined sugar intake – sugar is basically empty calories and for women who have unbalanced glucose levels and an exaggerated insulin level to carbohydrates will continue to have symptoms associated with this during PMS. High sugar intake also increases prostaglandin levels, which make pain and other symptoms worse and in addition to this, excessive sugar intake makes the body excrete too much magnesium, which is needed to calm down the muscles and help them relax and less magnesium means more PMS symptoms
• Limit saturated fats – saturated fats, especially from non-organic meat may contain various hormones and other chemicals which can further cause imbalance to hormones (especially by increasing oestrogen to excessive levels) and should be avoided
• Reduce dairy intake – intake of high fat dairy foods is associated with a higher than normal oestrogen to progesterone ratio and the anxiety-type symptoms during PMS, so either eating only law fat dairy foods (milk and yoghurt) and restricting other forms of dairy may be beneficial in reducing symptoms
• Reduce salt intake – women who have an increased sodium retention during PMS need to limit the amount of salt in foods they eat, especially limiting processed foods, which contain high levels of sodium
• Strictly limit alcohol – this is because alcohol is a natural depressant, so it really does not help PMS symptoms and should be avoided as much as possible

Lifestyle modifications

There are a number of lifestyle modifications which are recommended for helping women with PMS reduce symptoms:

• Exercise – studies show that regular exercise in combination with a healthy diet can help reduce all PMS symptoms to a degree. The reason exercise helps alleviate PMS is because during physical activity, all the cells receive more oxygen and are able to eliminate more waste (including excess fluid, excess oestrogen and toxins), plus exercise releases endorphins, which create a sense of positivity and happiness, which can reduce symptoms such as depression, irritability and mood swings. Exercise is a great outlet for pent-up frustrations and anxiety, plus it helps to keep hormones in balance
• Sleep – getting enough sleep is important because is helps the body repair and recover from the day’s activities. Without adequate sleep, PMS symptoms can be aggravated as lack of sleep causes anxiety, mood swings and tension
• Socialise – feeling socially isolated can lead to feelings of depression and anxiety, which only further exacerbate PMS symptoms. It is important to keep in touch with friends and socialise to feel connected to other people, plus it’s always good to talk to other women about PMS as they may be able to sympathise
• Meditate – studies show that any type of meditation which helps to calm the mind is beneficial for significantly reducing symptoms of PMS, especially the anxiety and depression symptoms
• Tai chi – numerous studies have shown that tai chi has a calming effect on the mind, in a similar way to meditation and can help to reduce symptoms of PMS, especially the anxiety and depression symptoms
• Yoga – numerous studies show that yoga (either the meditation or the higher energy forms) are very beneficial for helping reduce PMS symptoms. Yoga has several stances and breathing techniques specifically aimed at relaxing the mind, relieving anxiety and depression and helping the female sex organs (including ovaries and uterus) in general

Alternative treatments

• Acupuncture – a number of studies show that women who regularly received acupuncture for a specific duration had relief of symptoms

Always ensure that you notify your medical practitioner of any supplements that you want to take – it may interfere with other medication or conditions you have. Confirm with your doctor it is safe to take BEFORE you try it.

Living with pre-menstrual syndrome (PMS)

There are a number of strategies which are recommended to help you better deal with pre-menstrual syndrome (PMS):

• Avoid alcohol – if you suffer from the breast tenderness and fluid retention symptoms, then any level of alcohol will be highly dehydrating and you need to avoid it, especially during PMS as it will only make your symptoms worse
• Drink enough water – ensure you are properly hydrated by drinking at least eight glasses of water every day. This is important because your body may not be handling fluid properly and you need more fluid to help flush out excessive fluid in the body
• Eat more vegetables and fruit – your body requires more nutrients during PMS to more effectively deal with this condition and this can be effectively managed through a higher intake of vegetables and fruits. You should be eating 5-7 portions of vegetables and 3-5 portions of fruit each day and the darker green or purple or brightly coloured the better
• Exercise regularly – it is really important that you incorporate regular exercise into your daily routine of at least 30-40 minutes, some which should be cardio and some of which should be resistance training (to keep the heart and bones strong). Exercise is a great way to help alleviate PMS symptoms because during physical activity, all the cells receive more oxygen and are able to eliminate more waste (including excess fluid, excess oestrogen) and exercise released endorphins, the “feel good” chemicals which increase happiness and reduce feelings of anxiety and depression
• Increase foods high in vitamin B6 (pyridoxine) – if you suffer from fluid retention and breast tenderness symptoms during PMS you may benefit from the natural diuretic effects of vitamin B6 (pyridoxine). Eating more foods rich in vitamin B6 (pyridoxine) may help to reduce these symptoms
• Increase intake of essential fatty acids – the omega-3 essential fatty acids and GLA (and omega-6 fatty acid) both help to reduce inflammation and reduce levels of prostaglandins in the body, which are elevated during PMS. It would be helpful in reducing symptoms of PMS (especially the cramping, mood and fluid retention symptoms) if you increase intake of: fish, especially salmon, tuna, mackerel as well as nuts and seeds
• Increase intake of calcium-rich foods – your levels of calcium may be decreased during PMS and some experts believe this could be part of the cause of PMS symptoms, and so would be beneficial if you increase your intake of foods rich in calcium. Dairy foods are not the only foods rich in calcium
• Increase intake of magnesium-rich foods – your levels of magnesium may be lowered during PMS and as magnesium is necessary for relaxing the body, this could be a factor in the mood problems. You can try to increase your intake of foods rich in magnesium to help reduce symptoms of PMS. A handful of raw, unsalted almonds is one of the highest natural sources of magnesium
• Keep blood sugar levels balanced – symptoms of irritability, mood swings, anxiety, confusion and difficulty concentrating are not only symptoms of PMS, but also symptoms of low blood sugar levels. To avoid this, eat five to six small meals every 3-4 hours and ensure to include some good quality protein with every meal and snack to prevent fluctuations of the blood sugar levels and help reduce many of the the emotional symptoms of PMS
• Limit caffeine intake – any type of caffeine dehydrates the body, which is unhelpful during PMS, as this can worsen fluid retention and breast tenderness symptoms. In addition to this, caffeine can over-stimulate the brain and worsen anxiety, agitation and feelings of depression, so it is best to avoid caffeine intake during PMS. Foods high in caffeine include: coffee, black tea, green tea, chocolate, energy drinks, some fizzy soft drinks
• Limit intake of processed foods – most processed (or packaged) foods contain a lot of sodium (salt) which will only make fluid retention and breast tenderness symptoms worse and besides, these foods have little nutritional value, are usually very high in saturated fat, high in calories and should be strictly limited in the diet
• Low glycemic foods – if you experience the symptoms of low blood sugar levels (irritability, depression, agitation, nervousness, inability to concentrate) you should try to eat a diet that includes more low glycemic index (GI) foods, to help stabilise blood glucose levels and reduce these symptoms during PMS. Foods that have a low to medium GI include: vegetables, fruits, legumes, nuts, seeds, fish, poultry, lean red meat, low fat dairy and should be the mainstay of the diet
• More fibre in the diet – an adequate intake of fibre is necessary in the diet to help slow down the release of glucose into the blood, which means blood glucose levels are more stable. Fibre also helps to improve digestion and keeps it healthy, allowing wastes to pass out of the body ensuring toxins do not build up. Fibre also binds with excessive oestrogen and helps the body get rid of it – this helps to normalise levels of eostrogen and reduce symptoms of anxiety, depression, agitation, nervousness and depression
• More phytonutrients – all plant foods have some phytonutrients, which are important for health. Some contain substances that help to keep eostrogen levels normalised (phytoestrogens), by blocking the receptors on cells when there is too much oestrogen in the blood. The fibre in these foods then helps the body get rid of the excessive oestrogen. The foods highest in phytoestrogens are: apples, barley, carrots, cherries, flax, plums, potatoes, rice, soy, wheat and certain herbs
• Reduce salt intake – if you experience a lot of fluid retention, then it would be beneficial if you reduce your salt (or sodium) intake in your diet. Sodium is found not just in table and cooking salt, but in processed foods, so look at the ingredients lists and if you find sodium high in the ingredients list, avoid that food
• Stress reduction techniques – it could be beneficial in reducing symptoms of depression, anxiety and tension if you engage in stress reduction techniques such as meditation, tai chi or visualisation. These techniques help to induce a feeling a calmness and relaxed state of mind
• Supplements – talk to your doctor or qualified naturopath about using specific supplements to help you combat symptoms of PMS. The supplements most often prescribed for women with PMS are: calcium, evening primrose oil, GLA, magnesium, vitamin B6 (pyridoxine). In addition to these, there are a number of herbs which have properties to help reduce a number of PMS symptoms: chaste berry, dong quai, st john’s wort, valerian. It is important not to self-prescribe these supplements as they could adversely interact with other medications or conditions you may have, always consult with a professional
• Yoga – an excellent way to reduce symptoms of PMS is through the practice of yoga, many forms of which use meditation as part of the yoga practice. In addition to the meditation, yoga can also be very robust and active, which can provide an excellent exercise to practice every day

Caring for someone with pre-menstrual syndrome (PMS)

Partner

If you have a partner with PMS, there are a number of strategies you can use to help them deal with it:

• Allow your partner time to relax – it is really important that your partner engages in some form of relaxation to help reduce emotional symptoms and induce a state of calmness and relaxation to help reduce her PMS symptoms. Allow your partner the space to engage in this at home without disturbance
• Cook more fish – ensure your partner (and whole family) eats oily fish three times a week, as this will provide omega-3 essential fatty acids, which may help reduce her symptoms of inflammation, pain and fluid retention
• Don’t smoke – if you smoke cigarettes, make sure you do so outside and not near your partner as the fumes from cigarette smoke may make their symptoms worse. If your partner smokes, encourage her to stop
• Encourage exercise – your partner’s mood and symptoms of PMS will generally decrease if they are regularly engaging in some form of exercise, so it would also benefit you to encourage them to do so. You can always join in or encourage your partner to exercise with a friend or join a gym
• Healthier diet – ensure that you and your partner are cooking healthy meals made from fresh ingredients and not from packages, as they contain little nutritional value and besides which, contain too much salt, calories and fat, which can only make your partner’s symptoms worse
• Limit alcohol in the house – alcohol intake is very detrimental to your partner’s PMS symptoms, so it would be beneficial for your partner if you could also limit your alcohol intake at home with your partner, as it will help them to perceive your support and solidarity
• Support – it is important for your partner to know that she has your full support and understanding, as this will help her better deal with her symptoms. Try not to tell her it’s just “all in your head” as that is unsupportive and will only aggravate her symptoms of irritation even more. Just try to be sensitive

Friends

If you have a friend with PMS, there are a number of strategies you can use to help them deal with it:

• Don’t smoke – if you smoke cigarettes, make sure you do so not near your friend as the fumes from cigarette smoke may make their symptoms worse
• Limit alcohol – try to ensure your social interactions with your friend do not involve alcohol, as it can make your friend’s symptoms much worse
• Support – your friend will greatly benefit if they have your understanding and support, especially when they are suffering the worst of their PMS symptoms. Just try to be sensitive

Parents

If you have a daughter with PMS, there are a number of strategies you can use to help them deal with it:

• Cook more fish – ensure your daughter (and whole family) eats oily fish three times a week, as this will provide omega-3 essential fatty acids, which may help reduce her symptoms of inflammation, pain and fluid retention
• Don’t smoke – if you smoke cigarettes, make sure you do so outside and not near your daughter as the fumes from cigarette smoke may make their symptoms worse, or at least irritate them. If your daughter smokes, encourage her to stop
• Encourage exercise – your daughter’s mood and symptoms of PMS will generally decrease if she is regularly engaging in some form of exercise, so it would also benefit you to encourage them to do so. You can always join in or encourage your daughter to exercise with a friend or join a gym
• Healthier diet – ensure that you and your family are cooking healthy meals made from fresh ingredients and not from packages, as they contain little nutritional value and besides which, contain too much salt, calories and fat, which can only make your daughter’s symptoms worse
• Support – it is important for your daughter to know that she has your full support and understanding, as this will help her better deal with her symptoms. Try not to tell her it’s just “all in your head” as that is unsupportive and will only aggravate her symptoms of irritation even more. Just try to be sensitive

References

• American College of Obstetrics and Gynecology Opinion, “Pre-menstrual syndrome”. International Journal of Gynecology and Obstetrics, volume 50, pp 80-84, 1995
• Bendich A. The potential for dietary supplements to reduce premenstrual syndrome (PMS) symptoms. J Am Coll Nutr. 2000 Feb;19(1):3-12
• Bertone-Johnson ER, Hankinson SE, Bendich A, Johnson SR, Willett WC, Manson JE. Calcium and vitamin D intake and risk of incident premenstrual syndrome. Arch Intern Med. 2005 Jun 13;165(11):1246-52
• Cooke Kaz, Trickey R. Problem Periods – Natural and Medical Solutions. Allen and Unwin Australia, 2002
• Dell DL, Svec C. The PMDD Phenomenon: Breakthrough Treatments for Premenstrual Dysphoric Disorder (PMDD) and Extreme Premenstrual Syndrome (PMS). Contemporary Books, USA 2003
• Douglas S. Premenstrual syndrome. Evidence-based treatment in family practice. Can Fam Physician. 2002 Nov;48:1789-97
• Griffith HW. Minerals, Supplements and Vitamins: The Essential Guide. Fisher Books, USA, 2000
• Harris C, Cheung T. You can beat PMS! Feel fantastic all month long with this 12-week nutrition and lifestyle plan. Thorsons London, 2004
• Jarvis CI, Lynch AM, Morin AK. Management strategies for premenstrual syndrome/premenstrual dysphoric disorder. Ann Pharmacother. 2008 Jul;42(7):967-78. Epub 2008 Jun 17
• Murray M, Pizzorno J. Encyclopedia of Natural Medicine, 2nd Edition. Prima Publishing USA, 2000
• NIH News Release: Hormones Trigger PMS Symptoms–But Susceptibility Still a Mystery. January 1998. Accessed: 18 Feb 2009
• Osieki H. The Physician’s Handbook of Clinical Nutrition. 6th edition, Bioconcepts Publishing, Australia, 2001
• Rapkin A. A review of treatment of premenstrual syndrome and premenstrual dysphoric disorder. Psychoneuroendocrinology. 2003 Aug;28 Suppl 3:39-53
• Singleton G. Premenstrual disorders in adolescent females– integrative management. Aust Fam Physician. 2007 Aug;36(8):629-30
• Talalaj S, Czechowicz AS. Herbal Remedies: Harmful and Beneficial Effects. Hill of Content Publishing, Australia, 1989
• Theiss B & P. The Family Herbal. Healing Arts Press, Vermont, 1989
• Thys-Jacobs S. Micronutrients and the premenstrual syndrome: the case for calcium. J Am Coll Nutr. 2000 Apr;19(2):220-7
• Tratter R, Jones A. Better Health Through Natural Healing: How to Get Well Without Drugs or Surgery, 2nd Edition. McGraw Hill, 2001
• Weisz G, Knaapen L. Diagnosing and treating premenstrual syndrome in five western nations. Soc Sci Med. 2009 Apr;68(8):1498-505. Epub 2009 Feb 21
• Whelan AM, Jurgens TM, Naylor H. Herbs, vitamins and minerals in the treatment of premenstrual syndrome: a systematic review. Can J Clin Pharmacol. 2009 Fall;16(3):e407-29. Epub 2009 Oct 29
• Wyatt KM, Dimmock PW, Frischer M, Jones PW, O’Brien SP. Prescribing patterns in premenstrual syndrome. BMC Womens Health. 2002 Jun 19;2(1):4

Last reviewed and updated: 14 May 2024

What is pre-menstrual dysphoric disorder (PMDD)

A small percentage of women (between 2%-9% of the women that experience PMS) have symptoms so severe they can be destructive to their relationships and their life.

When symptoms of PMS (pre-menstrual syndrome) are very extreme and severe, they are referred to as PMDD, pre-menstrual dysphoric disorder, a condition which has only been recently identified.

Some PMDD symptoms are similar to major depression, which is why some medical specialists believe that PMDD is a psychological disorder, which is exacerbated during the two weeks prior to menstruation. There is some disagreement in the medical community about the classification of PMDD as a psychological disorder and therefore there is no definite concurrence about treatment of this condition in medical experts.

PMDD symptoms normally disappear (or are reduced significantly) once menstruation starts.

Facts about pre-menstrual dysphoric disorder (PMDD)

• PMDD is a really extreme and very severe form of PMS (pre-menstrual syndrome)
• PMDD only affects a very small percentage of women who suffer PMS (maybe about 3-5%)
• An extremely small percentage of women who suffer from PMDD may have an underlying mental health disorder such as depression or anxiety
• PMDD is different from PMS where there is no minimum set of symptoms that need to appear to be diagnosed with this disorder
• PMDD may or may not be a psychological disorder – the medical experts are not all in agreement about this
• It may be advisable to make dietary modifications and lifestyle changes to help reduce symptoms, even if conventional medicines are being prescribed to treat PMDD
• Some experts do not think PMDD is an actual disorder, rather that a small percentage of women experience more severe PMS than others
• PMDD is a very misdiagnosed and misunderstood medical disorder

Symptoms of pre-menstrual dysphoric disorder (PMDD)

There are a number of symptoms associated with pre-menstrual dysphoric disorder (PMDD), mainly emotional or mental, but also with a number of physical symptoms too.

Women with PMDD will usually experience many of these physical and psychological symptoms in the two weeks prior to their menstrual cycle and the symptoms normally dissipate once menstruation (and bleeding) starts:

Psychological symptoms

• Agitation and irritability
• Angry, hostile and feelings of rage
• Anxiety and nervousness
• Confusion and forgetfulness
• Crying very easily and over seemingly trivial matters
• Depression and feeling sad
• Easily overwhelmed and feeling out of control
• Emotionally hypersensitive
• Excessive sleepiness
• Inability to concentrate properly
• Inability to make decisions properly or at all
• Insomnia
• Lethargy and severe fatigue
• Lowered self-image
• Mood swings
• Strong desire to be left alone

Physical symptoms

• Abdominal cramps and pelvic heaviness
• Aggravation of cold sores or other health conditions
• Allergies
• Breast tenderness, pain and fullness
• Constipation or diarrhoea
• Dizziness or fainting
• Flare-up of acne
• Fluid retention
• Headache
• Infections
• Fluid retention in the ankles, feet and hands
• Heart palpitations (irregular heartbeat)
• Nausea and vomiting
• Numbness or tingling in either the arms or legs (or both)

Other symptoms

• Clumsiness
• Decreased or increased libido and sexual desire
• Food cravings
• Hot flashes
• Menstrual cramps

To be diagnosed with PMDD a woman must experience 5 or more of the following symptoms on a regular basis (each month) and in a severe way:

• Anxiety and tension
• Bloating
• Breast tenderness
• Changes in appetite
• Depression
• Fatigue
• Feeling overwhelmed and out of control
• Irritability
• Mood swings
• Sleep difficulties (insomnia or sleepiness)

Causes of pre-menstrual dysphoric disorder (PMDD)

The cause of PMDD, like PMS is not really known. Many medical experts believe that PMDD is a psychological disorder which has an underlying mental disorder. This theory is widely contested by other medical experts and an agreement on the cause of PMDD is not yet fully understood or agreed today.

The theories that have been proposed on the possible underlying causes of PMDD are:

Abnormal function of the ovaries

Researchers believe that due to the fact that PMDD only occurs in relation to the menstrual cycle, then there could be an underlying problems with the function of the ovaries, which are not releasing the hormones in the correct ratios and this may give rise to the cyclic PMDD symptoms.

The ovarian hormones that are released and which fluctuate during the luteal phase are: oestrogen and progesterone. These two hormones are responsible for enabling the egg to be released from the ovary and enabling fertilisation to occur.

Abnormal function of the central nervous system

Another theory that has been proposed that some women may have an underlying abnormal response to the normal fluctuations of the female hormones that circulate the blood in the two weeks prior to menstruation. It is thought that women that have PMDD have a central nervous system responds very abnormally to the fluctuating hormone levels during the luteal phase (the two weeks prior to menstruation) and this is what causes the PMDD symptoms.

The hormones that fluctuate during the luteal phase

• Adrenal hormones – the only adrenal hormone that is affected is cortisol
• Endorphins – these hormones are produced in the hypothalamus and cause the “feel good” feelings, which may be lowered
• Neurotransmitters – a number of neurotransmitters are also affected: serotonin, GABA, dopamine, norepinephrine. The serotonin levels are particularly low in women with PMDD, especially in late luteal phase, close to menstruation
• Ovarian hormones – the main ovarian hormones affected are: eostrogen and progesterone
• Pituitary hormones – the hormones which are affected are: follicle stimulating hormone (FSH), luteinising hormone (LH) and prolactin, all of which are triggered to fluctuate during the luteal phase

Prevention of pre-menstrual dysphoric disorder (PMDD)

Non-preventable risk factors

Pre-menstrual dysphoric disorder (PMDD) may be unpreventable in certain circumstances:

• Abnormal hormones – some women have abnormal blood levels of certain hormones (eostrogen, progesterone, prolactin, FSH, LH, serotonin) during the monthly menstrual cycle and this may result in PMDD symptoms. Current science does not know why some women have abnormally high or low levels of certain hormones. Studies show that when the ratio of oestrogen to progesterone is unbalanced, this can trigger symptoms of PMDD, irrespective of whether the ratio is too low or too high. The correct levels of oestrogen (which increases energy) and progesterone (which acts as a depressant) are needed to maintain a proper balance and create harmony. Other studies have shown that PMDD may be triggered by imbalances in other hormones – serotonin, adrenaline and androgen. In addition to this, an under active thyroid function can also exacerbate symptoms of PMDD
• Abnormal central nervous system function – some women have a central nervous system that simply does not function in a normal manner to the normal fluctuations of hormones during the monthly menstrual cycle and instead the central nervous system (CNS) instead behaves abnormally and causes the PMDD symptoms. Current science does not know why some women’s CNS behaves abnormally and so do not know how to prevent PMDD from this factor
• Genetics – studies show that women whose direct female relatives (mothers and grandmothers) had PMDD will most likely experience it too and probably very similar symptoms too

Preventable risk factors

There may be ways to prevent PMDD from occurring or at least preventing symptoms from becoming very severe:

• Exercise – a lot of research suggests that regular exercise can reduce the symptoms of PMDD, by increasing levels of endorphins, the “feel good” hormones as well as increasing levels of serotonin, one of the hormones thought to be responsible for the mood problems during PMDD. Exercise should be engaged on a regular basis, every day to be effective
• Reduce salt – excessive salt intake can lead to fluid retention symptoms such as breast tenderness and general fluid retention. The substance in salt that is responsible for the fluid retention is sodium. Sodium occurs naturally in all foods, but it is in a specific ration with potassium (a natural anti-diuretic) to prevent fluid retention problems. There is a lot of hidden sodium in processed or packaged foods, so avoiding these at least in the two weeks prior to menstruation may help to avoid the worst of the fluid retention symptoms during PMDD
• Relaxation strategies – any type of relaxation strategy may help to reduce the emotional symptoms of PMDD by increasing levels of serotonin. Some good relaxation therapies are: meditation, tai chi, yoga
• Treat underlying nutritional deficiencies – in some cases there may be an underlying nutritional deficiency which is causing the PMDD. If the diet does not contain all the nine essential amino acids, the vitamin, minerals and antioxidants, then there could be a deficiency and this needs further investigation by a registered dietician. Most commonly the following supplements are prescribed for women with PMDD: calcium, omega-3 essential fatty acid (in the form of fish oil), evening primrose oil (which has a high content of GLA) and magensium. Many experts believe that nutritional deficiencies could be the main reason that PMDD occurs. It is thought that a diet high in processed foods, refined sugar, excess salt and lacking in fresh fruits, vegetables, legumes and foods high in omega 3 essential fatty acids (such as oily fish). Numerous studies have shown that calcium levels are greatly reduced in a high percentage of women with PMDD, which means the body may not be using calcium properly during PMDD and this could be causing a deficiency in this essential mineral, which could be further exacerbating symptoms. Studies also show a deficiency of vitamin B6 (pyridoxine) could be a contributing factor to the bloating symptoms. Other studies show that many women could be deficient in magnesium, a mineral that helps the muscles relax, which could be why many women binge on chocolate during PMDD, as chocolate is high in magnesium. Yet other studies show the whole range of B vitamins may be deficit in women with PMDD, as well as the essential fatty acids and especially gamma-linoleic acid (GLA) (which is the reson why naturopaths prescribe evening primrose oil for PMDD as it is very high in GLA)

Complications of pre-menstrual dysphoric disorder (PMDD)

The complications of PMDD can occur if this disorder is unrecognised and untreated, which can cause an exacerbation of the symptoms and make life very difficult.

The two most severe complications that can occur in relation to untreated PMDD symptoms are:

Anxiety

One of the most debilitating symptoms of PMDD is anxiety, which can manifest as feelings of tension, agitation and general anxiety. Women with PMDD tend to experience anxiety at a high level in the whole two weeks prior to menstruation, but even more so in the days just before the start of menstruation. If the PMDD remains unrecognised and untreated, the anxiety symptoms can make the woman feel as though there is something very wrong with her mind because she is feeling so anxious and “on edge” without any apparent reason. If this goes on for some time, it can be severely debilitating and really disrupt a woman’s enjoyment of life. This is the reason why this disorder must be appropriately diagnosed and treated.

Depression

Women with PMDD can experience very severe depression symptoms in the whole of the two weeks prior to menstruation and specifically even more so in the days running up to the start of menstruation. If the PMDD remains unrecognised and untreated, then the depressive symptoms can make the woman feel as though there is something very wrong with her mind because she is feeling all those depressed, low mood feelings without any apparent reason. If this goes on for some time, it can be severely debilitating and disrupt a woman’s enjoyment of life. This is the reason why this disorder must be appropriately diagnosed and treated.

When to see a doctor about pre-menstrual dysphoric disorder (PMDD)

If you experience any of the symptoms of PMDD, especially if they only occur in the two weeks prior to menstruation you should visit your doctor to discuss your concerns. Your doctor will diagnose your symptoms or send you to a gynaecologist for further review.

If you already suspect you have PMDD and have been tracking your symptoms with a PMDD tracker for several months, you should present your symptoms to your doctor for diagnosis and appropriate treatment options – both conventional treatment (medication and/or hormones) or alternative/complementary treatment.

Diagnosis of pre-menstrual dysphoric disorder (PMDD)

The only way to diagnose PMDD is through monitoring the severity, duration and onset of symptoms and report this to your doctor.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) has very definitive guidelines for diagnosing PMDD, as follows:

A. In at least five of the menstrual cycles for the year, the following symptoms were present (they were only present in the two weeks preceding menstruation and were gone within a few days of bleeding):

• Very depressed, feeling hopeless, or self-deprecating
• Extreme anxiety, feeling “on edge” much of the time
• Sudden feelings of high emotion, sensitivity to rejection
• Very angry or irritable, lots of conflicts in relationships
• Uninterested in regular activities
• Difficulty in concentrating properly
• Lethargy
• Overeating and food cravings
• Sleepiness or insomnia
• Feeling overwhelmed or “out of control”
• Physical symptoms – breast tenderness, fluid retention, headache, muscle and joint pains

B. The pre-menstrual symptoms interfere enough with regular life (work, school, social activities, relationships) that they cause conflict or disturbances in any or all of these areas.

C. The pre-menstrual symptoms are not simply a result of some type of underlying mental disorder, such as any depressive disorder, anxiety disorder or a personality disorder.

D. The criteria A, B and C must be confirmed by careful monitoring of symptoms over two consecutive menstrual cycles and presenting this to a medical doctor for definite diagnosis.

In addition to this, the following should also be taken into consideration to help diagnose PMDD:

• If symptoms are not considerably reduced by the end of menstruation, then it may not be PMDD that is responsible for the symptoms
• Symptoms need to be a lot worse (over 30-50%) worse during the two-weeks prior to menstruation to be considered PMDD

Use the PMDD Tracker to accomplish this. Print it out and use it as your menstruation diary and take it to your doctor for discussion.

Conventional treatment of pre-menstrual dysphoric disorder (PMDD)

The conventional (western) medical approach to treating PMDD is through a combination of the following treatments:

Hormone therapy

These are used to regulate hormones by preventing ovulation and prevent or ease PMDD symptoms:

• Contraceptive pill – usually contains both eostrogen and progesterone in specific ratios, but there are also contraceptive pills that contain only one or the other hormone only. There are many variations of the Pill, with different amounts of each of the hormones oestrogen and progesterone. Today, most doctors prescribe a particular contraceptive pill called Yasmin^® with a special combination of hormones (drosperinone/ethinyl estradiol), as research has shown it can greatly assist in reducing the symptoms of PMDD by suppressing ovulation, reducing fluid retention and countering the effects of testosterone
• Danazol – this medication reduces the output of both follicle-stimulating hormone (FSH) and luteinising hormone (LH) and oestrogen, so it stops the menstrual cycle, which may help with some women’s PMDD symptoms. If the menstrual cycle stops, then PMDD symptoms are generally not going to occur. While Danazol is effective at reducing symptoms of PMDD, it is only prescribed as a medication of extreme last resort, when other options are not viable, as it has really severe side effects (acne, cramps, depression, flushing, increased HDL (“bad”) cholesterol levels, increased male characteristics, reduced breast size, weight gain) and also cannot be prescribed for longer than six months
• GnRH agonists – Gonadotropin releasing hormone agonists (GnRH) are a type of medication that suppresses ovulation by stopping the production of oestrogen and progesterone. The GnRH agonists are effective at reducing symptoms of PMDD, but they are only prescribed as a medication of last resort, when other options are not viable, as they have severe menopause-like side effects (in particular, hot flushes and night sweating) and they also cannot be prescribed for longer than six months
• Bromocriptine – this drug selectively targets one of the abnormal hormones, but is not used very much these days as it can cause a worse imbalance of the hormones

These drugs all have side effects, some of which are quite severe and cause many women to stop taking them. These medications just treat the symptoms and not the actual cause of the PMDD, so they do not really provide a major benefit for PMDD long-term. This is the reason why many doctors these days are more inclined to suggest an alternative / complementary approach to treating PMDD and only suggest medication as a last resort.

The contraceptive pill for example, should not be taken by women who smoke, who have had any type of blood clots or who have had any type of oestrogen female cancers. The other medications also have their own set of side effects and the risks should be discussed with your doctor.

Medications

The following medications are prescribed, either on their own or in a combination advised by your doctor, depending on symptoms:

• Fluid retention relief – to relieve symptoms associated with bloating in the breasts, abdomen and the whole body
  • Diuretics – both over-the-counter and prescription are used to relieve the fluid retention and breast tenderness symptoms associated with PMDD by blocking the function of the hormone aldosterone. Examples are: Aldactone (not to be taken at night as they can cause disrupted sleep when they wake you with the need to urinate often)
• Prostaglandin inhibitors – to relieve inflammation
  • COX-2 Inhibitors – these medications are used to relieve menstrual cramping and premenstrual symptoms. Examples are: Celebrex (other Cox-2 inhibitors have been taken off the market due to significant side effects, including heart attack, stroke and possible death)
• Analgesics – to relieve pain and/or inflammation
  • Naproxen, ibuprofen, or mefenamic acid – these are non-steroidal anti-inflammatory medications which relieve premenstrual pain and reduce menstrual pain and bleeding. They work to reduce inflammation by reducing prostaglandin production. Examples are: Advil, Naprogesic, Nurofen, Ponstan
• Anti-depressants – these are recommended to be used just in the two weeks prior to menstruation, during PMDD (or sometimes all month for some women) to reduce symptoms associated with depression. Today, there are a number of anti-depressant medications which are specifically tailored to be used for PMDD
  • Benzodiazepines – are only recommended to be used for a few days prior to menstruation for anxiety symptoms, when other treatments have been ineffective. These medications depress the central nervous system, but they lose their effectiveness over time and can be very addictive. Examples are: Xanax
  • SSRIs – these medications work by helping the brain retain more serotonin, the neurotransmitter responsible for regulating mood and which may be low in women with PMDD. These medications help to relieve depression, anxiety, irritability, aggression, and many physical symptoms of PMDD. Examples are: Prozac, Sarafem, Paxil, Zoloft, Luvox, Celex

Alternative / complementary treatment of pre-menstrual dysphoric disorder (PMDD)

Alternative medical practitioners such as naturopaths do not really think that PMDD is a psychological condition, but that it is just an amplification of PMS, which means that PMDD basically has nutritional deficiencies which can be treated with alternative/complementary therapy.

To get a better understanding of your PMDD (or PMS), see a qualified naturopath who can tailor a program of nutrition, supplements, lifestyle changes and herbs just for you.

Herbs

There are a number of herbs which are routinely recommended for assisting with not only reducing symptoms but also to help balance hormones:

• Chamomile (matricaria chamomila) – an excellent herb for relaxing the whole body and is particularly useful for women whose PMDD causes sensitivity, irritability, crying, timidity and feelings of inadequacy
• Chaste berry (agnus castus) – this is the berries of the chaste tree, indigenous to Southern Europe, the Mediterranean and Asia. The berries contain compounds which act on the pituitary gland, specifically on the production of luteinising hormone to influence progesterone levels during the second half of the menstrual cycle, which is when PMDD occurs. Chaste berry is highly effective in treating menstrual irregularities, breast pain and premenstrual complaints
• Dandelion (taraxacum officinale) – is an excellent natural anti-diuretic which is well tolerated by most women, which makes it an excellent tonic for women that have symptoms of fluid retention symptoms. Dandelion also works on the liver to detoxify it from all toxins in general and excessive amounts of eostrogen in particular
• Dong quai (angelica polymorpha) – is a herb widely used for treating PMDD as it has analgesic and sedative properties, which is good for treating anxiety and pain symptoms. Note: excessive doses can cause uterine contractions and should be avoided in women who are trying to get pregnant
• Lavender (lavandula vera) – as an essential oil is beneficial for reducing nervous tension and to treat insomnia as it is a relaxant. Lavender can be applied in a number of ways – a few drops to the pillow, some drops to an oil burner, as a room spray or even a few drops on the skin (as long as it is the diluted form). Note: some people may be allergic to the oil if applied topically, so use with caution in this manner
• Lemon balm (melissa officinalis) – is a very soothing herb, which has mild muscle relaxant properties, so is beneficial for anxiety symptoms, especially for insomnia as it helps to reduce the time to get to sleep and assists with a better quality of sleep. Lemon balm is very effective if stress has adversely affected the stomach and digestive system too
• St John’s wort (hypericum perforatum) – is a well known and much used herb to treat mild to moderate depression from any cause. It is widely used in many countries by doctors) as an alternative treatment to anti-depressant medications. St John’s wort helps to support the nervous system as a whole, which means it is helpful for all PMDD symptoms, but it also has a sedative effect which means it is good for women with anxiety and insomnia symptoms. Note: St John’s wort should never be used together with anti-depressant medications as this combination can produce serious health effects
• Valerian (valeriana officinalis) – is a herb that is widely used for its calming effects on the mind. It is especially useful for stress-related anxiety, tension and insomnia and for depression caused by stress or nervous tension. Studies show that valerian is an excellent non-addictive sleep aid, as it helps people fall asleep quite quickly and improves the quality of sleep. Valerian is useful for anxiety and stress, but lower doses needed to be used during the day for this purpose. Note: about 2%-5% of people experience the opposite effects when taking valerian – they become more alert, more awake, more wired up and do not calm down and relax if they take valerian, so try it at a smaller dose to be sure or try other herbs such as chamomile or lemon balm which are gentle and soothing

Vitamins

There are a number of vitamins especially beneficial for reducing PMDD symptoms:

• Vitamin B1 – thiamin is very useful in supporting the nervous system, which may not be functioning as effectively as normal and may not be able to handle stress as well as it should
• Vitamin B2 – riboflavin is very useful in supporting the nervous system, which may not be functioning as effectively as normal and may not be able to handle stress as well as it should
• Vitamin B3 – niacin is very useful in supporting the nervous system, which may not be functioning as effectively as normal and may not be able to handle stress as well as it should
• Vitamin B5 – pantothenic acid is very useful in supporting the nervous system, which may not be functioning as effectively as normal and may not be able to handle stress as well as it should
• Vitamin B6 – pyridoxine is involved in the synthesis of specific neurotransmitters that regulate mood and which may be at abnormally low levels during PMDD. Vitamin B6 helps to balance the amount of certain neurotransmitters, thereby reducing mood swings and depression, anxiety and regulating mood during PMDD
• Vitamin B12 – cyanocobalamin is very useful in supporting the nervous system, which may not be functioning as effectively as normal and may not be able to handle stress as well as it should
• Vitamin D – the hormone vitamin D assists in the absorption of calcium and thereby gives relief to some of the symptoms associated with PMDD which are related to a deficiency of calcium (excess of oestrogen)
• Vitamin E – the powerful antioxidant and free radical scavenger vitamin E helps to alleviate breast tenderness, fluid retention and pain symptoms associated with PMDD

Minerals

There are a number of minerals especially beneficial for reducing PMDD symptoms:

• Calcium – plays quite a big role in hormone regulation. It has been shown in various studies that the level of calcium drops in the two weeks preceding menstruation. Those studies showed that if calcium levels were increased at this time, many of the symptoms of PMDD were reduced. Calcium supplements should be taken with Vitamin D and magnesium to ensure there are correct ratios of all three nutrients
• Chromium – is especially beneficial for regulating insulin levels in women with an exaggerated insulin response and reducing the cravings associated with PMDD
• Magnesium – is important for hormone production and metabolism, as well as for the proper use of calcium and vitamin D. Magnesium deficiency during PMDD is associated with decreased levels of dopamine (which is a neurotransmitter that helps to calm the brain) and an inability to synthesise linoleic acid properly. Studies show that magnesium deficiency is common in women with PMDD. Chocolate, which contains magnesium, is a food often craved by women experiencing PMS, due to the body’s need for magnesium
• Zinc – acts as a hormone regulator due to its function with various enzyme processes in the body, so it is very useful for controlling PMDD symptoms by balancing the hormones circulating in the body. In addition to this, zinc helps to metabolise linoleic acid properly (which is needed to produce the anti-inflammatory PGE1 prostaglandins that help reduce pain and fluid retention)

Other nutrients

There are a number of important nutrients which can be beneficial in helping reduce symptoms:

• DHA/EPA – these two omega-3 essential fatty acids are found mainly in fish oil and have excellent anti-inflammatory properties due to the excellent omega-3 fatty acids they contain. Fish oil which contains high levels of DHA/EPA are often prescribed for women with PMDD to help with pain, depression and fluid retention especially
• Evening primrose oil – this supplement is especially beneficial for the pain group, but it is also great for all women experiencing all types of PMDD as it helps to reduce inflammation. Evening primrose oil is also great for women experiencing breast pain and tenderness, depression, irritability and fluid retention. The GLA (gamma-linolenic acid) in EPO (evening primrose oil) helps to regulates the hormone prolactin, which may be too high in some women, causing the symptoms of PMDD
• Linoleic acid – is required to ensure proper synthesis and metabolism of PGE1, which is a specific anti-inflammatory prostaglandin that has been shown to assist women who have either fluid retention or pain symptoms. One of the richest sources of gamma-linoleic acid (GLA) is evening primrose oil, which is why it is most often prescribed for women with PMDD
• Tryptophan – is an essential amino acid which is the precursor of serotonin, a neurotransmitter in the brain that helps to normalise mood (it relaxes and calms the brain). Some scientists think that an imbalance in serotonin could be an underlying factor in women who experience the depression and anxiety symptoms, so supplementation of tryptophan may help to ease these type of symptoms
• Tyrosine – is a non-essential amino acid which is involved in the proper function of the thyroid, as well as adrenal and pituitary glands. Some scientists think that an imbalance in any of these glands, but especially the adrenal glands (which control how well we handle stress) could be one of the underlying factors of PMDD and especially the anxiety symptoms and tyrosine may be the key to this. In addition, an imbalance of the thyroid hormones can cause symptoms very similar to PMDD and in fact, most women with PMDD (or severe PMS) seem to have some type of thyroid disorder – these two conditions seem to go hand-in-hand (although science is yet to prove why and solve the riddle of these disorders)

Dietary modifications

There are a number of dietary modifications that can be implemented to help reduce symptoms of PMDD:

• Increase fibre intake – fibre binds with excess oestrogen in the blood to help get rid of it and help normalise levels of eostrogen, which reduces the symptoms associated with anxiety. Fibre also helps digestion, by ensuring there is no build-up of toxins or waste by removing them and reducing bloating
• Increase foods high in vitamin B6 – this mineral is really important in PMDD as it is a precursor to serotonin, a neurotransmitter that is responsible for maintaining mood on an level (and happier) basis. Eating foods rich in vitamin B6 (and taking a supplement if necessary) can help to regulate serotonin levels, improve mood and may reduce anxiety and depression symptoms associated with PMDD
• Increase intake of fish – oily fish contains the beneficial omega 3 essential fatty acids DHA/EPA, which have a proven anti-inflammatory effect on the body and are very useful in preventing pain, fluid retention and inflammation symptoms of PMDD
• Increase intake of phytonutrients – (or phytochemicals) are responsible for flavor, color, and disease-resistance in plants (fruits, vegetables, whole grains and legumes). Most are antioxidants that benefit humans by enhancing immunity, strengthening heart and blood vessels and preventing tumors. They are also found in smaller amounts in nuts and seeds. Certain phytonutrients (namely phytoeostrogens) can help to balance abnormal hormone levels that occur during PMDD – and they are found mainly in: soya, flax seeds, wheat, rice, oats, barley, carrots, potatoes, apples, cherries, plums and parsley. Vegetable oils such as safflower, wheatgerm, corn, olive, linseed (flaxseed), peanut, soya and coconut oils also have some level of phytoestrogens
• Increase intake of sunflower seeds – which are rich in the essential fatty acid linoleic acid which helps to reduce symptoms of PMDD by increasing the amount of the anti-inflammatory prostaglandin PGE1 and reduce pain and inflammation as well as fluid retention
• Increase intake of vegetables – vegetables contain so many vitamins and minerals which may be in deficit during PMDD and so exacerbate PMDD symptoms. Fruit and vegetables are also rich in potassium, which helps to regulate sodium levels in the body and prevent symptoms of fluid retention
• Limit caffeine – coffee, tea (except for most herbal teas), chocolate and some energy drinks all have caffeine, which can all over stimulate the brain and aggravate feelings of depression, irritability and anxiety as well as worsening breast tenderness and bloating, which are not beneficial during PMDD, when calm and relaxation are required
• Limit processed foods – most processed foods are very high in saturated fat, sugar, salt, calories and have little nutritional benefit at any time, but have even less relevancy at PMDD when foods high in nutrients are needed to help support the body and reduce symptoms
• Limit refined sugar intake – sugar is basically empty calories and for women who have unbalanced glucose levels and an exaggerated insulin level to carbohydrates will continue to have symptoms associated with this during PMDD. High sugar intake also increases prostaglandin levels, which make pain and other symptoms worse and in addition to this, excessive sugar intake makes the body excrete too much magnesium, which is needed to calm down the muscles and help them relax and less magnesium means more PMDD symptoms
• Limit saturated fats – saturated fats, especially from non-organic meat may contain various hormones and other chemicals which can further cause imbalance to hormones (especially by increasing eostrogen to excessive levels) and should be avoided
• Reduce dairy intake – intake of high fat dairy foods is associated with a higher than normal eostrogen to progesterone ratio and the anxiety-type symptoms during PMDD, so either eating only law fat dairy foods (milk and yoghurt) and restricting other forms of dairy may be beneficial in reducing symptoms
• Reduce salt intake – women who have an increased sodium retention during PMDD need to limit the amount of salt in foods they eat, especially limiting processed foods, which contain high levels of sodium
• Strictly limit alcohol – this is because alcohol is a natural depressant, so it really does not help PMDD symptoms and should be avoided as much as possible

Lifestyle modifications

There are a number of lifestyle modifications which are recommended for helping women with PMDD reduce symptoms:

• Exercise – studies show that regular exercise in combination with a healthy diet can help reduce all PMDD symptoms to a degree. The reason exercise helps alleviate PMDD is because during physical activity, all the cells receive more oxygen and are able to eliminate more waste (including excess fluid, excess eostrogen and toxins), plus exercise releases endorphins, which create a sense of positivity and happiness, which can reduce symptoms such as depression, irritability and mood swings. Exercise is a great outlet for pent-up frustrations and anxiety, plus it helps to keep hormones in balance
• Sleep – getting enough sleep is important because is helps the body repair and recover from the day’s activities. Without adequate sleep, PMDD symptoms can be aggravated as lack of sleep causes anxiety, mood swings and tension
• Socialise – feeling socially isolated can lead to feelings of depression and anxiety, which only further exacerbate PMDD symptoms. It is important to keep in touch with friends and socialise to feel connected to other people, plus it’s always good to talk to other women about PMDD as they may be able to sympathise
• Meditate – studies show that any type of meditation which helps to calm the mind is beneficial for significantly reducing symptoms of PMDD, especially the anxiety and depression symptoms
• Tai chi – numerous studies have shown that tai chi has a calming effect on the mind, in a similar way to meditation and can help to reduce symptoms of PMDD, especially the anxiety and depression symptoms
• Yoga – numerous studies show that yoga (either the meditation or the higher energy forms) are very beneficial for helping reduce PMDD symptoms. Yoga has several stances and breathing techniques specifically aimed at relaxing the mind, relieving anxiety and depression and helping the female sex organs (including ovaries and uterus) in general

Alternative treatments

• Acupuncture – a number of studies show that women who regularly received acupuncture for a specific duration had relief of symptoms

Always ensure that you notify your medical practitioner of any supplements that you want to take – it may interfere with other medication or conditions you have. Confirm with your doctor it is safe to take before you try it.

Living with pre-menstrual dysphoric disorder (PMDD)

There are a number of strategies which are recommended to help you better deal with pre-menstrual dysphoric disorder (PMDD):

• Avoid alcohol – if you suffer from the breast tenderness and fluid retention symptoms, then any level of alcohol will be highly dehydrating and you need to avoid it, especially during PMDD as it will only make your symptoms worse
• Drink enough water – ensure you are properly hydrated by drinking at least eight glasses of water every day. This is important because your body may not be handling fluid properly and you need more fluid to help flush out excessive fluid in the body
• Eat more vegetables and fruit – your body requires more nutrients during PMDD to more effectively deal with this condition and this can be effectively managed through a higher intake of vegetables and fruits. You should be eating 5-7 portions of vegetables and 3-5 portions of fruit each day and the darker green or purple or brightly coloured the better
• Exercise regularly – it is really important that you incorporate regular exercise into your daily routine of at least 30-40 minutes, some which should be cardio and some of which should be resistance training (to keep the heart and bones strong). Exercise is a great way to help alleviate PMDD symptoms because during physical activity, all the cells receive more oxygen and are able to eliminate more waste (including excess fluid, excess eostrogen) and exercise released endorphins, the “feel good” chemicals which increase happiness and reduce feelings of anxiety and depression
• Increase foods high in vitamin B6 (pyridoxine) – if you suffer from fluid retention and breast tenderness symptoms during PMDD you may benefit from the natural diuretic effects of vitamin B6 (pyridoxine). Eating more foods rich in vitamin B6 (pyridoxine) may help to reduce these symptoms
• Increase intake of essential fatty acids – the omega-3 essential fatty acids and GLA (and omega-6 fatty acid) both help to reduce inflammation and reduce levels of prostaglandins in the body, which are elevated during PMDD. It would be helpful in reducing symptoms of PMDD (especially the cramping, mood and fluid retention symptoms) if you increase intake of: fish, especially salmon, tuna, mackerel as well as nuts and seeds
• Increase intake of calcium-rich foods – your levels of calcium may be decreased during PMDD and some experts believe this could be part of the cause of PMDD symptoms, and so would be beneficial if you increase your intake of foods rich in calcium. Dairy foods are not the only foods rich in calcium
• Increase intake of magnesium-rich foods – your levels of magnesium may be lowered during PMDD and as magnesium is necessary for relaxing the body, this could be a factor in the mood problems. You can try to increase your intake of foods rich in magnesium to help reduce symptoms of PMDD. A handful of raw, unsalted almonds is one of the highest natural sources of magnesium
• Keep blood sugar levels balanced – symptoms of irritability, mood swings, anxiety, confusion and difficulty concentrating are not only symptoms of PMDD, but also symptoms of low blood sugar levels. To avoid this, eat five to six small meals every 3-4 hours and ensure to include some good quality protein with every meal and snack to prevent fluctuations of the blood sugar levels and help reduce many of the the emotional symptoms of PMDD
• Limit caffeine intake – any type of caffeine dehydrates the body, which is unhelpful during PMDD, as this can worsen fluid retention and breast tenderness symptoms. In addition to this, caffeine can over-stimulate the brain and worsen anxiety, agitation and feelings of depression, so it is best to avoid caffeine intake during PMDD. Foods high in caffeine include: coffee, black tea, green tea, chocolate, energy drinks, some fizzy soft drinks
• Limit intake of processed foods – most processed (or packaged) foods contain a lot of sodium (salt) which will only make fluid retention and breast tenderness symptoms worse and besides, these foods have little nutritional value, are usually very high in saturated fat, high in calories and should be strictly limited in the diet
• Low glycemic foods – if you experience the symptoms of low blood sugar levels (irritability, depression, agitation, nervousness, inability to concentrate) you should try to eat a diet that includes more low glycemic index (GI) foods, to help stabilise blood glucose levels and reduce these symptoms during PMDD. Foods that have a low to medium GI include: vegetables, fruits, legumes, nuts, seeds, fish, poultry, lean red meat, low fat dairy and should be the mainstay of the diet
• More fibre in the diet – an adequate intake of fibre is necessary in the diet to help slow down the release of glucose into the blood, which means blood glucose levels are more stable. Fibre also helps to improve digestion and keeps it healthy, allowing wastes to pass out of the body ensuring toxins do not build up. Fibre also binds with excessive oestrogen and helps the body get rid of it – this helps to normalise levels of oestrogen and reduce symptoms of anxiety, depression, agitation, nervousness and depression
• More phytonutrients – all plant foods have some phytonutrients, which are important for health. Some contain substances that help to keep eostrogen levels normalised (phytoestrogens), by blocking the receptors on cells when there is too much oestrogen in the blood. The fibre in these foods then helps the body get rid of the excessive oestrogen. The foods highest in phytoestrogens are: apples, barley, carrots, cherries, flax, plums, potatoes, rice, soy, wheat and certain herbs
• Reduce salt intake – if you experience a lot of fluid retention, then it would be beneficial if you reduce your salt (or sodium) intake in your diet. Sodium is found not just in table and cooking salt, but in processed foods, so look at the ingredients lists and if you find sodium high in the ingredients list, avoid that food
• Stress reduction techniques – it could be beneficial in reducing symptoms of depression, anxiety and tension if you engage in stress reduction techniques such as meditation, tai chi or visualisation. These techniques help to induce a feeling a calmness and relaxed state of mind
• Supplements – talk to your doctor or qualified naturopath about using specific supplements to help you combat symptoms of PMDD. The supplements most often prescribed for women with PMDD are: calcium, evening primrose oil, GLA, magnesium, vitamin B6 (pyridoxine). In addition to these, there are a number of herbs which have properties to help reduce a number of PMDD symptoms: chaste berry, dong quai, st john’s wort, valerian. It is important not to self-prescribe these supplements as they could adversely interact with other medications or conditions you may have, always consult with a professional
• Yoga – an excellent way to reduce symptoms of PMDD is through the practice of yoga, many forms of which use meditation as part of the yoga practice. In addition to the meditation, yoga can also be very robust and active, which can provide an excellent exercise to practice every day

Caring for someone with pre-menstrual dysphoric disorder (PMDD)

Partner

If you have a partner with PMDD, there are a number of strategies you can use to help them deal with it:

• Allow your partner time to relax – it is really important that your partner engages in some form of relaxation to help reduce emotional symptoms and induce a state of calmness and relaxation to help reduce her PMDD symptoms. Allow your partner the space to engage in this at home without disturbance
• Cook more fish – ensure your partner (and whole family) eats oily fish three times a week, as this will provide omega-3 essential fatty acids, which may help reduce her symptoms of inflammation, pain and fluid retention
• Don’t smoke – if you smoke cigarettes, make sure you do so outside and not near your partner as the fumes from cigarette smoke may make their symptoms worse. If your partner smokes, encourage her to stop
• Encourage exercise – your partner’s mood and symptoms of PMDD will generally decrease if they are regularly engaging in some form of exercise, so it would also benefit you to encourage them to do so. You can always join in or encourage your partner to exercise with a friend or join a gym
• Healthier diet – ensure that you and your partner are cooking healthy meals made from fresh ingredients and not from packages, as they contain little nutritional value and besides which, contain too much salt, calories and fat, which can only make your partner’s symptoms worse
• Limit alcohol in the house – alcohol intake is very detrimental to your partner’s PMDD symptoms, so it would be beneficial for your partner if you could also limit your alcohol intake at home with your partner, as it will help them to perceive your support and solidarity
• Support – it is important for your partner to know that she has your full support and understanding, as this will help her better deal with her symptoms. Try not to tell her it’s just “all in your head” as that is unsupportive and will only aggravate her symptoms of irritation even more. Just try to be sensitive

Friends

If you have a friend with PMDD, there are a number of strategies you can use to help them deal with it:

• Don’t smoke – if you smoke cigarettes, make sure you do so not near your friend as the fumes from cigarette smoke may make their symptoms worse
• Limit alcohol – try to ensure your social interactions with your friend do not involve alcohol, as it can make your friend’s symptoms much worse
• Support – your friend will greatly benefit if they have your understanding and support, especially when they are suffering the worst of their PMDD symptoms. Just try to be sensitive

Parents

If you have a daughter with PMDD, there are a number of strategies you can use to help them deal with it:

• Cook more fish – ensure your daughter (and whole family) eats oily fish three times a week, as this will provide omega-3 essential fatty acids, which may help reduce her symptoms of inflammation, pain and fluid retention
• Don’t smoke – if you smoke cigarettes, make sure you do so outside and not near your daughter as the fumes from cigarette smoke may make their symptoms worse, or at least irritate them. If your daughter smokes, encourage her to stop
• Encourage exercise – your daughter’s mood and symptoms of PMDD will generally decrease if she is regularly engaging in some form of exercise, so it would also benefit you to encourage them to do so. You can always join in or encourage your daughter to exercise with a friend or join a gym
• Healthier diet – ensure that you and your family are cooking healthy meals made from fresh ingredients and not from packages, as they contain little nutritional value and besides which, contain too much salt, calories and fat, which can only make your daughter’s symptoms worse
• Support – it is important for your daughter to know that she has your full support and understanding, as this will help her better deal with her symptoms. Try not to tell her it’s just “all in your head” as that is unsupportive and will only aggravate her symptoms of irritation even more. Just try to be sensitive

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Last reviewed and updated: 14 May 2024