PMDD & PMS, PME Care

Female Mental Health Spotlight on Medical Conditions
Psych Team

Topics about menstrual cycles can be uncomfortable to talk about, but in general, these symptoms can be debilitating, physically and mentally. I encouraged patients to talk about it because sometimes they don’t know how much it’s going to affect their mental health, including being suicidal, and how it also can affect which medication to consider…

pms, pmdd, pe

PMS (premenstrual syndrome) is more common among women. Women with PMS can usually continue in their everyday activities without issue. PMDD ( premenstrual dysphoric disorder) is more likely to cause disturbances in daily activities and relationships. Late luteal phase = time between the release of an egg from the ovaries to the onset of menses. No known cause – but is suggested that it comes from a sensitivity to fluctuations in hormones. PME (Premenstrual Exacerbation) symptoms are present throughout a woman’s cycle. Worsening of symptoms from an underlying psychiatric disorder.

Usually, the issues start PRE-menstrual, which is about a week before the onset of menses when a person may see the worse of the behaviors including; emotional instability, crying/depression, irritability, insomnia, and anxiety. The somatic problems include weight gain, bloatedness, edema, breast tenderness, n/v, and syncope… Sources said it’s over 150 PMS symptoms! -(MD Edge/Journal of Family Practice)

As you can see, these symptoms shouldn’t be taken lightly or ignored, despite the symptoms being temporary. Even when I ask my patients about cycles, they sort of look shocked but it’s truly me just asking some simple questions, it doesn’t have to be an interrogation:

  • How’s your cycle? Is it heavy, painful, light, or regular? this is also a quick way to r/o anemia, which can also affect the mood and I usually recommend supplementing or consulting OB if the cycle is too heavy. If their cycle is too light, it may be because of sports, stress, etc. so I still ask the patient to consider supplementing. Side note, I had a patient without a cycle for months (pregnancy was already r/o), I recommended a physical, labs, etc. and her prolactin was super elevated. I started risperidone only for a month but d/c’d it and prescribed aripiprazole. She’s still following up about her cycles but I wanted to note how asking basic questions can lead to avoiding other complications.
  • How are you managing your cycles? so regardless if it’s well managed or not, I’m really asking how a person is tracking them or I give suggestions like using an app (I usually recommend MyCalendar/iPhone). I ask patients to track them because it’s not only important to know if they’re regular but, it’s extra important to know if it’s LATE. The most critical time of a baby’s development is the 1st trimester and this also affects the treatment and basically everything.
  • Ask the patient about her thoughts on pregnancy or family planning. Sometimes my feisty teenage patients will just blurt out how they’re pregnant. I do pregnancy tests and usually, it’s negative but that’s not the point or what the teen is really asking about… what they’re really wondering is the terms of being emancipated. I know it’s different from state to state, but I’m blunt and let teens know they will still be under some form of guardianship, and more than likely the baby will go to the family and/or the state. So before it gets to that point, I really try to give people a reality check about how being responsible and managing their mental health is really important.

DSM Criteria 

–AFP

About Treatment

According to general literature, PMS/PMDD develops within the luteal phase of the menstrual cycle and resolves shortly after menstruation. The luteal phase begins after ovulation and ends with the start of menstruation. However, at the end of the luteal period (the late luteal phase), breakthrough psych symptoms may occur due to an increase in the body’s metabolism (that occurs with cycles, thus you eat more/have cravings) and as a result, the medication blood levels can drop…so increasing the dose of SSRI medications may be helpful for PMS/PMDD. For Example: 

An SSRI-Choice (Fluoxetine): the person will take 10-20mg the week before the period starts; or daily with an additional 10mg the week before the period (to overcome increased metabolic rate in the late luteal phase). Another option will be to take the 10mg dose every day and a week before the period increase it to 20mg, but if pt. is already on 20mg then add 10mg in the late-luteal cycle.

…Only 3 meds are FDA-Approved for PMDD (though any SSRI can be helpful):

–Psychopharmacology Inst.

Here’s a quick disclaimer; anything with hormones requires management and good tracking skills, which a young patient may struggle with, and why I don’t normally treat based on luteal phases… For teens, their bodies are still regulating, some early/some late so I’m really just concerned about the amount of blood loss. It’s easier to use the antidepressant on a continuous basis (and proven to have better results) but for my adults, the luteal-phase method may be helpful.

In theory, the cause of PMS/PMDD is related to the allopregnanolone (the calming metabolite of progesterone) not keeping up with the estrogen levels because the estrogen levels increase towards the end of the cycle… estrogen has norepinephrine activities that lead to more activation, sleep problems, irritability, restlessness… so an antidepressant is not only treating the mood but also trying to balance the hormones (increasing allopregnanolone). Therefore, you can also recommend adding natural remedies/complementary treatments:

PRACTICE RECOMMENDATIONS via MD Edge/Jornal of Family Practice

  • Start calcium supplementation in all patients who report significant premenstrual symptoms. Rated-A
  • Add a selective serotonin reuptake inhibitor (SSRI) to calcium supplementation for patients with more severe premenstrual psychological symptoms. Rated-A
  • Consider hormonal treatment options for patients who require treatment beyond calcium and an SSRI. Rated-B
  • Provide nutrition and exercise information to all patients who report significant premenstrual symptoms. Rated-C

In Conclusion 

The only thing that has helped me is to avoid food and people. And since both are usually impossible, it has become easier when I started tracking them to just brace for impact and it made a huge difference. Many young folks use birth control and can avoid all of this, but I planned on doing another post about how hormone treatment increases the risk for HTN, infertility, blood clots…etc. I did a post about discouraging kids from using puberty blockers and I didn’t even think about the culture or trends…I personally know people who have used birth control and witnessed how it affected their fertility, and it’s no joke seeing what a person has to go through… I think it possibly traumatized me. Ever since I’ve been in healthcare I just vowed to myself to not do anything to affect a person’s fertility but don’t judge people or go against any orders, I simply wish people were more aware of the risks. Anywho, my advice for improving PMS symptoms is to try the least invasive methods (for as long as possible) and go from there, Happy PMD Awareness Month!!

–Choosing Therapy

Additional Resources and References

–MDPI

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