Is it PMS, PMDD or Perimenopause

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It is a rare woman who has never experienced some symptoms of PMS (Premenstrual syndrome) and it is estimated that at least 90% of us will be familiar with at least some of the common ones like bloating, abdominal cramps, headache, feeling irritable, angry, emotional, tearful and having cravings for refined carbohydrates and sugar. Whilst these side effects might be inconvenient, and not exactly cause for celebration, most of us learn to live with them. However, an estimated 5-8% of women have a much, much tougher time of it suffering with a particularly severe and disabling form of PMS known as premenstrual dysphoric disorder – or PMDD.[1] The good news is that both PMS and PMDD tend to be resolved when you hit the menopause. The bad news is that as you transition into the perimenopause phase they can actually get worse. Plus, to confuse things further symptoms of perimenopause can be strikingly similar to those of PMS. How then, do you unpick one set of symptoms from the other, and what can you do to alleviate them?

PMS, PMDD and perimenopause; what is the difference?

PMS – Premenstrual Syndrome (PMS) is the name given to the physical and emotional symptoms experienced by women weeks before their monthly period. According to the National Association for Premenstrual Syndromes over 150 symptoms of PMS have been identified[2] but as Dr Rebeccah Tomlinson, a GP and menopause expert, explains it is generally characterised by a cluster of symptoms that commonly include:

  • Breast tenderness
  • Abdominal cramps
  • Back pain
  • Nausea
  • Diarrhoea or constipation
  • Bloating
  • Headaches
  • Fatigue
  • Intolerance to alcohol
  • Spots or acne
  • Mood swings and tearfulness
  • Feeling out of control
  • Social withdrawal
  • Trouble thinking and concentrating
  • Insomnia
  • Irritability and anger
  • Feeling of sadness and despair

Experts are unsure what exactly causes PMS but it is generally agreed it is related to changes in levels of the hormones oestrogen and progesterone.[3] Some women will sail through life with no PMS symptoms or very mild ones, for others they may be moderate to severe and for most of us will be somewhere in between. Symptoms of PMS, in particular period pain, are also known to get worse if you are under severe stress.[4] There is no simple ‘cure’ for PMS but the condition can usually be managed well with lifestyle changes. All symptoms, however, should subside a few days after your period begins.

PMDD – (premenstrual dysphoric disorder) Symptoms of PMS and PMDD can be similar but what marks them out as different is the severity and intensity of them. PMDD is a far more severe and debilitating form of PMS that is believed to affect around 5-8% of women and can hugely diminish their quality of life – affecting some for around two weeks of every month. Symptoms can include painful cramps, joint and muscle pain, depression, suicidal thoughts, panic attacks and anxiety, severe mood swings, bouts of crying, lack of motivation and interest in daily activities you normally enjoy, trouble sleeping, difficulty in focusing and binge eating. Nobody knows why some women appear to suffer so severely – it seems some are more hypersensitive to changing levels of hormones, particularly progesterone, but you are at an increased risk if there is a family history of it or severe PMS and/or a history of depression or other mood disorders. Smoking also appears to make it worse.[5]

What can also distinguish PMS from PMDD is that in PMDD psychological symptoms can be more of an issue than physical ones. Many women living with PMDD report feeling deeply depressed and it is suggested this may be linked to compromised levels of the neurotransmitter serotonin – a brain chemical responsible for regulating, and stabilising, mood and sleep.[6] Low serotonin levels are associated with increasing anxiety, sadness, low mood, insomnia, impulsive behaviour and social anxiety and suicidal thoughts.[7] Dr Tomlinson adds, ‘PMS and PMDD is more common in non-Caucasian ethnicities and is less prevalent in Asian communities – leading to the view that genetics and lifestyle factors, like diet, could also play a part.’ Both PMS and PMDD symptoms can worsen as you enter perimenopause.

Perimenopause – Typical symptoms of perimenopause – the transitional time leading up to the menopause which most women go through in their mid-40s – can be startlingly similar to those of PMS including mood swings, bloating, headache, feelings of anger, brain fog and loss of libido (and these are just some of the overlapping symptoms). The reason both PMS and PMDD can get worse during perimenopause is because your periods start to become increasingly erratic as your hormones are fluctuating more – often becoming more frequent and heavier or less frequent and lighter, or a combination of both – making symptoms harder to manage as they become increasingly unpredictable. Both PMS and PMDD tend to be resolved as you reach menopause.

How do you know if YOU have PMS, PMDD or are perimenopausal?

If you have always suffered with moderate to severe PMS the idea that you might be perimenopausal might not even be on your radar given the symptoms can be so similar. So how do you differentiate between them? Dr Rebeccah Tomlinson explains, ‘If your symptoms happen in the two weeks before your period and then stop it is probably PMS. If you’ve been experiencing them continuously, at any time of the month, or they have only recently started this is likely to suggest you are in perimenopause.’

Do PMS and PMDD get worse as you age?

Yes. Your usual PMS symptoms can also feel more intense and might also be exacerbated by the onset of perimenopausal symptoms like hot flushes, night sweats, brain fog and vaginal dryness. You may also experience low mood and feel teary more frequently. Once your periods stop your PMS symptoms will stop although it should be pointed out that some menopause symptoms can be similar to those of PMS like breast tenderness, bloating and mood swings. Similarly, symptoms of PMDD can worsen in the run up to perimenopause and become harder to manage as your hormones become increasing erratic.[8] However, these should also resolve as you transition into menopause and your hormones ‘level out’.

What can help PMS, PMDD and Perimenopause?

Whatever your age there are medical interventions and lifestyle changes that can help considerably with PMS, PMDD and perimenopause:

Medical treatments – Most women with PMS manage their symptoms with lifestyle changes, as do many women going through perimenopause, but those with PMDD or more severe PMS or perimenopausal symptoms may require medical treatment. Dr Rebeccah Tomlinson outlines what is available:

  • Birth control pills. Taking a combined contraceptive pill and one that contains drospirenone (for example, Yasmin or Lucette) can be effective in reducing symptoms of PMS and PMDD.[9] The pill can be taken continuously to avoid having a monthly period. The theory is that by doing this you should avoid the hormonal changes that cause the unwanted symptoms.
  • HRT. Hormone replacement therapy can be helpful for perimenopause-related symptoms as it helps to replace and balance fluctuating and declining hormones.
  • Prostap. This is a hospital-initiated medication that can be used for a six-month period to try and subdue all female hormones in the body.[10] HRT can be used to manage any menopausal symptoms that may occur when using this medication.
  • Antidepressants – Selective Serotonin Reuptake Inhibitors (SSRIs) such as Sertraline or Fluoxetine can be helpful in all three conditions but they do have some unwanted side effects such as loss libido and mood changes. Many women also report nausea and tiredness as common symptoms.[11]
  • Surgery. A hysterectomy – the surgical removal of the ovaries and the uterus – can be life-changing for some women with debilitating symptoms.[12] HRT can be given to prevent and/or manage any menopausal symptoms.

Lifestyle changes

There are also a range of things you can incorporate into your life to help manage your symptoms better – all of which can be done in tandem with medication if you have been prescribed any – including:

  • Tracking your symptoms. Download the free Health & Her symptom tracker and try to establish your premenstrual patterns over two or three menstrual cycles. Log not only the frequency of your periods (marking the days when they start and when they end) but also chart your moods, potential food cravings and pick up on any potential triggers (like caffeine or stress) that exacerbate your symptoms (here are the most common perimenopause and menopause triggers). This will not only give you the information you need to make changes yourself but also will provide a good record of information when, or if, you need to talk to your GP or health specialist about your symptoms.
  • Diet. A healthy, balanced diet will help keep you generally healthier but there are certain foods that appear to be particularly helpful in reducing symptoms of PMS and perimenopause. These include ones high in omega 3 like oily fish (salmon, mackerel, sardines), nuts, seeds (like pumpkin and linseed), pulses and extra virgin olive oil which may improve the severity of PMS[13] and some menopausal symptoms.[14] If you feel you don’t get enough from your diet taking a supplement can help. There is also evidence to show that women who eat a diet rich in calcium (good food sources include dairy foods, canned sardines, soybeans and green leafy vegetables) and vitamin D (found in small amounts in oily fish, egg yolks and liver but mainly produced on the skin on exposure to UV light) are less likely to suffer with PMS.[15] Cutting down on salt can help reduce bloating, fluid retention and breast tenderness. Eating regularly is also important to maintain healthy blood sugar levels – when it drops you are likely to feel headache-y, light-headed, stressed, irritable and have difficulty concentrating, plus you will probably crave sugary or white refined carbohydrate foods (like white pasta and/or bread and cake) – symptoms which, of course, are not dissimilar to those of PMS and perimenopause. So try to eat well, including plenty of fruit and vegetable; complex carbohydrates (like brown rice, whole-wheat pasta and pulses), some sources of calcium-rich dairy (like live yogurt, milk and cheese) and lean protein (chicken, eggs, tofu, fish) – and eat regularly. For more healthy food suggestions read Nutritional Therapist Rosie Letts’ advice in Diet and recipes to help balance hormones in menopause.
  • Evidence shows that supplements can be another useful tool when managing PMS and perimenopause symptoms. It has been shown, for example, that those experiencing PMS can benefit from taking Vitamin B6 which can help to support hormone regulation, energy and the nervous system. Making sure you are getting adequate amounts of iron can also help contribute to normal cognitive function when you are premenstrual. These nutrients, and more, can be found in Health and Her Pre Menstrual Multi-Nutrient Support Supplement The tiredness which is so often a side effect of perimenopause can be helped by getting adequate amounts of vitamins B6 and C and the mineral magnesium. If you are experiencing tired and achy muscles – another one of the common side effects of perimenopause – Vitamin D3 and magnesium have been shown to help to support muscle function. Vitamins B6, B12, C and magnesium are also known to help support normal psychological functioning. These nutrients are included in the best-selling Health and Her Perimenopause Multi-Nutrient Support Supplement.
  • Studies have shown that doing regular aerobic exercise can effectively help reduce PMS symptoms. One has shown that doing three one-hour exercise sessions over two months significantly reduced PMS symptoms in women who didn’t normally exercise.[16] Yoga can help with menstrual cramps and bloating.[17]
  • Manage stress. There is research to link increased stress (particularly early on in your cycle – around two weeks before your period starts) and increasingly severe PMS symptoms. Researchers suggest that the stress hormone cortisol may exacerbate PMS symptoms by stopping ovulation, which can affect when, and if, your period starts.[18] Exercise is one of the most well-documented effective ways to manage stress and getting enough sleep will help and Dr Shilpa McQuillan offers other helpful suggestions in Coping with stress and anxiety during menopause.
  • Avoid caffeine and alcohol. Sorry coffee and tea lovers but the more caffeine you consume, the more likely you are to suffer with PMS and have longer and heavier periods.[19] It has been suggested that caffeine can cause sleep problems in those who are sensitive to it and may also interfere with the absorption of some important nutrients including calcium and magnesium.[20] And as comforting as drowning your PMS or perimenopause sorrows with alcohol might seem, research analysing 19 studies into the effects of alcohol on PMS found that it was 45 per cent higher in those who drank as opposed to those who didn’t. That risk increased to 79 per cent for women classed as heavy drinkers (taken to mean more than one drink a day).[21] The study concludes, however, that more research is needed to establish the exact level of alcohol likely to cause problems but most of us can testify to the fact drinking alcohol can contribute to feelings of anxiety and these can be magnified when you are premenstrual and/or perimenopausal. In recent research carried out by Health & Her, alcohol is one of the most common triggers for exacerbating perimenopausal symptoms, with four out of 10 women reported becoming increasingly intolerant to its effects when they were going through perimenopause.
  • CBT (Cognitive behavioural therapy). This talking therapy has been found to be equally as effective as the antidepressant fluoxetine (Prozac) in treating symptoms of PMDD.[22] Our CBT expert gives her insight into CBT for menopause There is also a CBT tool on the free Health and Her app (download from the Apple Store or Google Play).
  • Stop smoking. A 2020 review of 13 studies has shown that cigarettes and e-cigarettes are linked to worse symptoms of PMS and PMDD.[23]
  • Speak to a specialist. Talk to your GP or find a menopause specialist GP or nurse through the Health and Her My Menopause Centre to discuss potential treatments and lifestyle changes that can help you as effectively as possible.

Further resources

National Association for Premenstrual Symptoms

Sources and references

[1] https://www.med.unc.edu/psych/wmd/resources/mood-disorders/menstrually-related/

[2] https://www.pms.org.uk/about-pms/

[3] https://www.ncbi.nlm.nih.gov/books/NBK560698/

[4] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1740691/

[5] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7725748/#:~:text=Stratified%20by%20diagnosis%2C%20PMDD%20showed,)%2C%20p%20%3C%200.0001%5D.

[6] https://www.healthline.com/health/mental-health/serotonin#functions

[7] https://www.healthline.com/health/serotonin-deficiency#causes

[8] https://www.premierhealth.com/your-health/articles/women-wisdom-wellness-/what-s-worse-than-pms-pmdd#:~:text=Most%20women%20with%20PMDD%20have,over%20time%2C%20lasting%20until%20menopause.

[9] https://www.rcog.org.uk/for-the-public/browse-all-patient-information-leaflets/managing-premenstrual-syndrome-pms-patient-information-leaflet/#:~:text=Combined%20oral%20contraceptive%20pill&text=Newer%20types%20of%20contraceptive%20pills,break%2C%20for%20better%20symptom%20control.

[10] https://www.wwl.nhs.uk/media/.leaflets/60a268a98bbb59.54546399.pdf

[11] https://www.nhsinform.scot/tests-and-treatments/medicines-and-medical-aids/types-of-medicine/selective-serotonin-reuptake-inhibitors-ssris

[12] https://www.nhs.uk/conditions/hysterectomy/

[13] https://obgyn.onlinelibrary.wiley.com/doi/10.1111/jog.15217?af=R#:~:text=difference%20(SMDs).-,Results,%E2%88%921.471%20to%20%E2%88%920.464).

[14] https://www.sciencedaily.com/releases/2009/01/090128104702.htm

[15] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6422848/#:~:text=Different%20studies%20suggest%20that%20calcium,to%20other%20women%20%5B22%5D.

[16] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3748549/#:~:text=%5B30%5D%20Some%20researches%20showed%20that,the%20psychological%20symptoms%20of%20PMS.

[17] https://www.health.com/condition/stress/10-yoga-poses-that-help-with-bloating-back-pain-and-more

[18] https://www.nih.gov/news-events/news-releases/prior-stress-could-worsen-premenstrual-symptoms-nih-study-finds

[19] https://www.sciencedirect.com/science/article/pii/S1658361214000651

[20] https://www.researchgate.net/publication/279923885_Effects_of_caffeine_on_health_and_nutrition_A_Review

[21] https://pubmed.ncbi.nlm.nih.gov/29661913/

[22] https://pubmed.ncbi.nlm.nih.gov/12436805/#:~:text=In%20conclusion%2C%20CBT%20and%20fluoxetine,be%20considered%20in%20treatment%20decisions.

[23] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7725748/#:~:text=Smoking%20was%20associated%20with%20an,)%2C%20p%20%3C%200.0001%5D.

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Dr Rebeccah Tomlinson

General Practitioner

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