PMS and PMDS – When the Second Half of the Cycle Becomes a Burden

PMS, or premenstrual syndrome, is real, common, and not all in your head. Many women are familiar with those days before their period when their bodies and moods go haywire—and yet they often hear that they shouldn’t “make such a fuss.” We see it differently: The symptoms follow a clear hormonal pattern, they should be taken seriously, and they can be effectively treated. On this page, we explain how to recognize PMS and what can help.

What Is PMS—and What Is PMDD?

PMS refers to physical and emotional symptoms that occur regularly during the second half of the menstrual cycle—after ovulation—and disappear with the onset of menstruation. Almost every woman experiences some of these symptoms; for about 20 to 30 percent of women, they are severe enough to be classified as PMS. The severe form, characterized by highly distressing emotional symptoms, is called PMDD (premenstrual dysphoric disorder) and affects about 2 to 5 percent of women (RCOG Green-top No. 48). It can significantly impair relationships, work, and quality of life—and warrants targeted treatment.

PMS has a biological basis

PMS is not a matter of personality or willpower. In affected women, the brain reacts more sensitively to the perfectly normal hormonal fluctuations of the menstrual cycle—it is not the level of hormones that is the problem, but rather their fluctuation. Waste products from the premenstrual breakdown of­the uterine lining, which enter the brain via the bloodstream, also play an important role. This is impressively demonstrated by a study in which the ovaries were temporarily suppressed: as long as hormone levels remained constant, the women were symptom-free—the symptoms only returned when hormone levels began to fluctuate again (Schmidt et al. 2017). This is precisely where our two treatment approaches come into play.

The Symptoms—Physical and Emotional

PMS manifests in many different ways. Common symptoms include:

• physical: breast tenderness, bloating and water retention, headaches, food cravings, fatigue, joint or muscle pain;
• emotional: irritability, low mood, inner tension, anxiety, lack of motivation, tearfulness, or sleep problems.

Which symptoms occur and how severe they are varies from woman to woman—and can change over the course of a woman’s life.

The Defining Pattern

The key to recognizing PMS isn’t a single symptom, but its pattern: Symptoms appear in the second half of the cycle and subside quickly with the onset of menstruation—most women are symptom-free during the first half of the cycle. It is precisely this pattern that is almost conclusive. The surest way to recognize it is by keeping a simple symptom diary over about two cycles: You record how you’re feeling day by day. This clearly shows whether PMS is present—and later serves as a way to monitor the success of treatment (RCOG Green-top No. 48). If, on the other hand, the symptoms do not disappear completely but persist even during the first half of the cycle, there is likely another underlying cause—such as depression that worsens before your period—which we then address differently.

Treatment: Two Approaches

PMS is caused by normal hormonal fluctuations during the menstrual cycle and their effect on brain metabolism. Accordingly, there are two effective strategies that we use—either individually or in combination—depending on the symptoms.

Strategy 1—Smoothing out hormonal fluctuations. When we mitigate the cyclical hormonal fluctuations, the symptoms often lose their trigger.

• For milder forms, it’s worth trying herbal remedies such as chasteberry (Agnus castus, e.g., Premens).
• Micronized progesterone (Utrogestan) taken during the second half of the cycle is also used—we mention it, but note that the scientific evidence supporting its use is limited.
• The most effective approach is usually to suppress ovulation—and thus the fluctuations—right away—for example, with hormonal contraception that includes a short hormone-free interval (such as Slinda or Drovelis) (RCOG Green-top No. 48).

Strategy 2 – Targeting the Neurotransmitter Level. If psychological symptoms are predominant, we focus on the neurotransmitters in the brain. Certain antidepressants from the SSRI class are very effective and act quickly for PMS and PMDS—in some cases, taking them during the second half of the menstrual cycle is sufficient. Several active ingredients (such as sertraline, paroxetine, or escitalopram) are effective; none is clearly superior to the others, so we select the medication on an individual basis (Shah et al. 2008). Unlike in depression, this is not about long-term therapy but rather targeted relief during the most distressing days.

Basic treatment for physical symptoms. If fluid retention and feelings of tension are the primary symptoms, a diuretic (spironolactone) may help (RCOG Green Top No. 48). And regardless of the chosen approach, the basics are essential: regular exercise, good sleep, and stress reduction alleviate symptoms, and cognitive behavioral therapy has been proven effective.

When the strain becomes overwhelming

PMDD can be accompanied by severe mood swings. If your mood becomes very low or you have thoughts of harming yourself, please contact us immediately or seek help—there’s always room for that, and effective support is available. You don’t have to face this alone.

How we’ll work together

We start with a symptom diary. This helps us assess the severity of your PMS and identify the predominant symptoms—and together, we choose the right approach. If the first approach isn’t effective enough, we’ll combine methods or switch strategies. PMS is highly manageable; you don’t have to simply “get through” the days leading up to your period.