Premenstrual Syndrome (PMS)

We still know far too little

For several years there has been little clear new information worth posting (in my view), which is amazing (most of this page was originally written in 2003). Here’s one new interesting study, though; and I’ll try to keep posting more as they emerge.

Update 6/2006: as an example of the research finally getting underway, here’s one on suicidal thinking and action and how that is affected by menstrual cycling. In a massive review of studies which had looked at suicidal behavior,^{Saunders and Hawton} the authors found that suicidal actions did indeed vary with a woman’s position in her menstrual cycle. More suicidal events (attempts, completed suicides) occurred in the first week of the cycle. The authors think perhaps this relates to the low levels of estrogen in that phase, perhaps leading to low levels of serotonin (low levels of serotonin have previously been associated with increased suicidal behavior).

Wouldn’t you think that something like this would deserve very close study? The authors, one of whom is female, would surely agree. They recommend studies in which hormone levels are measured directly, as in all the research they reviewed, there were no data on estrogen levels, which would shed more light on their theory. (For my part, as a clinician not a researcher, I’m guessing it’s not just low estrogen alone (after all, women after menopause do not experience a dramatic increase in suicidal thinking and behavior — some, but not dramatic). Instead I think it might be an effect of going into a low-estrogen state after being in a very high estrogen state, in mid-cycle. In other words, I think big fluctuations are part of the problem, maybe most of it — not low levels, or high levels, themselves. But I’m only guessing, really. Having some direct data on this would be tremendously helpful.

Lamotrigine for PMDD?

Another new detail:  Just a single case report but interesting that someone tried it, it worked, and they thought it worth writing up.^Sepede 

More basic information

The original 2003 page follows:

There are basic primers online about PMS you can check out. To these, I add here my thoughts about treatment, and a caution about the relationship to Bipolar II (which is my primary research interest), and an example of the mood chart you must keep . The format is a letter in reply to a woman who wrote to a bipolar site, where I was [for about 3 years] the “ask-a-doc”.

Q: I am curious about mood swings and PMS. Lately (since having my second child), I notice that I get mildly depressed prior to my period. For instance, I don’t have as much patience with my children (4 and 2), I don’t enjoy playing with them as much and am “grumpy” according to my husband. It just lasts for a few days and then I feel fine and more energetic.

Dear Chris —
If you are indeed “fine” all the days of your cycle except these days that you describe (10 days or less), and if you absolutely certain you could confirm that with written monitoring of energy, mood and irritability (your three “target symptoms”), then you by definition have “PMS”. Like, duh, you knew that.

But the point is, you by definition don’t have something like “bipolar disorder”. We start with that because from here, it gets much more complicated, or can. For example, you note that this
started after your second child was born. Somehow that event, perhaps the hormonal event itself, “sensitized” your brain to the “normal” fluctuations of your menstrual cycle — at least that’s our
current model of this problem.

And the point of all that is that you don’t need treatment for “bipolar disorder” with the symptoms you describe. I’ll confess that I think your mild PMS is related to the same fundamental problem that causes much more severe symptoms, for all or almost all of a monthly cycle, in other women, that we do call “bipolar disorder”. But since we understand neither, in terms of actual causes, that issue is moot for now.

It’s moot because there are “treatments” for you, and they don’t look like the treatments for bipolar disorder. As you’ve probably learned, there’s a lot of excitement now about using serotonergic antidepressants for PMS (e.g. what used to be called Prozac and is now marketed as “Serafem”; editorial comment withheld). The evidence there is very good. What gets passed over in that excitement is evidence for other treatments.

There is one study showing that moderately high doses of calcium (like two Tums twice/day) is effective in controlling symptoms like yours. Just one study, but it was a large (466 women) “randomized controlled trial”, meaning it had a placebo group — and that distinguishes this approach from almost everything else you’ll hear about out there, including evening primrose oil and exercise. However, neither of those seems to carry much risk, so not too much harm in trying them, and certainly that’s true for the exercise approach, which as you know has many other potential benefits!

Which brings us back around to the “Sarafem” (and other SRI’s) approach. How about risk there? Well, as you may know, antidepressants are known to make bipolar disorder worse. So if PMS is like bipolar disorder (i.e. like a tiny version of it) somewhat, then is there potentially some risk if women with PMS are given an antidepressant? A risk of making the PMS worse, making it more like “bipolar disorder” itself? This has not been reported nor even suggested anywhere else that I’ve read, so realize this is my worry and could be completely unfounded. At the same time, if there are “treatments” out there with no risk at all, in fact strong potential for other benefits — namely exercise, and to a lesser extent the calcium approach, which could decrease osteoporosis risk and carries only a mild risk of causing a kidney stone in susceptible women — then why not start with those!?

Here is the kind of chart you’d want to keep, no matter what treatment approach you take (for a fancy version, personalized to your symptoms, print one  — but a hand version works fine, and the important thing is not to miss recording!):

Note that this woman began to have her symptoms rather suddenly on Day 22, with equally sudden return to “fine” on the first day of menstrual flow. (I hope that’s not your timing, as it would make for a tough Christmas).

Finally, here is the official “expert consensus” on PMS from several mood experts who studied the opinions and practices of many experienced psychiatrists: Premenstrual Dysphoric Disorder: A Guide for Patients and Families.

(Updated 12/2014)