Hormones, Mood Swings, and Menopause: Understanding PMS and PMDD

Feeling overwhelmed, tearful, anxious, or angry in the run-up to your period? You're not alone. This emotional turbulence is often due to Premenstrual Syndrome (PMS), a common experience rooted in your body's hormonal rhythm. PMS covers a wide range of physical and emotional symptoms, including mood swings, low mood, anxiety, irritability, tiredness, trouble sleeping, bloating, breast tenderness, headaches, and changes in appetite or sex drive.

These symptoms arise in the second half of your menstrual cycle, the luteal phase, and disappear shortly after your period starts—a key diagnostic factor. The culprits are often the natural fluctuations in your hormone levels, specifically progesterone and estradiol. While most women experience some degree of PMS, for about a third, the symptoms are significant enough to interfere with daily life.

What if my symptoms are much, much worse? Is it something else?

Yes. If your symptoms are far more intense and debilitating, you may have Premenstrual Dysphoric Disorder (PMDD). PMDD is a severe form of PMS, estimated to affect about 5% of women. The psychological impact is extreme, and diagnosis requires experiencing at least five specific, severe psychological symptoms (including a major mood issue) in the two weeks before your period. PMDD can severely disrupt life, and tragically, has been linked to suicide ideation. Experts caution that PMDD is often unacknowledged or dismissed by healthcare providers who are unaware of how debilitating it can be.

How will perimenopause affect my PMS or PMDD?

The years leading up to menopause—known as perimenopause—can unfortunately make your PMS or PMDD significantly worse, or even cause PMS to develop in women who never had it before. This worsening is due to the major hormonal upheaval that occurs as your hormone levels start to decline.

Symptoms tend to be more severe during these times of intense hormonal change, with existing PMS sufferers often finding their symptoms—particularly the emotional and psychological ones—become more intense. Furthermore, as your menstrual cycle becomes erratic and ovulation is less regular, the duration of symptoms can also increase, sometimes spreading out and lasting longer throughout your cycle.

What can I do to help manage my symptoms?

The first and most crucial step is to keep a detailed symptom and menstrual cycle diary for a few months. This tracking is vital for getting an accurate diagnosis, especially for PMDD, as the timing is everything.

Beyond diagnosis, initial guidance involves several lifestyle changes: improving diet and sleep, increasing exercise (which can be particularly beneficial), stopping smoking, reducing alcohol intake, and reducing stress. While these steps are important, they should not be seen as a substitute for medical treatment.

What about treatment options for severe symptoms?

Since PMS and PMDD are caused by hormone changes, replacing or regulating those hormones is often the most effective treatment.

• Hormone Replacement Therapy (HRT): For women in perimenopause, HRT is often the best choice. A combination of an estrogen skin patch with cyclical progestogen is a recognized management strategy for severe PMS symptoms. HRT provides additional benefits over other options by also easing other menopausal symptoms and providing long-term health protection against conditions like osteoporosis.

• Body-Identical Progesterone: Since the rapid fall in progesterone in the late luteal phase is thought to be an underlying cause, high doses of body-identical progesterone can be very helpful for its calming, anti-anxiety properties. However, some women have progesterone intolerance, where it has the paradoxical effect of worsening mood.

• The Contraceptive Pill: This is sometimes prescribed, but it contains synthetic hormones that can sometimes cause side effects like low mood and anxiety, and carries certain health risks.

• Antidepressants (SSRIs): For severe cases leading to depression, a type of antidepressant called an SSRI may be prescribed. Interestingly, these often work better when taken alongside HRT.

Finding the right combination of medication is often a journey, requiring persistence. Sadly, many doctors lack full awareness of PMDD, so if the first treatment doesn't work, don't give up—ask to be referred to a PMS specialist.

What if my PMDD still can't be controlled well?

For the most extreme, treatment-resistant cases, the surgical removal of the womb and ovaries is a last-resort option. This procedure triggers surgical menopause and should only be considered after all other avenues have been unsuccessful. Following this surgery, it is crucial for women to take HRT until at least the usual age of menopause for long-term health benefits.

What about when I reach menopause?

Here is the good news! When you officially reach menopause (12 months after your last period), your PMS and PMDD symptoms will likely resolve. This welcome relief occurs because the erratic, often intense, fluctuations of your hormones will have stopped. While you may then experience typical menopausal symptoms (like hot flashes, joint aches, and low mood), these can also be effectively managed with HRT.