Understanding PMS: What It Is, Why It Happens, & How To Fix It
Posted by Courtney Mayszak, RDN, LDN
Dec 21, 2019
You know when you’ve been crazy emotional all week and you assume Mercury is in retrograde? Then you get your period and you’re like… oh 🙄
It’s not the cosmos. It’s PMS—a legitimate medical condition that can cast a dark cloud over an entire week of your life, every single month.
But that doesn’t mean you have to suffer through it. This article discusses:
- What PMS is
- Why PMS happens
- And importantly, what you can do about it
What is PMS?
‘PMS’ is short for ‘Premenstrual Syndrome’. It’s an umbrella term for the cluster of physical, emotional, and/or behavioral symptoms that can present as early as 10 days before your period starts, and can last until your period ends.1
Physical: headaches and migraines, dizziness, nausea, sensitivity to light and sound, acne, tender or swollen breasts, bloating, muscle aches, joint pain, back pain, constipation, diarrhea, gas, and swelling in the hands and feet
Emotional: anxiety, depression, irritability, mood swings, confusion, tension, loneliness, and aggression
Behavioral: fatigue, food cravings, crying, social disengagement, trouble concentrating, sleep disturbances, and low libido
It’s common to have some of these symptoms but not others. It’s also common for your symptom profile to change month-to-month—both in severity and the types of symptoms you get—and get worse as you age.4
Up to 90% of menstruators get at least one PMS symptom each month,5 yet only 10-15% of PMS sufferers seek medical assistance.6 These patterns are universal worldwide.7
PMS is tremendously emotionally, socially, and economically burdensome. PMS costs each menstruating human an average of $4,392 hard-earned dollars each year in direct and indirect expenses.8 70% of people with PMS report impaired work performance and loss of productivity.9
PMS-sufferers have significantly greater rates of relationship dissatisfaction and psychosocial distress.10 Up to 8% of people with periods experience a severe form of PMS called Premenstrual Dysphoric Disorder, or PMDD, in which symptoms are as disabling as a major depressive disorder.11
Why does PMS happen?
We know PMS is tightly linked to the luteal phase of the menstrual cycle, when levels of the reproductive hormones estrogen and progesterone rise, then fall dramatically.12
We also know people who use hormonal birth control, and have steady levels of estrogen and progesterone as a result, generally don’t PMS, or get very mild symptoms.3 These facts point to falling levels of estrogen and progesterone as the PMS culprit.
However! Two menstruating humans can have the exact same levels of circulating estrogen and progesterone, yet completely different PMS experiences. Two menstruating humans can also have very similar PMS experiences, yet completely different levels of circulating hormones.
Hormones interact with the body through a complex interplay of receptors and neurotransmitters, and a bleeder’s susceptibility to PMS may lie somewhere in this interplay.
Hormone receptors live on all areas of the body, which could explain why PMS is a head-to-toe event. Neurotransmitters like dopamine and serotonin influence our emotions, perceptions, and behaviors, which could explain why PMS can manifest as anxiety, depression, irritability, compulsivity, and other brain-based symptoms.19
Some researchers have even found that hormone sensitivity (and thus, PMS severity) is genetic. Studies involving twins from the US,20 UK,21 and Australia22,23 show anywhere between 30 and 80% of PMS symptoms are inheritable.
Other researchers think PMS is less a matter of reproductive hormones, and more about metabolic energy. There’s an alternative theory (note: just a theory) that PMS is a condition of "impaired self-control"24 (the study authors' words, not ours).
Self-control is metabolically expensive. The theory posits that because considerable metabolic energy is allocated to the ovaries during the luteal phase of the menstrual cycle, less energy is available for the brain to control emotions and impulses. Thus, PMS symptoms manifest.24
There are flaws in this theory. It doesn’t explain the physical symptoms we mentioned above, like bloating, breast tenderness, and body aches. Nor does it explain why simply eating more calories doesn’t erase PMS symptoms. (But wouldn’t that be nice!)
Yet another group of researchers believe PMS is a sociocultural product—the sum of our environment, stressors, and past traumas, even those that happened long before one’s first period.
These researchers propose we hold memories in our bodies, as if the muscles and tissues remember previously inflicted pains. Trauma alters the hypothalamic-pituitary-adrenal (HPA) axis, a part of the brain that processes stressful situations and tells the rest of the body about them.
Studies show women with childhood traumas have a dysregulated HPA axis, a higher sensitivity to pain, and more PMS later in life.25 But this theory has its flaws too, as it doesn’t fully explain the connection between stress and the menstrual cycle, or why stressed cis-men don’t also get PMS.
So which of these theories should you believe? The largest body of science supports the hormone sensitivity theory, but the real answer may be some combination of all of them. PMS doesn’t get the scientific attention it deserves, and more research is needed.
Regardless of its underlying cause, PMS is neither "all in your head" nor a personal failing. PMS is real, and really disruptive. But it doesn’t have to be your monthly fate.
What you can do about PMS
Bleeders have three options for managing PMS: pharmaceutical drugs, lifestyle changes, and alternative medicine. Some of these options are better than others.
Three types of pharmaceutical drugs are typically used to treat PMS: over-the-counter painkillers, antidepressants, and hormonal birth control.
Any of these may be useful for treating some (but not all) PMS symptoms in the short-term. But all of these drugs come with considerable risks in the long-term, and none address the whole problem.
- Over-the-counter painkillers can treat some of the physical symptoms of PMS, like sore muscles, back pain, and headaches. BUT, up to 60% of those who use these drugs experience some sort of adverse event.26 They also do nothing for emotional or behavioral PMS symptoms. Read more about why painkillers are *not* the answer to period problems here.
- Antidepressant drugs like Prozac and Zoloft—two types of Selective Serotonin Reuptake Inhibitors, or SSRIs—are prescribed to treat the emotional symptoms of PMS, but ignore the physical symptoms. Studies show 40-60% of people who use SSRIs experience no benefit at all from them.27 45% of Prozac and 40% of Zoloft users stop using these drugs due to side effects.28 And to make matters worse, their side effects mimic PMS symptoms, and include headaches, nausea, irritability, sexual dysfunction, weight gain, fatigue, dizziness, diarrhea, and sleep problems.29
- Hormonal birth control shuts down ovulation, thus preventing those hormonal peaks and crashes thought to trigger PMS. Of course, these drugs come with the benefit of preventing pregnancy, if that's your goal. But despite their usefulness as contraception, 57% of women prescribed birth control pills stop using them within 6 months, 34% citing side effects as the reason.30 Like antidepressants, side effects of hormonal birth control mimic PMS symptoms, and include weight gain, headaches, migraines, breast pain, mood disturbances, low libido, acne, and nausea.31 Everyone reacts to different types and formulations of hormonal birth control differently, so it may take a few tries to find one that’s right for you.
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Is this you the first day of your period? (Maybe the second and third day, too?) You can be honest, we've been there. Then we took a long, hard look at the drugs we were popping month in and month out, and what we learned convinced us to quit our painkillers for good. You can, too! Smash that link the bio for a 3-minute read on why painkillers are NOT the answer to period pain, and what to do instead. 📷: @periodhacks4girls
Lifestyle ChangesIf drugs aren’t for you, there are also a number of lifestyle changes you can try, such as:
- Regular aerobic exercise throughout the month32
- Eating a healthy diet rich in fruits, vegetables, whole grains, and lean proteins, and low in salt, sugar, alcohol, and caffeine33
- Getting at least 8 hours of quality sleep every night34
- Stress-management strategies, such as yoga and meditation35,36
- Not smoking37
In our professional and common sense opinion, the best PMS therapies are both free of side effects and actually work. We see natural remedies like nutritional and herbal supplements as the only therapies that consistently meet both criteria.
According to womenshealth.gov, the best supplements for PMS include:
- Calcium. Studies show calcium helps reduce PMS symptoms like fatigue, cravings, and depression.38,39 The American College of Obstetricians and Gynecologists (ACOG) recommends PMS sufferers take calcium supplements.40
- Vitamin B6. Research says vitamin B6 is helpful for PMS symptoms like moodiness, irritability, forgetfulness, bloating, and anxiety.41 In clinical trials, vitamin B6 outperforms prescription antidepressants for treating mood-related PMS symptoms.42
- Magnesium. According to clinical studies, magnesium works in synergy with vitamin B6 to thwart PMS-related mood changes.43 Magnesium works alone, too. Research shows it can soothe menstrual migraines and reduce bloating.44,45
- Saffron, a vibrant spice with antioxidant and anti-depressant properties. Multiple studies show it can naturally tweak brain chemistry to lift the mood and curb an overactive appetite.46,47 In clinical trials, saffron is as effective as prescription medications for mild to moderate depression.48
- Rhodiola, an adaptogenic herb, has been used for millennia to quiet anxiety, manage stress, and stabilize emotions. It energizes the brain's cognitive functions, helping to clear the mind, fight fatigue, and sharpen concentration.49
- Iron is a natural fatigue-fighter. It also powers the conversion of tryptophan to serotonin, which may help to boost levels of this important anti-PMS chemical in the brain.51
- Zinc levels are in flux throughout the menstrual cycle, and tend to plummet just as PMS kicks in. Research shows those who supplement with zinc face fewer PMS symptoms like depression, dizziness, and constipation.52
2. Steiner, M., & Born, L. (2000). Diagnosis and treatment of premenstrual dysphoric disorder: an update. International Clinical Psychopharmacology.
4. Pinkerton, J. V., Guico-Pabia, C. J., & Taylor, H. S. (2010). Menstrual cycle-related exacerbation of disease. American journal of obstetrics and gynecology, 202(3), 221-231.
5. Winer, S. A., & Rapkin, A. J. (2006). Premenstrual disorders: prevalence, etiology and impact. The Journal of reproductive medicine, 51(4 Suppl), 339-347.
6. Pérez-López, F. R., Chedraui, P., Perez-Roncero, G., López-Baena, M. T., & Cuadros-López, J. L. (2009). Premenstrual syndrome and premenstrual dysphoric disorder: Symptoms and cluster influences. The Open Psychiatry Journal.
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12. Bäckström, T., Andreen, L., Birzniece, V., Björn, I., Johansson, I. M., Nordenstam-Haghjo, M., ... & Zhu, D. (2003). The role of hormones and hormonal treatments in premenstrual syndrome. CNS drugs, 17(5), 325-342.
13. Ziomkiewicz, A., Pawlowski, B., Ellison, P. T., Lipson, S. F., Thune, I., & Jasienska, G. (2012). Higher luteal progesterone is associated with low levels of premenstrual aggressive behavior and fatigue. Biological psychology, 91(3), 376-382.
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17. MUNDAY, M. R., Brush, M. G., & Taylor, R. W. (1981). Correlations between progesterone, oestradiol and aldosterone levels in the premenstrual syndrome. Clinical Endocrinology, 14(1), 1-9.
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20. Kendler, K. S., Karkowski, L. M., Corey, L. A., & Neale, M. C. (1998). Longitudinal population-based twin study of retrospectively reported premenstrual symptoms and lifetime major depression. American Journal of Psychiatry, 155(9), 1234-1240.
21. Van Den Akker, O. B. A., Eves, F. F., Stein, G. S., & Murray, R. M. (1995). Genetic and environmental factors in premenstrual symptom reporting and its relationship to depression and a general neuroticism trait. Journal of psychosomatic research, 39(4), 477-487.
22. Condon, J. T. (1993). The premenstrual syndrome: a twin study. The British Journal of Psychiatry, 162(4), 481-486.
23. Treloar, S. A., Heath, A. C., & Martin, N. G. (2002). Genetic and environmental influences on premenstrual symptoms in an Australian twin sample. Psychological Medicine, 32(1), 25-38.
24. Gailliot, M. T., Hildebrandt, B., Eckel, L. A., & Baumeister, R. F. (2010). A theory of limited metabolic energy and premenstrual syndrome symptoms: Increased metabolic demands during the luteal phase divert metabolic resources from and impair self-control. Review of General Psychology, 14(3), 269-282.
25. Bertone-Johnson, E. R., Whitcomb, B. W., Missmer, S. A., Manson, J. E., Hankinson, S. E., & Rich-Edwards, J. W. (2014). Early life emotional, physical, and sexual abuse and the development of premenstrual syndrome: a longitudinal study. Journal of Women's Health, 23(9), 729-739.
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29. Anderson, H. D., Pace, W. D., Libby, A. M., West, D. R., & Valuck, R. J. (2012). Rates of 5 common antidepressant side effects among new adult and adolescent cases of depression: a retrospective US claims study. Clinical therapeutics, 34(1), 113-123.
30. Westhoff, C. L., Heartwell, S., Edwards, S., Zieman, M., Stuart, G., Cwiak, C., ... & Kalmuss, D. (2007). Oral contraceptive discontinuation: do side effects matter?. American journal of obstetrics and gynecology, 196(4), 412-e1.
32. El-Lithy, A., El-Mazny, A., Sabbour, A., & El-Deeb, A. (2015). Effect of aerobic exercise on premenstrual symptoms, haematological and hormonal parameters in young women. Journal of Obstetrics and Gynaecology, 35(4), 389-392.
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37. Dennerstein, L., Lehert, P., & Heinemann, K. (2011). Global epidemiological study of variation of premenstrual symptoms with age and sociodemographic factors. Menopause international, 17(3), 96-101.
38. Canning, S., Waterman, M., & Dye, L. (2006). Dietary supplements and herbal remedies for premenstrual syndrome (PMS): a systematic research review of the evidence for their efficacy. Journal of reproductive and infant psychology, 24(4), 363-378.
39. Ghanbari, Z., Haghollahi, F., Shariat, M., Foroshani, A. R., & Ashrafi, M. (2009). Effects of calcium supplement therapy in women with premenstrual syndrome. Taiwanese Journal of Obstetrics and Gynecology, 48(2), 124-129.
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45. Walker, A. F., De Souza, M. C., Vickers, M. F., Abeyasekera, S., Collins, M. L., & Trinca, L. A. (1998). Magnesium supplementation alleviates premenstrual symptoms of fluid retention. Journal of Women's health, 7(9), 1157-1165.
46. Abedimanesh, N., Bathaie, S. Z., Abedimanesh, S., Motlagh, B., Separham, A., & Ostadrahimi, A. (2017). Saffron and crocin improved appetite, dietary intakes and body composition in patients with coronary artery disease. Journal of cardiovascular and thoracic research, 9(4), 200.
47. Gout, B., Bourges, C., & Paineau-Dubreuil, S. (2010). Satiereal, a Crocus sativus L extract, reduces snacking and increases satiety in a randomized placebo-controlled study of mildly overweight, healthy women. Nutrition research, 30(5), 305-313.
48. Kashani, L., Eslatmanesh, S., Saedi, N., Niroomand, N., Ebrahimi, M., Hosseinian, M., ... & Akhondzadeh, S. (2017). Comparison of saffron versus fluoxetine in treatment of mild to moderate postpartum depression: a double-blind, randomized clinical trial. Pharmacopsychiatry, 50(02), 64-68.
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