An OB-GYN’s Guide to PMS
This entry was posted on February 22, 2018.
While some are able to fully appreciate the incredible complexity of the menstrual cycle—our ovaries and brain in conversation, our bodies’ ability to release an egg every month, the miracle of life!—most of us flat out dread the bloating, cramps, and general discomfort that signals the arrival of our periods.
There are many different theories when it comes to mitigating PMS. Always helpful is the advice of an ob-gyn you trust; enter Dr. Caitlin Fiss: Board certified by the American Board of Obstetrics and Gynecology and a diplomate of the American College of Obstetricians and Gynecologists, Fiss is a clinical instructor at Mount Sinai Medical Center and in private practice in NYC. We asked her about what’s actually normal (and not) when it comes to our cycles, and what the options are for regulating periods, coping with PMS, as well as treating more severe cramps, mood swings, and fatigue.
Girls typically get their first period when they are between ten and fifteen years old. In societies with higher-fat diets, and where growth hormone is more widespread in the industrial food chain, puberty starts earlier but actual menarche (the start of your menstrual cycle) occurs, on average, around the same time. Girls continue to grow after their first period but their growth does slow down. In the United States, the average age of menarche is twelve. If a girl is not menstruating by age fifteen, she should see her doctor.
Initially, cycles are usually irregular because the young woman is not yet ovulating each month. But within the first year they become regular—meaning a cycle lasts between twenty-five and thirty-five days. If periods are less than twenty-one days apart, that’s not normal, and requires medical attention. Same goes if periods are more than thirty-eight days apart.
If you think your cycle is irregular, it’s helpful to use a period tracker app for a couple of months, so you can look at your period pattern with a doctor. (Some of my patients use Spot On.)
Heavy bleeding the first couple of days of your period (even up to three days) can be normal, but after that it typically slows down. It’s hard to estimate how many tampons/pads is normal to use because people vary in how often they like to change them. If you feel the need to wear a tampon and a pad, your bleeding is on the heavy side. If you feel the need to change that tampon and that pad every 2 hours or less, after the first day or two, it’s worth mentioning to your doctor.
Most periods are bright red to maroon for the first two days, and then the color of the blood tapers off and becomes dark brown or blackish. Most girls/women have some small clumps in their blood; we call these clots. If the clots are large—like the size of a clementine or a kiwi—talk to your doctor.
Potential physical symptoms include: weight gain from water retention (usually 1-3 pounds but can be as much as 5 pounds), diarrhea or constipation, muscle aches, breast tenderness, fatigue.
And then there are the emotional symptoms, which might include: feeling irritable, anxious, or moody, or having sudden bouts of unexplained crying. Women can experience social withdrawal and even difficulty concentrating.
Many women also have food cravings—some people for salt, some for sweet.
All of the above symptoms describe PMS (premenstrual syndrome). If symptoms become so severe that they interfere with your daily routine and function—that’s not normal and called PMDD (premenstrual dysphoric disorder). PMDD is when you get so angry that you may become violent. You may experience symptoms of depression like appetite suppression or feeling so tired that you cannot get out of bed. If you repeatedly miss work or school because of symptoms related to your menstrual cycle, you need to seek help. There are treatments for PMDD.
PMDD has symptoms similar to anxiety and depression but PMDD symptoms increase several days before menses. It can be severe and in rare instances PMDD can drive people to become suicidal or homicidal. So once again, it is important to seek help from a medical professional.
Everyone is familiar with the idea that if you move into a dorm full of women or share an apartment with a bunch of women, your cycle might change to sync up with one another’s. Some people even match their coworker’s schedule. We think this phenomenon is in part caused by the pheromones that women secrete, which are hormonally driven smells. We’re not aware of it, but we emit hormonal odor that can impact the people around us. It’s part of sexual attraction for humans (and animals).
Stress can also impact the timing of your period—delaying it or causing you to skip a period—although it’s less understood how that actually works. Travel often changes your cycle, and this might be because of the stress it puts on the body.
In general, extreme changes that affect your body can interfere with your cycle.
If you have a significant amount of weight loss, you might skip your period. This usually happens when you lose a large percentage of your body fat (say 10 percent) in a short amount of time. (In this case, there is a biofeedback mechanism that suppresses your hypothalamic pituitary axis; this is called secondary amenorrhea.)
If you are binge eating or crash dieting, extreme exercising and then going through periods when you’re not exercising at all, your cycle is likely to be interrupted. Still, it’s hard to stop your cycle: The body wants to procreate, and is designed to produce that egg. So, it’s typically at the extremes where we see people losing their periods.
Some hormonal illnesses are associated with hormonal changes that can impact your cycle timing, too. Examples are hypo/hyperthyroidism, hyperprolactinemia, and polycystic ovarian syndrome (PCOS). So if you notice sudden changes in a very regular cycle, it’s important to talk to your doctor.
PMS usually hits 7 to 10 days before your period, and can last into the first or second day of your period. It’s caused by changes in estrogen and progesterone. Here’s how it works:
- Each month, the cycle starts at a low level of estrogen. As you’re producing the egg, the egg follicle produces estrogen and your estrogen level increases. Estrogen peaks mid-cycle. (FSH, or follicle stimulating hormone, is released by the pituitary gland and stimulates the ovarian follicles to grow.)
- The egg gives feedback to the brain—a message is sent from the egg follicle to the hypothalamus/pituitary axis (in the hypothalamic region of the brain of the brain) to release LH, or luteinizing hormone.
- LH peaks surges for 24 hours, and tells the follicle to release the egg.
- You start to produce more progesterone. The progesterone primes the uterine lining after ovulation—so you can maintain it if you were to become pregnant.
- If you don’t become pregnant, towards the end of the cycle, progesterone levels fall—this is what causes the bleeding to start. You’re shedding your uterine lining.
- The change in estrogen and progesterone after ovulation is what makes you feel PMS. At the peak of progesterone, you start to feel bloated and have water retention. As it falls, you can start to feel tearful, sad, energy-depleted. When you get to about the day before your period, your hormone levels are near their lowest point of the entire month.
Another cause of PMS symptoms is decreased availability of the neurotransmitter serotonin. For that reason, people who already suffer from depression are at increased risk of suffering from PMS or PMDD.
It’s tough to say not to eat something and you’ll feel better… But food cravings can start a vicious circle because eating what you’re craving can exacerbate your symptoms. I usually think the body serves us really well, and we crave what we need, but this is one instance where the body betrays us. For instance, you might be craving salt, but eating more salt can make you feel more bloated and lethargic. If you crave carbs or chocolate and overload, this can deplete your energy levels and leave you feeling more tired and lethargic. During your period it’s better to eat energy food, i.e. complex carbohydrates and protein.
Limiting alcohol can help, as drinking can also make you feel tired, lethargic, and bloated; if you drink at a time when you already feel that way, it’s going to exacerbate your symptoms.
“I usually think the body serves us really well, and we crave what we need, but this is one instance where the body betrays us.”
I’ve seen people improve their PMS symptoms and report feeling more energized when they go gluten-free. It’s hard to say if that’s because they aren’t eating gluten or because they are subsequently eating more protein and more complex carbs, and making healthier choices about the carbs they do eat. I don’t think we really know the answer to this yet.
Endorphins from exercise can block some of the symptoms of hormonal changes and make you feel better. Most importantly, endorphins have been shown to increase the neurotransmitter serotonin in our brains by blocking its reabsorption at the level of the neuronal axon surface. If you exercise regularly and then take days off during your PMS, you’re likely to feel worse. So, even though it can feel like the hardest thing in the world to get to the gym during a lethargic period—if you can power through, exercising can actually ameliorate some of your symptoms.
What kind of exercise? Do whatever feels good! If you want to get that endorphin rush—swim, run, or do a spin class, and so on.
Less strenuous exercise, like a gentle yoga class, won’t give you the same endorphin relief, but can be wonderful for helping with cramps and muscle aches, and helps your mind feel centered and strong.
Some people find heating pads helpful. For some people with severe cramps, we recommend taking ibuprofen (which blocks prostaglandin, the chemical made in your body that makes you feel the pain), or something like mefenamic acid (which is the active ingredient in a medication called Ponstel). Some women will take this for 48 hours before and into their period to mitigate some of the symptoms. Most people can tolerate some ibuprofen but if you have stomach issues or ulcers, if you’re prone to GERD, or if you have kidney disease, Crohn’s disease, or ulcerative colitis, ibuprofen might not be a good choice for you. Speak to your doctor.
There is a lot of interest but not a lot of data on the effectiveness around chasteberry helping to regulate some symptoms of PMS. Chasteberry is supposed to interact with the hypothalamus/pituitary gland and the ovulation signaling process. It’s not FDA approved or regulated, and it is not recommended if you are already on the birth control pill or other hormones to regulate your cycle. It’s available over the counter. I’m always a little cautious when it comes to recommending a supplement that isn’t FDA approved but I am curious to use chasteberry in my practice.
PMS symptoms are often worse at the start of menarche and then at menopause—both periods of life when you’re having surges of hormones that you haven’t experienced before. Symptoms of PMS often go away during the childbearing years. I do see a lot of premenopausal moms who still have PMS, but in general, if you look at PMS symptoms over the course of someone’s whole life, they are quieter during the childbearing years and get worse as a woman approaches menopause.
“As you’re going into menopause, the ovaries work harder to produce the egg, so you’re having higher levels of estrogen in those first perimenopausal years—and then it drops.”
As you head towards menopause, things tend to get worse. Around age forty-seven or forty-eight, we often see patients complaining of crazy periods: Cycles get shorter and closer together. They’re really feeling the extremes of hormonal change, which can be very uncomfortable. As you’re going into menopause, the ovaries work harder to produce the egg, so you’re having higher levels of estrogen in those first perimenopausal years—and then it drops. (This is what causes hot flashes.) Higher peaks and lower lows make people feel their PMS symptoms more acutely—so they can feel more moody, more irritable, even depressed.
All of the above are options. For people suffering with PMDD who need more help, we might also treat hormonal symptoms—mood, cramps, etc.—with the birth control pill. The pill gives you a steady dose of estrogen and progesterone continuously throughout the month, which blocks ovulation and can decrease PMDD symptoms. In very serious cases, I recommend that patients take the pill continuously without a monthly withdrawal week. Typically, the patient will do nine weeks in a row, and then have a week off to withdrw from the hormones.
People often ask: Doesn’t the pill make you moody? Initially, yes, it changes your mood. But once you’re on it for two or three months, you reach a steady state of hormones, and if we’ve chosen the right pill for you and your body, it should even out your mood. Cramps are likely to decrease, too, some cravings can be ameliorated, and you may feel more energetic.
“People often ask: Doesn’t the pill make you moody?”
(Everyone also asks if the pill affects future fertility. It can in the short-term but is unlikely to affect fertility in the long-term. The reason you have to take the pill every day is because it goes out of your system very rapidly. For women who have been on the pill for ten to fifteen years, it typically takes one to three months for their cycles to come back and be regular. On average, fertility comes back to over 80 percent within the first year of being off the pill. If you’re only on the pill for a year or two, this time shrinks dramatically—so you’d be more likely to get pregnant the month you go off the pill.)
Some women (particularly those who can’t be on the birth control pill for medical reasons) might be prescribed medications that increase serotonin (by blocking the serotonin receptor on the neuron), which can be very helpful. SSRI medications (like Prozac) increase the amount of serotonin at the neuron. There is then more serotonin available at the neuron synapse. They can be prescribed for ten days out of month, just around the time when you’re most susceptible to PMDD symptoms, or, they can be prescribed for continuous use throughout the month.
I think it’s the opposite—that there’s less tolerance for it. It’s become acceptable to tell your mom that your periods are bad, and you think you need to go on the pill, and moms say it’s okay. I regularly get fourteen to sixteen-year-old patients who use painful periods as a reason to go on the pill, but once their parents leave the room, they tell me that they are sexually active. Maybe, on some level, the parents know their teens want to go on birth control because they are sexually active and they just don’t want to acknowledge this.
“It’s become acceptable to tell your mom that your periods are bad, and you think you need to go on the pill, and moms say it’s okay.”
Since the pill is so widely used and accepted today, older women in perimenopause are also much more likely to ask for it for help ameliorating symptoms, and we’re much quicker to treat this perimenopausal age group with low dose hormonal contraception than we were ten years ago.
Caitlin Fiss, M.D. is board certified by the American Board of Obstetrics and Gynecology and a diplomate of the American College of Obstetricians and Gynecologists. She earned her medical degree from Brown University School of Medicine and completed her residency in Obstetrics and Gynecology at Mount Sinai Hospital in New York City. She’s in private practice in NYC and a clinical instructor at Mount Sinai Medical Center.
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