Premenstrual dysphoric disorder (PMDD) is a severe form of premenstrual syndrome (PMS) affecting 5 to 8 percent of menstruating women. Whilst PMS can be challenging enough, sufferers of PMDD endure debilitating physical, mental, and emotional symptoms in the days leading up to their period, which ends within a few days after menstruation commences. Whilst the condition is not fully understood, it is thought to be due to a heightened sensitivity to changing hormone levels during the menstrual cycle.
Of the various hormone-related causes suggested by studies, one is a sensitivity to changes in progesterone levels. Other non-hormone factors may include stress, a genetic predisposition, having experienced previous episodes of depression or trauma, being overweight, and smoking. Progesterone can be calming for most women, but those with progesterone intolerance may experience irritability, lowered mood, trouble concentrating, anxiety, breast tenderness, and bloating, amongst other symptoms. So what happens when a perimenopausal woman with a history of PMDD wants to take HRT but fears the progesterone component may trigger – or worsen – her symptoms?
HRT can help for some sufferers of PMDD
First of all, HRT doesn’t trigger PMDD symptoms for all those predisposed to it. According to the Balance website, the leveling out of hormonal fluctuations that HRT imparts can be beneficial for some PMDD sufferers.
For other PMDD sufferers, symptoms can worsen
HRT contains progesterone in either body identical form or as a synthetic progestogen, either of which may trigger PMDD symptoms in women with progesterone sensitivity. Body-identical (micronised) progesterone is the preferable form for PMDD sufferers as it is associated with fewer side effects; as such, it is less likely to trigger PMDD symptoms.
However, some patients will still react negatively, even to body-identical progesterone. Before stopping HRT, it is worth talking to your doctor about trying other methods of taking it.
There are other methods of taking progesterone
There are many alternative ways to take progesterone in HRT. Possible methods are:
– modifying the dose,
– altering the number of days on which you take it,
– changing to a different type of progesterone preparation,
– changing the method of delivery (see below).
It is important to discuss any changes you make with your doctor before implementing them.
Local progesterone delivery
Body-identical tablets
Taking progesterone orally introduces it to your whole body, making you more likely to experience any side effects, including those of PMDD. Inserting the body identical tablet vaginally (at night) bypasses the digestive system, placing it where it is needed, near the womb. Just half the oral dose is required with this delivery method.
Progesterone pessaries
Progesterone preparations that are specifically designed as pessaries are available; talk to your doctor about getting a prescription.
Mirena coil
The Mirena is an IUD (intrauterine device) that is often used as a contraceptive but is effective in HRT, too. Once fitted, it stays in place for 4-5 years, releasing a steady amount of progesterone into the womb. This low, collected release works for some women with PMDD because there are no progesterone fluctuations. The downside is some women report having PMS symptoms up to 3 to 6 months after fitting, although for most, it settles after this.
Treatments for psychological symptoms
For PMDD sufferers taking HRT and suffering psychological symptoms, cognitive behavioral therapy (CBT) may be beneficial, as may taking SSRI (selective serotonin reuptake inhibitor) antidepressants.
Lifestyle factors and changes may help
Adaptations to your lifestyle can help to reduce or eliminate symptoms of PMDD, particularly on the days you are taking progesterone.
Diet
Eating healthily modifying the diet to include more protein and carbohydrates, reducing salt and sugar, and avoiding caffeine and alcohol can help.
Exercise
Aerobic physical activity can improve mood and energy levels; it can also help you feel sleepy and counteract any insomnia, one of the symptoms of PMDD.
Sleep
Adequate and regular sleep is vital to deal with challenging feelings and experiences.
Stress
Research suggests PMDD worsens with stressful events, so it is important to minimize stress on the days that symptoms might be triggered.
Social interactions
Talking to friends about your feelings can help, as can spending time together.
Time in nature
Spending time in natural spaces (parks, forests, by the coast) can help promote feelings of well-being.
Mindfulness practices
Yoga and meditation are known to have a calming effect, which can help lower the impact of stress and promote better sleep. Scientific studies have also shown that mindfulness may help with PMDD symptoms.
Join a support group
Find a group locally or join one online.
Reach out for specialist advice
If your doctor is unable to help you work on eliminating or managing your PMDD symptoms whilst on HRT, reach out to a specialist menopause doctor for advice. Alternatively, one of the organizations dedicated to helping women with premenstrual disorders, such as the National Association for Premenstrual Syndrome (NAPS) or the International Association for Premenstrual Disorders (IAPMD), can provide help.
Stop taking HRT
If you’ve tried everything and you’re still suffering from PMDD symptoms whilst on HRT, it may be that HRT is not for you. It is important to decide to come off HRT with a doctor’s advice, as suddenly stopping any medication can cause adverse reactions.
Good luck with your PMDD. This is not easy, but there are options.
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