PMS and Menstruation
Severe PMS and PMDD treatment
By Dr. Sarika Arora, MD
Some women experience such terrible PMS (premenstrual syndrome) that it completely
devastates their lives. Many need advanced treatment measures to get relief from
their symptoms and feel normal again.
If your symptoms are not fully responding to the steps we’ve previously outlined,
or if you have a diagnosis of PMS or PMDD and your symptoms are severe and entrenched,
consider the following advanced treatment measures.
In most cases, these advanced strategies are needed on a temporary basis only —
anywhere from a few months to a few years — with the idea that as the body
naturally begins to function more normally, women’s physical and emotional
symptoms smooth out and the more potent therapies can be tapered off.
Note that you will need the guidance of a qualified healthcare practitioner to pursue
Natural neurotransmitter testing and support
For those women who are still symptomatic after boosting their nutritional support,
making dietary changes, improving exercise habits, and using bioidentical progesterone
support, we often consider more focused natural neurotransmitter support. Some options
for targeting neurotransmitter function include the following:
- Additional omega–3 fatty acids in the form of EPA/DHA, boosting to 2–3
grams per day total.
- 5–HTP, 50–100 mg, generally taken in the evening. More may be needed
during the PMS time-frame (up to 800 mg), but dosage and timing depend on your body’s
- Vitamin D (25-OH vitamin D) blood testing and supplemental treatment to achieve
optimal blood levels (50–60 ng/mL).
- A trial of St. John’s wort, dosage and formulation varying with the individual,
and not to be taken in conjunction with prescription antidepressants.
- Neurotransmitter testing: evaluating levels of serotonin, dopamine, norepinephrine
and GABA levels, as well as others, to gain an overall sense of what levels are.
- Neurologic support with amino acid and herbal combination formulas.
Prescription-dose bioidentical progesterone for PMS and PMDD
Some women with severe premenstrual symptoms may want to ask their healthcare provider
about trying higher dose prescription-strength natural progesterone. It is also
an excellent alternative for women who prefer to avoid using birth control pills
or antidepressants for PMS or PMDD, or those who cannot tolerate their side effects.
You can choose between brand name formulas, such as Prometrium, or custom-compounded
USP (bioidentical) progesterone from specialty pharmacies. This is not currently
an FDA-approved use of Prometrium; it is considered “off-label” use,
so your healthcare provider has to be comfortable with this method. If a woman is
at an age where we suspect chronic progesterone deficiency, we may have her use
it longer term as well (until menopause), as it can help address underlying causes
of problems other than PMS that are associated with low progesterone, such as irregular
periods and heavy bleeding.
In any event, it’s a good idea for you to have your baseline progesterone
levels tested. This may even reveal overt luteal phase progesterone deficiency to
support the premise behind this approach. In fact, when progesterone is the issue
behind a woman’s symptoms, supplemental progesterone can be miraculous for
her. Yet the range of normal is so wide that it can be difficult for less experienced
practitioners to interpret what is low for an individual woman.
Note that women taking oral bioidentical progesterone should have their levels checked
every three to six months — but we will check levels of all the hormones to
make sure progesterone is not being converted into estrogen.
Where the conventional approach falls short —
prescription antidepressants for PMS and PMDD
The possibility of a cyclical neurotransmitter balance is why the first stop for
many conventional practitioners treating patients with PMS and PMDD is antidepressants.
At Women's Health Network, we strongly encourage women to try a number of highly effective
first-line therapies that can naturally restore neurotransmitter balance before
signing on to synthetic designer drugs for PMS, whether antidepressants or birth
control pills, particularly if their symptoms are mild or moderate.
Neurotransmitters are built from amino acids, and amino acids are found in proper
nutrition and can be naturally supplemented. If a woman’s neurotransmitters
are off premenstrually, taking cyclic antidepressants may have a temporary effect
on her mood swings, but it will not heal her physiology. It is altogether too common
for us to see patients who have been drowning out their bodies’ signals with
prescription antidepressants. These drugs may help get rid of the symptoms in the
short-term, but do nothing to encourage the body to resume control of its internal
balancing mechanisms. In the long-term, these medications don’t work; in fact,
they may even make the situation worse.
Moreover, as common as premenstrual symptoms are, each woman has her own PMS-inducing
stressors, so it makes little sense to treat everyone with identical synthetic drug
formulas. So instead of opting for the pharmaceutical option first, think of the
bigger picture and start with the basics by learning to understand the causes of
PMS and PMDD.
Antidepressants for PMS and PMDD — serotonin stop-gaps
In extremely severe cases where a woman simply cannot get herself out of bed, or
becomes unsafe to herself or others when premenstrual, antidepressants serve as
a last resort. SSRI medications such as Sarafem are often used in these situations.
In addition to Sarafem for PMDD, other antidepressants commonly prescribed for premenstrual
symptoms include Zoloft, Lexapro, Effexor, and Wellbutrin. However, without a thorough
investigation of a woman’s individual health picture, it can be hard for many
conventional practitioners to determine whether the patient has underlying dysthymia
(a milder form of chronic depression) or another depressive disorder.
Before turning to an antidepressant for “rescue,” we encourage you to
investigate your symptoms fully with a trusted healthcare practitioner and/or a
mental health specialist. You need time and a safe place to tell your story. Along
with helping you and your provider gain a more accurate picture of your mental and
physical health, this process can help you heal. If a woman still feels that she
needs emergency support, I generally acquiesce, as long as she continues under the
close guidance and monitoring of a healthcare provider skilled in advanced implementation
of these medications.
Of course, I always encourage any woman to continue trying to improve her nutrition
and lifestyle choices while on these medications. If you opt to use Sarafem for
PMDD or PMS, consider a compromise approach with a trial of bioidentical progesterone
or targeted neurotransmitter support as well, which can help to replete your neurotransmitters
Some women are just beginning to navigate their health issues, and are unwilling
or unable to adopt a more natural approach — fundamental nutritional and lifestyle
changes or advanced measures — for whatever reason. For such a woman, antidepressant
medication can serve as a bridge over troubled waters, motivating her to begin making
more positive changes. From there, we hope she can adopt more holistic therapies
until she feels well and strong enough to wean from her medication.
NOTE OF CAUTION: If you are on prescription antidepressants or mood stabilizing
medications, consult your prescribing doctor before making any changes in your medications.
These medications cause a change in your body chemistry, and some individuals experience
severe symptoms, including anxiety, chest pain, and headaches, if these medications
are abruptly stopped. Nevertheless, you can always consider adding fundamental nutritional
and lifestyle support measures to enhance your progress. If you order
our PMS Package for additional support, please be sure to schedule an appointment
with our Nurse–Educators for further guidance as well.
How birth control pills obliviate your PMS and menstruation
For some women who need contraception and want to be put on the birth control pill,
this measure ameliorates their symptoms of PMS — but principally because the
synthetic hormones in the Pill stop your body from ovulating. It can also make some
women feel worse. Using oral contraceptives to inhibit ovulation seems to tamp down
some of the symptoms of hormonal imbalance that occur in the second half of the
cycle for a PMS person. We respect this choice some women make, but urge them to
take on nutritional support and healthy lifestyle choices as well.
Currently popular choices include the third-generation lower-estrogen pills such
as Ortho Tri-Cyclen, Ortho Try-Cyclen Lo, Mircette and their various generic forms,
as well as the NuvaRing vaginal delivery method. The new Yasmin pill and lower dose
Yaz have been shown in studies to have a significant impact on mood and physical
symptoms, leading to their heavy marketing toward PMS and PMDD sufferers.
Changing the pattern of birth control pill usage is coming into increased favor
now too, either by shortening the pill-free (placebo) interval at the end of each
pack cycle, or by extending the length of cycles so that the women on them bleed
every 6–12 weeks rather than every four. Pill choices for manipulating cycles
in this way are monophasic, meaning that each pill in the pack contains
the same dose of synthetic hormones, rather than being varied over the cycle. So
using Ortho Cyclen, for example, would be better than trying it with Ortho Tri-Cyclen.
One formulation that has been packaged and formally approved for such use is called
Seasonale (or the newer Seasonique). There are also many others that can be tried
in this fashion under the guidance of a healthcare practitioner, as long as they
are monophasic and you are given enough extra packs to get you through the extended
Again, while birth control pills are popular as a form of contraception, we see
their use for treating a range of women’s health issues, such as irregular
cycles, acne, and symptoms of PMS, as palliative only — this means
they relieve the symptoms without effecting a cure. This is not a solution that
fully serves you because it cannot resolve the core imbalances that underlie these
issues. Nor can antidepressant medications. The benefits of these medications are
temporary at best.
What does “PMS” stand for?
We hope you will consider your individual health picture and learn what severe PMS
stands for in your life. We wholeheartedly feel that every woman with premenstrual
syndrome can learn to transform “the curse” into a blessing by embracing
the measures that create a foundation of health — not just for the reproductive
years, but the perimenopausal transition and well beyond. And we’re here to
help each step of the way.
Last Modified Date: 06/25/2014