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An integrative psychiatry approach to mood-related PMS symptoms




If you are a female, there's a good chance that you struggle with mood changes related to your menstrual cycle. You're in good company - up to 50 to 80% of women experience some form of PMS during the days leading up to their period, whether that be increased moodiness, depression, bloating, cramping, sleep difficulties, or food cravings. Let's dive in to what we think causes period-related mood symptoms and what can help from the perspective of an integrative psychiatrist.


What causes this?

During the week before your period, estrogen levels decrease and progesterone levels are higher. Low estrogen levels then cause serotonin to drop, which is thought to be why women experience mood-related changes before their period. Serotonin is a chemical messenger known to be a mood booster. Additionally, let's talk about inflammation. There is thought to be some connection between levels of inflammation in the body and premenstrual symptoms. High sensitivity C-Reactive Protein (hsCRP) is an acute inflammatory marker that has been found to be elevated (>3 mg/L) in women who have PMS. There is also a well-established bidirectional relationship between mental health symptoms and increased inflammation.


Track your period

Tracking your cycle can help you understand when during the month you might be more emotionally sensitive, depressed, or anxious. For many women, this is during the luteal phase, which is the 12-14 day timeframe after ovulation and before the first day of your period. As much as possible, try not to schedule anything too challenging during this period of time. Consider it an opportunity to listen to yourself and your intuition, which is often highest then - write it down and consider putting it into action after your period starts.



Exercise for Mood-Related Premenstrual Symptoms

Moving your body regularly can really help with mood related premenstrual symptoms. Aerobic exercise can help balance levels of estrogen and progesterone, and increases endorphins in the brain. It also can help increase libido and improve mood throughout the month. Studies show that the intensity of exercise doesn't matter as much for mood related premenstrual symptoms but aim for at least 20 minutes three times a week. Exercise like dance, pilates, yoga, fast walking, and water aerobics have all been shown to be helpful. The goal is to find something that works for you and is doable a few days a week.



Foods for Mood-Related Premenstrual Symptoms

Aim for eating foods that are higher in tryptophan, which is needed to make serotonin in your body. Tryptophan-rich foods include turkey, chicken, oats, milk, lentils, and salmon. Eating carbohydrates is known to boost serotonin levels as well but its best to choose more complex carbohydrates such as oatmeal and other whole grains that are less likely to cause fluctuations in blood sugar levels that can worsen anxiety and mood. One study found that women who ate more chocolate, candy, and caffeine had worse pre-menstrual symptoms so if possible, reach for a bowl of oatmeal over a box of cookies.


Supplements for Mood-Related PMS

It's a good idea for women who have mood-related premenstrual symptoms to make sure they are getting enough Vitamin D and magnesium.


Magnesium

Magnesium deficiency is thought be a contributing factor to premenstrual symptoms and magnesium supplementation can be particularly helpful for anxiety, mood, insomnia, and food cravings. It also has a diuretic function and has been shown to be effective for decreasing swelling and bloating (which can indirectly improve mood because no one feels great when they are bloated and swollen). Magnesium-rich foods include pumpkin seeds, almonds, cashews, bananas, and peanut butter. Other options include supplementation by pills form or epsom salt baths with two cups of epsom salts.


Vitamin D

Most of us are Vitamin D deficient and women who experience pre-menstrual mood symptoms are even more likely to be deficient in Vitamin D. Vitamin D supplementation decreases inflammatory markers in the body and has been found to improve premenstrual symptoms. We can get Vitamin D through the sun (particularly in the summer for those of us living in the northern two-thirds of the United States) but often that is not enough. To ensure the right amount of vitamin D supplementation for your body, its best to first get a Vitamin D 25-hydroxy lab checked by your health car provider.


Vitamin B6

Vitamin B6 is needed to make neurotransmitters like serotonin and dopamine and has a role in making fatty acids in the body. Supplementation with Vitamin B6 (which is often combined with magnesium in studies) is helpful for mental health related symptoms related to PMS - and particularly helpful for lessening depression experienced during the luteal phase.


Omega 3 Fatty Acids

One of the supplements I recommend routinely to my female patients is a high quality omega 3 fatty acid daily supplement that has been third party tested and sustainably harvested. Omega 3 fatty acids repeatedly have been shown to be effective, through their anti-inflammatory properties, for lessening reactivity and irritability, as well as being helpful for balancing out mood swings.


Multi-Ingredient Formulas

There are several multi-ingredient direct to consumer supplement products out there that advertise their effectiveness for premenstrual symptoms, including mood issues. While some of these might look like great products, many of them contain sub-therapeutic dosages of the active ingredients. So it's often"a lot of a little" and may not be as beneficial. Do your homework and it's a good idea to ask your healthcare provider for their thoughts on certain products.



When to Consider Medications for Pre-Menstrual Mood Symptoms

If women are experiencing severe fluctuations in their mood, sleep, and anxiety related to their menstrual cycle and aren't able to complete their day-to-day activities, there are prescription options that can be very effective. Psychiatrists and primary care providers can prescribe SSRIs (serotonin reuptake inhibitors like fluoxetine/Prozac, sertraline/Zoloft, and escitalopram/Lexapro). I have some patients who take these pills just in the week leading up to their period and some who find most benefit taking them daily throughout the month.


Some women find oral contraceptives/birth control pills to be particularly helpful for improving mood-related premenstrual symptoms. It's important to know that for some women, oral contraceptives can worsen mood or might not be tolerated.





The information and any products mentioned in this article are not intended to diagnose, treat, cure, or prevent any disease. The information provided is for educational purposes only and not intended to replace the relationships with your physician(s). Before initiating any conventional or integrative treatments, please first consult with a licensed medical provider.



Sources:


Ebrahimi E, Khayati Motlagh S, Nemati S, Tavakoli Z. Effects of magnesium and vitamin b6 on the severity of premenstrual syndrome symptoms. J Caring Sci. 2012 Nov 22;1(4):183-9. doi: 10.5681/jcs.2012.026. PMID: 25276694; PMCID: PMC4161081.


Fathizadeh N, Ebrahimi E, Valiani M, Tavakoli N, Yar MH. Evaluating the effect of magnesium and magnesium plus vitamin B6 supplement on the severity of premenstrual syndrome. Iran J Nurs Midwifery Res. 2010 Dec;15(Suppl 1):401-5. PMID: 22069417; PMCID: PMC3208934.


Freeman, E.W. (2002) Treatment of depression associated with the menstrual cycle: premenstrual dysphoria, postpartum depression, and the perimenopause, Dialogues in Clinical Neuroscience, 4:2, 177-191, DOI: 10.31887/DCNS.2002.4.2/efreeman


Gold EB, Wells C, Rasor MO. The Association of Inflammation with Premenstrual Symptoms. J Womens Health (Larchmt). 2016 Sep;25(9):865-74. doi: 10.1089/jwh.2015.5529. Epub 2016 May 2. PMID: 27135720; PMCID: PMC5311461.


Heidari, H., Amani, R., Feizi, A. et al. Vitamin D Supplementation for Premenstrual Syndrome-Related inflammation and antioxidant markers in students with vitamin D deficient: a randomized clinical trial. Sci Rep9, 14939 (2019). https://doi.org/10.1038/s41598-019-51498-x


Pearce E, Jolly K, Jones LL, Matthewman G, Zanganeh M, Daley A. Exercise for premenstrual syndrome: a systematic review and meta-analysis of randomised controlled trials. BJGP Open. 2020 Aug 25;4(3):bjgpopen20X101032. doi: 10.3399/bjgpopen20X101032. PMID: 32522750; PMCID: PMC7465566.