PMS: How do I survive my period?

Trying to get things done, while wanting to quit everything on a random monday comes as a shock that is only explained when I check which week it is ! Yep … My period is due next week ! For something that is so regular ,it is clear through increased online conversation that the physical and non physical pains are an annoying occurrence that continuously surprises and changes over the years.

Menstrual health is poorly understood from the time of your first period (menarche) into adulthood. Whichever age you experienced it, your cycle and the emotions attached to them have probably changed as you aged.The general consensus is most experience at least one symptom due to their menstrual cycle. If your cycle is just another day- how does it feel to be a chosen one? To everyone that has had to abruptly pay attention to their cycle, you end up shocked with how little you knew.

My interest in periods began after experiencing really heavy periods and being diagnosed with PCOS. With heavy and irregular periods, as a 17 year old with good skin the idea of birth control pills that could lead to skin problems was a deterrent so the only other options were to wait it out or do something about it. Outside of PCOS there are many uterine related health issues that go unspoken and are poorly understood including: endometriosis, fibroids, ovarian cysts, pelvic adhesion and more. In addition to the physical manifestations there are commonly reported emotional issues and mood changes that come with the menstrual cycle which will be the main focus of this post.

The question of what is ‘normal’ for my body - when do my periods seem bearable? and when is it too much? - I began to ask as I got older . With the rise in cycle tracking apps, we get a small glimpse into ALL the symptoms faced in real time. The apps seem to be doing a good job in having more people in tune with their ‘normal’- but something is still missing !

As the menstrual cycle is a process starting due to failed fertilisation. A lot of the conversation and research falls around this very fact of what affects the health of the uterus. If its function is to maintain a pregnancy, findings and conversations are directed to improving a person's ability to have children. In treating disease or abnormality there is a focus to get it to ‘normal’ or ‘healthy’ and in the context of menstrual cycles this becomes incredibly varied outside of the extremities of disease.

World Health Organization, “health” is “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”

Online conversations have become louder around the burdens of menstruation. Even with regular periods and the absence of disease, the build up to the event is a burden for many. I really wanted to dig deep into what’s being said in the research world on ‘normal menstrual health’ to figure out how I survive with my period and feel less like I'm in crisis every month?

Women's health is under researched and underfunded ! A simple search of ‘erectile dysfunction’ will bring up 28,000 papers from 1945 to date and for PMS ( premenstrual syndrome) less than half ( 10,079) in the same time period.In contrast to that hormonal contraceptive was founded in the 1950’s and little change has occurred to the effects felt by continuous use of hormonal contraceptives and specifically progesterone. In the current day, there are alternatives to that pill but for so long women had complained over the great mood changes and it remains a common problem. Somehow we’re just meant to ‘deal with it’.

What affects my mood? And what’s being done about it?

The simple answer is: Progesterone.

High levels of progesterone is usually a sign of successful pregnancy. Progesterone is responsible for maintaining a thick uterus wall. In the events of failed fertilisation, the menstrual cycle starts soon after progesterone levels decrease.

The menstrual cycle starts at the first indication of blood. That is day 1 of the cycle. This marks shedding of the uterus lining after failed fertilisation of an egg in the uterus. The cycle is split into two phases:follicular and luteal phase. The follicular phase is the first half of your cycle and the luteal phase is the second half of your cycle after ovulation has occurred. In this second phase progesterone levels rise, peak and decrease. Personally my mood changes are around two weeks before my next period. This coincides with the second half of the menstrual cycle - the ‘luteal phase’. This fits the evidence reported in science articles on menstrual cycles , what remains unclear is what exactly is my body responding to? And can I do anything about it ?

Mood swings and anxiety ranked second in the list of most frequent symptoms in research analysed from FLO -period tracking app used mainly by young adults (18-37). Other symptoms included: cravings, fatigue, abdominal spasms, skin rashes, sleep-changes and more. Understanding these changes has led to a lot of discussion amongst researchers of different fields mainly biology and psychiatry.

The extremities of menstrual health are more researched and understood than what is normal. Biology has been able to track the levels of progesterone in different disease states and conditions while psychiatry has been able to link some of these findings to mood disorders such as PMDD(Premenstrual dysphoric disorder) and PPD( postpartum depression). This leaves everyone in the middle at a crossroads where maybe symptoms may not seem as extreme but noticeable enough to cause discomfort. Premenstrual syndrome (PMS) is the general term used to describe the range of symptoms faced before the menstrual cycle.

What do we understand about PMS?

Mood changes and other symptoms that arise cyclically due to the menstrual cycle are referred to as PMS( premenstrual syndrome) and like most things regarding women's health it’s rooted in some controversy. PMS was initially termed to link emotional led behaviour to a trait only women possess. Early research in the US interrogated the woman's ability to make ‘sound decisions’ and occupy work spaces due to the menstrual cycle. The research world has rejected this idea but interestingly PMS itself is looked as an expected outcome of menstruation and remedies understandably focus on extreme cases where PMS progresses into PMDD or is exacerbated in other conditions such as depression and anxiety disorders.

The clearest evidence supports progesterone as the root cause but it isn’t as straightforward.

The uncertainty lies in a few key questions which aren’t fully understood:

1. Is an increase only in progesterone responsible for mood change,

2. Is sensitivity to changes in progesterone responsible for mood change ( increase or decrease)?

3. Is a decrease only in progesterone levels responsible for the changes in mood

Progesterone isn’t the only hormone involved in the menstrual cycle but only its fluctuations have been linked to mood disorders. In pregnancy the drop in progesterone levels at the end of pregnancy are linked to PPD (postpartum depression) and similarly decreases during the luteal phase of the menstrual cycle have been linked to PMDD( premenstrual dysphoric disorder). Some women have been given progesterone to supplement this drop in levels of it but little changes have been seen in their mood. The benefits of progesterone supplement is yet to be supported by the scientific community.

The menstrual cycle and mood changes cannot be explained by fluctuations of a single hormone as to function as humans there is an interplay of many things. It is quite difficult to isolate findings and in the chances they are, the effects are studied in such small subsets of people that just isn’t generalisable. In the studies that have tried to map changes in hormones with changes in the brain the most interesting was an increase in negative processing of emotions linked to that second phase(luteal phase).

Other remedies such as diet, exercise and supplements for low mood are suggested. Without going into biological detail for each one the overarching conclusion is that all these additions nicely take remedies from other conditions of fatigue, depression, bloating and more to tackle the problem but we are yet to reach a stage of avoiding PMS altogether.

I started this post hoping to find a definitive answer to the question of solving my PMS forever .The most definitive answer I have is - my feelings before my period aren’t all sporadic and PMS isn’t only a progesterone related problem and is a combination of processes that seem to start unknown and remedy themselves on their own - in that one week after bleeding that everything seems achievable again !

Period tracking apps such as FLO and CLUE have made it easier for many users to be aware of their cycle and common symptoms that may occur. These apps alongside the many other tracking and fertility apps have also aided the research community in analysing data directly from people not on the extremities of disease. FLO and CLUE have further confirmed on a larger scale mood changes due to the luteal phase, while FLO has additional features set to help users detect medical conditions by tracking symptoms entered and further discuss with a medical professional.

This integration of personally led health and wellness reporting backed with more robust scientific study might be the new answers to fully understanding the role of progesterone or possibly something else in PMS. This breakthrough will not be able to happen without trust in the use of health data and full understanding of the scope of how such personal information is being handled. The implications of health apps in healthcare is a conversation for a different blog post !

Questions to think about ?

1. Would you take part in larger studies focused on understanding menstrual health

2. Have period tracking apps helped you have more ‘control’ over your cycle?

3. Would you want your health data to be analysed by a private company or integrated with hospital health data?

4. Would you want a drug to get rid of all the PMS symptoms?

5. Do you need to understand the ‘WHY’ to PMS?

References

1. Brain and menstrual cycle: https://www.nature.com/articles/s41386-019-0435-3

2. Brain Imaging and menstrual cycle: https://www.frontiersin.org/articles/10.3389/fnhum.2013.00374/full

3. Melatonin for PMS: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9868742/

4. PMS overview( diagnosis and treatment) : https://www.aafp.org/pubs/afp/issues/2016/0801/p236.html

5. Progesterone in the body: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9322133/

6. Menstrual cycle and cognitive function: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4241821/

7. Hormones and health tracking apps: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7614476/

8. Progesterone and all its functions: https://www.sciencedirect.com/science/article/pii/S0091302220300479

9. PMS data from FLO APP: https://link.springer.com/article/10.1007/s00737-022-01261-5

10. Menstruation science and society: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7661839/ ( An amazing paper to read) -

11. Nutrition: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9928757/

12. The gut microbiome and womens health: https://pubmed.ncbi.nlm.nih.gov/36421397/

13. Nutrition and PMS : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9928757/