Latest / The Sirona Health Podcast: PMDD, Hormones & Mental Health / Hormonal treatments for PMDD: Beyond the combined contraceptive pill

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Hormonal treatments for PMDD: Beyond the combined contraceptive pill · The Sirona Health Podcast: PMDD, Hormones & Mental Health

• 0:04
  Speaker: Hormones don't just run your cycle.
• 0:06
  Speaker: They run your mood, your mind, your whole sense of self.
• 0:10
  Speaker: I'm Dr.
• 0:12
  Speaker: Georgina Standen, GP and founder of Sirona Health, and this is the Sirona Health Podcast, where we talk about the relationship between female hormones and mental health properly without the mystique and without the dismissal.
• 0:25
  Speaker: Last time I went through the combined pill in detail, and specifically why drospirenone-containing combined pills have the best evidence behind them.
• 0:35
  Speaker: But the combined pill isn't right for everyone.
• 0:37
  Speaker: Some women can't take estrogen in that form.
• 0:40
  Speaker: Some have tried it, and it simply hasn't helped, and some just want to understand the full picture of what's actually out there.
• 0:46
  Speaker: So today, I want to go through the three other hormonal approaches that come up a lot in this conversation: transdermal estrogen combined with a progesterone, Progesterone taken on its own, and a progestin-only pill called Slind.
• 1:01
  Speaker: I'll be honest with you upfront, these three are not equally well-supported by evidence, and I think that's actually one of the most useful things I can tell you today.
• 1:10
  Speaker: Let's start with the one that actually has the best evidence behind it of the three, even though it's probably the least well-known.
• 1:17
  Speaker: This involves taking estrogen continuously through the skin, alongside a progestogen to protect the womb lining.
• 1:25
  Speaker: The mechanism is the same one we keep coming back to in this series, suppressing ovulation and the hormonal fluctuation that goes with it, so that instead of the natural rise and fall of each cycle, you've got a steady, stable level of hormone in your system.
• 1:41
  Speaker: There are two clinical trials behind this approach, both using transdermal estrogen alongside a progestogen called norethisterone, taken for about a week each month to protect the uterus, and both found a real benefit for emotional premenstrual symptoms compared to placebo.
• 2:00
  Speaker: The early trials used quite high doses of estrogen, and there's been some understandable concern about whether that's safe long-term, since higher estrogen exposure can raise the risk of estrogen-dependent cancers.
• 2:13
  Speaker: So in current practice, we tend to use a lower dose, around 100 micrograms, rather than the 200 micrograms used in some of the original research, and later work suggests the lower dose is likely just as effective.
• 2:27
  Speaker: I do want to be upfront about a few practical things with this approach.
• 2:32
  Speaker: First, it isn't contraceptive on its own.
• 2:34
  Speaker: Unless you're also using a coil alongside it, you'd need additional contraception if that's relevant to you.
• 2:41
  Speaker: Second, starting this treatment can genuinely be rough for the first month.
• 2:47
  Speaker: There's good evidence that people with PMDD can have an exaggerated negative emotional reaction while hormones are settling into that new stable level before things calm down.
• 2:58
  Speaker: So if you can get through that first month, symptoms usually do settle, but it's worth knowing in advance and building in some extra support for yourself rather than being caught off guard Third, this is prescribed off-license, and it's genuinely a lesser-known option, so not every GP or gynecologist will be familiar with it or confident prescribing it.
• 3:21
  Speaker: If you're struggling to find someone who'll consider it, it's worth seeking out a clinician who specifically has an interest in this area.
• 3:29
  Speaker: One thing worth knowing if you react badly to progestogens generally, taking estrogen entirely on its own isn't a safe alternative.
• 3:38
  Speaker: Unopposed estrogen can lead to overgrowth of the womb lining and raises cancer risk.
• 3:44
  Speaker: So the progestogen genuinely can't be dropped.
• 3:48
  Speaker: Some clinicians in the UK do use continuous micronized progesterone or a hormonal coil instead of norethisterone for women who struggle with that specific progestogen.
• 4:00
  Speaker: Though I want to be honest that there isn't clinical trial evidence specifically confirming that that substitution is equally safe and effective.
• 4:08
  Speaker: It's based on clinical experience rather than trial data.
• 4:12
  Speaker: I think this approach is particularly worth considering for a specific group, women who notice their PMDD symptoms newly developing or significantly worsening as they move into perimenopause.
• 4:25
  Speaker: That's a pattern I've talked about earlier in this series, and it makes biological sense that a treatment built around stabilizing fluctuating hormones would suit that transition especially well.
• 4:37
  Speaker: There's also a genuinely practical advantage here compared to the combined pill.
• 4:42
  Speaker: Combined hormonal contraception generally isn't continued past the age of fifty because of how the risk profile changes, whereas this approach, using HRT-type hormones, can be continued well beyond that age, with all the added benefits of menopause hormonal therapy alongside the PMDD benefit.
• 5:03
  Speaker: So, for a woman whose symptoms are worsening, specifically as she moves through her forties, this option has a genuine longevity advantage that the pill simply doesn't.
• 5:14
  Speaker: The next one I want to handle carefully because I don't think it's as simple as me telling you one theory is outdated and moving on.
• 5:23
  Speaker: This is a live, ongoing disagreement between well-respected people in this field, and I think you deserve to hear both sides rather than just my conclusion.
• 5:33
  Speaker: Micronized progesterone, taken on its own, meaning not alongside estrogen, but as the primary treatment, is something that gets prescribed and requested a fair amount for PMDD.
• 5:46
  Speaker: The theory behind it goes back to Dr.
• 5:49
  Speaker: Katharina Dalton, one of the genuinely important early pioneers in this field, who believed premenstrual symptoms were caused by a rapid drop in progesterone in the late luteal phase that theory still had real prominent contemporary advocates who continue to recommend progesterone alone, sometimes at high doses, as a treatment for PMS and PMDD built on that same rapid drop theory and on clinical experience of women who report feeling better on it.
• 6:19
  Speaker: Here's where I sit, and I want to explain my reasoning rather than just assert it.
• 6:25
  Speaker: When micronized progesterone alone has actually been tested against placebo, there wasn't a significant difference in menstrual symptoms between the two groups.
• 6:36
  Speaker: That's a different kind of evidence from clinical experience or a theoretical model, however well established that theory is historically or however many individual patients report feeling better.
• 6:48
  Speaker: Clinical experience is genuinely valuable.
• 6:52
  Speaker: It's often where new hypotheses worth testing come from, but it can also be influenced by things that have nothing to do with the hormone itself, the placebo response, which we know is large in this condition, the natural fluctuation of symptoms over time, and the benefit of simply being taken seriously and monitored closely.
• 7:12
  Speaker: I want to be fair to the other side of this too.
• 7:15
  Speaker: Those trials had genuine limitations, and it remains possible that a subset of women do respond specifically to progesterone alone that we simply haven't identified through the research we currently have.
• 7:27
  Speaker: I'm not saying nobody benefits from it.
• 7:30
  Speaker: What I am saying is that based on the evidence available right now, I can't tell you it's a reliable, evidence-backed first-line treatment for PMDD in the way I could tell you that about the combined pill or about transdermal estrogen with a progesterone.
• 7:48
  Speaker: If you're already on progesterone alone and it's genuinely helping you, that's valuable information about your own body, and it's not something I'd want to take away.
• 7:56
  Speaker: But if you're considering starting it specifically for PMDD, I think you deserve to know honestly that the trial evidence isn't there yet, whatever else you might have read or heard.
• 8:07
  Speaker: Where micronized progesterone does have a clearly established evidence-based role is alongside estrogen, protecting the womb lining, which is exactly what I described in the previous section, and what it's most commonly prescribed for, particularly around the menopause transition.
• 8:25
  Speaker: That's a real and important use and not a dispute.
• 8:29
  Speaker: It's specifically as a standalone PMDD treatment on its own merits that the picture is genuinely contested.
• 8:36
  Speaker: The last one I want to cover is Slynd, a progestogen-only pill containing drospirenone, the same progestogen from the combined pill I talked about last episode, but here without any estrogen at all.
• 8:50
  Speaker: I think it's worth explaining why some of the old-fashioned progestogen-only pills aren't generally expected to help PMDD in the first place.
• 8:58
  Speaker: Many of the traditional mini pills containing progestogens like norethisterone or levonorgestrel don't reliably stop ovulation, and if ovulation's still happening, you're still getting that post-ovulation hormone fluctuation that's driving symptoms in the first place, so there's no real reason to expect those particular pills to help.
• 9:20
  Speaker: Drospirenone at this specific dose is different.
• 9:23
  Speaker: It's one of only two progestogen-only pills, alongside one containing desogestrel, that's been shown to consistently suppress ovulation in the region of 95 to 99% of the time in clinical studies.
• 9:37
  Speaker: That's promising in theory, but I want to be completely honest with you, there are currently no clinical trials specifically testing Slynd for PMDD.
• 9:48
  Speaker: It's a plausible option based on the mechanism, not a proven one based on the evidence.
• 9:53
  Speaker: There's also a slightly complicated picture around progestogen-only methods and mood more broadly.
• 9:59
  Speaker: Some research suggests certain progestogen-only contraceptives are associated with a higher overall risk of depression compared to other options, though it's unclear whether that applies equally to drospirenone specifically, since it's the newest and least studied option in this category, and we have the evidence that when it's combined with an estradiol, it is better tolerated.
• 10:21
  Speaker: So where does that leave Slynd practically?
• 10:25
  Speaker: It tends to come up as an option for women who can't take oestrogen at all due to migraine with aura, a clotting history, or other contraindications, rather than as a first choice for someone who could take a combined pill instead.
• 10:39
  Speaker: If you're in a position to consider either, the current guidance actually favors starting with the combined drospirenone pill I covered last episode over the progestin-only version, precisely because that's where the actual trial evidence sits.
• 10:53
  Speaker: There's one specific combination worth knowing about, too, bringing together the two things I've talked about today.
• 11:00
  Speaker: For women in perimenopause who are also dealing with menstrual migraines, particularly if estrogen fluctuations seem to be part of what's triggering them, Slynd can sometimes be used alongside transdermal estrogen, same continuous steady dose estrogen I described in the first part of this episode.
• 11:19
  Speaker: Slynd handles ovulation suppression and endometrial protection without adding any estrogen of its own, while the transdermal estrogen gives you that stable level separately in a route that carries a lower clotting and stroke risk than an oral combined pill would.
• 11:36
  Speaker: So if migraines have become part of your picture alongside PMDD symptoms in perimenopause, that combination is worth specifically raising with whoever's treating you.
• 11:47
  Speaker: I'll go into menstrual migraines properly in their own episode later in the series.
• 11:52
  Speaker: So for today, I just wanted to flag that this particular combination exists bringing today together, I think this is the most important thing to take from this episode Of the three options I've covered today, transdermal estrogen with a progestogen has real trial evidence behind it, even though it's underused and not always easy to access.
• 12:14
  Speaker: Progesterone alone is genuinely contested.
• 12:17
  Speaker: It has real historical grounding and real contemporary advocates, but the placebo-controlled trial evidence for it as a standalone PMDD treatment isn't there yet, and I think that's important to know, even if you decide with your clinician that it's still worth trying.
• 12:33
  Speaker: And Slynd is a plausible, theoretically sound option, particularly for women who can't take estrogen, but it's not yet backed by PMDD-specific trials the way the combined pill is.
• 12:46
  Speaker: I think being honest with you about where the evidence actually sits, rather than presenting everything as equally settled, is really important, and it's exactly why a conversation with a clinician who knows this area well matters so much when you're working out what's actually right for you.
• 13:03
  Speaker: Next time, I want to move into a different category of treatment altogether, medication that works by switching off ovulation completely, GnRH analogs, and when that approach genuinely makes sense.
• 13:16
  Speaker: That's it for today.
• 13:20
  Speaker: I'm Georgina.
• 13:21
  Speaker: Thanks for listening.
• 13:22
  Speaker: A quick note before you go.
• 13:24
  Speaker: This podcast is for general information, not individual medical advice.
• 13:28
  Speaker: It doesn't replace seeing your own GP or a specialist.
• 13:32
  Speaker: So if anything you've heard today feels relevant to you, please do talk to someone.
• 13:37
  Speaker: And if you're struggling, please reach out to your GP, to someone you trust, or to a crisis line if you need one right now.
• 13:44
  Speaker: You can find Sirona Health and book your appointment at sironahealth.co.uk.
• 13:49
  Speaker: See you next time