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The Pill for PMDD: What It Actually Is, and Which One Has the Evidence · 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: Up until now, we've been focusing on what's causing symptoms in the brain for women whose brains are sensitive to hormones, and how to work out whether what you're dealing with is PMS or PMDD.
• 0:40
  Speaker: In the next stretch of this series, I want to move into treatment, and I know from clinic that a lot of women are predominantly interested in hormonal treatment first, so that's where I want to start, specifically with the pill.
• 0:52
  Speaker: The pill is a term that gets banded around a lot, but I don't think most people actually understand what we mean by it, so it's worth being clear before we go any further.
• 1:03
  Speaker: The pill refers to the combined hormonal contraceptive, and that combined element means it's got both an estrogen and progesterone in it.
• 1:13
  Speaker: It doesn't have to come as a pill either.
• 1:17
  Speaker: There's also a patch and a vaginal ring that work in a very similar way.
• 1:22
  Speaker: The other bit of complexity is that there are lots of different types of pill.
• 1:27
  Speaker: The estrogen side is fairly straightforward.
• 1:30
  Speaker: Almost all combined pills contain a synthetic estrogen, and that comes in different doses, broadly a low dose or an average dose.
• 1:41
  Speaker: There is one option on the market that uses a natural estrogen instead, which I'll come back to later.
• 1:47
  Speaker: The real complexity is on the progestin side.
• 1:51
  Speaker: Progestin is really just a term for a chemical that has progesterone-like effects.
• 1:56
  Speaker: A lot of the progestins used in the pill are actually derived from testosterone rather than from progesterone itself, though some are derived from progesterone, and there's one derived from an entirely different medication called spironolactone.
• 2:11
  Speaker: Different derivations mean different side effect profiles, so although we talk about the pill as if it's one medication, there can be real differences between different formulations and in the side effects you might get from them.
• 2:25
  Speaker: If you're looking specifically for hormonal treatment for PMDD, here's what's been investigated.
• 2:32
  Speaker: The pill with the most evidence behind it combines a low dose of synthetic estrogen, ethinyl estradiol, with a progestin called drospirenone, the one I mentioned that's derived from spironolactone rather than from testosterone.
• 2:47
  Speaker: Spironolactone is a well-established blood pressure medication that works on the kidneys, and drospirenone seems to be well-tolerated by a lot of women with PMDD, which is part of why this combination has the most evidence behind it.
• 3:03
  Speaker: The randomised placebo-controlled trials specifically looking at drospirenone for PMDD are from the mid-2000s.
• 3:11
  Speaker: The UK brand name for the low-dose version is Eloine.
• 3:16
  Speaker: There's also a standard dose version, better known as Yasmin, Yacella, Yaz, which can have advantages for bleeding control since you're more likely to get breakthrough bleeding on the lower oestrogen pill than on the standard dose.
• 3:31
  Speaker: This is the best evidence option we have, but I want to be honest, it still only works for about half the women who try it.
• 3:39
  Speaker: That's worth bearing in mind before you start.
• 3:42
  Speaker: I'll also be honest that there haven't been many head-to-head trials comparing drospirenone against other progestins for this specifically.
• 3:51
  Speaker: There is some evidence comparing it against pills containing levonorgestrel, one of the most commonly prescribed progestins, and drospirenone does tend to come out ahead, which is why we usually reach for it first.
• 4:04
  Speaker: But I want to be upfront that the strength of evidence behind that preference isn't enormous Here's something about the pill I think doesn't get explained often enough.
• 4:14
  Speaker: When it was invented back in the 1960s, it was deliberately designed to mimic a natural 28-day menstrual cycle.
• 4:22
  Speaker: So you'd take it for 21 days and stop it for seven, and have a bleed during that break.
• 4:28
  Speaker: Most pills are still packaged that way out of tradition, so when you get a prescription for the pill, you'd typically get 21 active pills.
• 4:38
  Speaker: But for PMDD specifically, that traditional break can actually be a problem.
• 4:44
  Speaker: Here's why.
• 4:45
  Speaker: The pill works as a contraceptive by stopping ovulation, and in doing that, it stops the natural rise and fall of your hormones across the cycle.
• 4:55
  Speaker: For women whose PMDD is being triggered by those rapid rises or drops, taking away the fluctuation and creating a constant stable hormone level is what actually helps.
• 5:08
  Speaker: It's not going to work as well for women whose sensitivity is more to progesterone itself rather than to the fluctuation.
• 5:16
  Speaker: But for the fluctuation-driven group, that stability is the whole mechanism.
• 5:21
  Speaker: So if you take the pill for three weeks and then stop it for a week, you're undoing that stability every single cycle, and symptoms can recur right on schedule.
• 5:31
  Speaker: Traditionally, one fix was to shorten that pill-free break down to four days, which is exactly what Eloine's twenty-four/four regime does.
• 5:41
  Speaker: But increasingly, what we tend to do is go further still and run pills back to back continuously, finishing one packet and starting the next straight away, rather than taking any break at all.
• 5:54
  Speaker: The trade-off with either of those approaches, the shortened break or running continuously, tends to be bleeding pattern, and I think this deserves attention because it's one of the questions I get asked most, and there's a lot of anxiety around it that usually isn't warranted.
• 6:12
  Speaker: On a twenty-four/four regime, most women get a predictable lighter withdrawal bleed during that four-day break, similar to a normal period, but usually shorter and lighter since it's not a true period.
• 6:25
  Speaker: There's no ovulation happening underneath it.
• 6:27
  Speaker: It's simply your body responding to the hormone drop.
• 6:31
  Speaker: That predictability is part of why some women prefer to keep a short break in each cycle, even knowing it may let a bit more symptom recurrence through.
• 6:41
  Speaker: On a continuous regimen, running packets back to back with no break, the pattern is different, and I'll be honest, less predictable, especially in the first few months.
• 6:52
  Speaker: Breakthrough bleeding or spotting is common early on.
• 6:56
  Speaker: Your body's adjusting to a genuinely different hormonal pattern than it's used to.
• 7:00
  Speaker: This isn't dangerous, and it isn't a sign anything's wrong, but it can be a nuisance, and it's the main reason some women give up on continuous dosing before giving it a proper chance.
• 7:10
  Speaker: What I tell patients is to expect the first two to three months to be the bumpiest and that things usually settle considerably after that.
• 7:19
  Speaker: By around three months, roughly 75% of the women find their bleeding stops altogether for the remaining group, a short planned four-day break every two or three packets rather than every single one is often enough to reset things and avoid ongoing breakthrough bleeding.
• 7:36
  Speaker: There is a bit of trial and error in this, finding your own pattern rather than assuming there's one right answer for everybody The one thing I always say clearly is any bleeding that's genuinely heavy, that's persistent beyond a few months without settling, or that starts after a long period of no bleeding at all on a stable regimen, is worth getting checked properly rather than assumed to be normal breakthrough bleeding.
• 8:03
  Speaker: It usually is nothing sinister, but it's not something to just push through indefinitely without a conversation.
• 8:09
  Speaker: one pill on the market uses a natural estrogen rather than a synthetic one.
• 8:15
  Speaker: That's Zoely, and it's worth going through because most of what makes it different from a standard combined pill comes down to that one ingredient swap.
• 8:24
  Speaker: Zoely combines natural estradiol with a progestin called nomogestrel, which is derived from progesterone rather than from testosterone, so it may carry a slightly different side effect profile from some of the testosterone-derived progestins.
• 8:39
  Speaker: Because the estrogen is natural rather than synthetic, it's thought it may act on the brain in a slightly different way, and that could be particularly interesting for a couple of groups of women.
• 8:52
  Speaker: Women who are moving into perimenopause and starting to get some perimenopausal symptoms alongside their PMDD might benefit from that natural estrogen doing double duty.
• 9:04
  Speaker: There's also a hypothetical link worth mentioning, honestly, as exactly that, hypothetical, between estrogen and the dopamine system in the brain, which raises the question of whether natural estrogen pills might be more favorable for women with ADHD, though I want to be clear there's no direct evidence for that yet.
• 9:24
  Speaker: It's a plausible idea rather than a proven one.
• 9:27
  Speaker: Similarly, there's a theoretical case that natural estrogen might carry a lower cardiovascular or blood clot risk than synthetic estrogen, but nobody's actually run the trials to confirm that with any certainty, so it's a factor some women and clinicians weigh in decision-making, not something I can give you a clear answer on yet.
• 9:47
  Speaker: Practically, you take Zoely exactly the same way as a drospirenone pill.
• 9:52
  Speaker: There's no real difference in how it's used, and the same limitation applies.
• 9:57
  Speaker: If your PMDD is driven by sensitivity to progesterone specifically, swapping the estrogen component doesn't get around that problem.
• 10:06
  Speaker: So it's not something that's necessarily going to work for everyone either.
• 10:10
  Speaker: Given how much circulates online about the pill, I want to spend a moment directly addressing a few things I hear constantly, because misinformation here puts women off a treatment that could help them.
• 10:22
  Speaker: One myth I hear a lot is that you need to take regular breaks from the pill to let your body have a rest, or to let your natural hormones come through occasionally.
• 10:32
  Speaker: There's no medical basis for this at all.
• 10:35
  Speaker: Your body isn't storing up harm from continuous use that a break clears out, and for PMDD specifically, taking a break is often the opposite of helpful, since it's the break itself that lets symptoms recur.
• 10:49
  Speaker: Another myth I hear constantly is that the pill causes infertility or makes it harder to conceive once you stop.
• 10:57
  Speaker: Fertility returns to normal very quickly for the overwhelming majority of women once they stop, often within one cycle.
• 11:05
  Speaker: What can cause confusion is that some women go on the pill in their teens or twenties before an underlying condition affecting their cycles, like polycystic ovarian syndrome, has ever been diagnosed.
• 11:18
  Speaker: And when they come off it years later to try for a baby, that underlying condition is still there.
• 11:24
  Speaker: It didn't appear because of the pill, it was simply masked by it.
• 11:28
  Speaker: There's also a persistent myth that not bleeding on a continuous pill regimen means blood is building up somewhere or that it's unsafe.
• 11:37
  Speaker: It isn't.
• 11:38
  Speaker: Without ovulation, the womb lining doesn't build up the way it does in a natural cycle, so there's nothing accumulating that needs to come out.
• 11:46
  Speaker: Not bleeding on continuous dosing is a completely normal, safe response to the hormones, not a suppressed or delayed period waiting to happen worth saying too, if you need contraception alongside treatment for your cycle-related mental health symptoms, any of these combined options give you that as a built-in benefit.
• 12:06
  Speaker: Or if you're getting heavy or painful periods, the pill can generally help there too.
• 12:11
  Speaker: So a good history of your mental health, your bleeding pattern, and your contraception needs all together helps guide which option actually makes sense for you.
• 12:20
  Speaker: So that's the pill unpacked, what it actually is, why drospirenone specifically has the best evidence behind it, why how you take it matters as much as which one you take, and where a natural estrogen option like Zoely might fit for particular groups of women.
• 12:38
  Speaker: It's not a guaranteed fix.
• 12:40
  Speaker: Roughly half of women find it helps, but understanding the mechanism means we can actually match the right formulation and regimen to the right woman rather than guessing.
• 12:51
  Speaker: Next time, I want to look at who this category isn't right for.
• 12:56
  Speaker: That's it for today.
• 12:58
  Speaker: I'm Georgina.
• 12:59
  Speaker: Thanks for listening.
• 13:00
  Speaker: A quick note before you go.
• 13:02
  Speaker: This podcast is for general information, not individual medical advice.
• 13:06
  Speaker: It doesn't replace seeing your own GP or a specialist.
• 13:10
  Speaker: So if anything you've heard today feels relevant to you, please do talk to someone, 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.
• 13:22
  Speaker: You can find Sirona Health and book your appointment at sironahealth.co.uk.
• 13:27
  Speaker: See you next time