Latest / The Sirona Health Podcast: PMDD, Hormones & Mental Health / Premenstrual Exacerbation (PME): PMDD or Something Else?

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Premenstrual Exacerbation (PME): PMDD or Something Else? · The Sirona Health Podcast: PMDD, Hormones & Mental Health

• 0:04
  Hormones don't just run your cycle.
• 0:07
  They run your mood, your mind, your whole sense of self.
• 0:11
  I'm Dr.
• 0:12
  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.
• 0:27
  At the end of the last episode, I said I'd explain something I've mentioned a few times in this series without unpacking it, premenstrual exacerbation, or PME for short.
• 0:39
  Here's the kind of woman I'm thinking of.
• 0:42
  She has depression or anxiety or bipolar, something that she's had for years and is being treated for, and every month in the week or two before her period, it gets worse.
• 0:55
  Not a little worse, worse enough that she knows when her period is coming before she's looked at a calendar.
• 1:02
  Then her period arrives, things ease, and she settles back to where she was, which isn't symptom-free.
• 1:09
  It's just her usual.
• 1:11
  Is that PMDD?
• 1:13
  Often it isn't, and the difference matters because it changes what we do about it.
• 1:19
  Let's start with the definitions, because this is one of those areas where the terminology has been a bit of a mess.
• 1:27
  PME is sometimes called premenstrual aggravation or magnification, and it's increasingly described as the third premenstrual cycle-related mental health condition, alongside PMS and PMDD.
• 1:43
  It's also the one that gets recognized least, which is why it so often ends up misdiagnosed or undertreated.
• 1:51
  PMDD, as we've covered, is a disorder defined by its timing.
• 1:57
  The symptoms come in the luteal phase, and then crucially, there's a symptom-free window after your period starts.
• 2:05
  You get a proper break.
• 2:08
  Premenstrual exacerbation is different.
• 2:10
  Here, there's an underlying condition that's present throughout the month, whether that's depression, anxiety, bipolar disorder, ADHD, or something else, and it gets worse premenstrually.
• 2:26
  So there's no symptom-free window.
• 2:29
  The best it gets is her baseline, and her baseline is already an illness There's also a variant you'll see called premenstrual breakthrough.
• 2:41
  This is when someone's condition is well-controlled with treatment most of the month, but symptoms break through in the premenstrual phase.
• 2:50
  Same idea, a bit more specific.
• 2:53
  I think the honest thing to say is that the line between PMDD and PME is blurrier in real life than it looks on paper.
• 3:02
  A woman can have both.
• 3:04
  She can have PMDD sitting on top of long-standing depression, and some of what looks like a symptom-free window turns out, when you ask carefully, to be a slightly better but not quite well window.
• 3:19
  So this is one of those places where I'd rather give you the shape of the problem than pretend there's a clean boundary.
• 3:27
  The overlap shows up in the numbers, too.
• 3:30
  A large Swedish study of more than 100,000 women diagnosed with a premenstrual disorder found that nearly half, about 48%, already had a psychiatric diagnosis, compared with about 30% of women without one.
• 3:47
  And the link ran both ways.
• 3:50
  Women with a premenstrual disorder were about twice as likely to be diagnosed with a psychiatric condition later on, and women with a psychiatric diagnosis were more likely to go on to develop a premenstrual disorder.
• 4:05
  The association was strongest for depression and anxiety, and also clear for ADHD, bipolar disorder, and personality disorder.
• 4:14
  It still held, though it was weaker, when women were compared with their own sisters.
• 4:20
  I should say that study is built on recorded diagnoses rather than daily symptom charts, so it can't tell us which of these women had PMDD and which had PME.
• 4:32
  What it does tell us is that these conditions don't live in separate boxes, which brings me to a problem that runs through this entire area, and it's one I keep returning to in this series.
• 4:43
  How do we actually know?
• 4:46
  If I ask a woman,"Does your mood get worse before your period?" A lot of women say yes.
• 4:52
  But when researchers have compared what women remember with what they recorded day by day, the two often don't match.
• 5:01
  Retrospective reports, remembering back over the last few months, tend to over-call it.
• 5:07
  That's one of the reasons why daily tracking over at least two cycles is the standard for diagnosing PMDD and is equally important for PME.
• 5:19
  There's a tool built for exactly this, and it was developed specifically to help tell these patterns apart.
• 5:26
  It's called the Carolina Premenstrual Assessment Scoring System, or CPASS.
• 5:32
  It takes the daily ratings, the same kind of diary I've talked about before, and it applies a set of rules to them rather than relying on someone eyeballing the chart.
• 5:44
  One of the key ideas in it is that for PME, you're not looking for symptoms to disappear after your period.
• 5:51
  You're looking for a meaningful change relative to her own baseline.
• 5:57
  The rule of thumb in CPASS is a change of at least 30% between the premenstrual days and the days after her period.
• 6:06
  It's a way of asking,"Is this a genuine pattern shift for her?" Rather than,"Does she have any symptoms at all?" When the CPASS developers tested it on a group of about 200 women, they were able to separate the picture into three groups: a group who met criteria for PMDD, a larger group who had another menstrual-related mood disorder, which includes exacerbation, and a group with neither.
• 6:35
  And what struck me is that the middle group was bigger than the PMDD group.
• 6:40
  In that sample, there were more women whose cycle was worsening something else than there were women with PMDD itself.
• 6:49
  I wouldn't hang a prevalence figure on one study, but it tells you PME is not a rare footnote.
• 6:56
  On a daily chart, the picture looks something like this.
• 7:00
  In PMDD, symptoms rise in the luteal phase and then fall right down to nothing, or close to nothing, after the period begins.
• 7:09
  In PME, the line rises premenstrually, but it comes back down to a higher baseline, not to zero.
• 7:18
  And in a third pattern, she might have a persistently elevated line with a small bump.
• 7:23
  Different shapes, and they mean different things.
• 7:27
  So how often is this happening?
• 7:29
  The honest answer is that the numbers vary because it depends on how you define it and how you measure it, but they're consistently bigger than people expect.
• 7:39
  Across studies of women with mood disorders, roughly 60% report that their symptoms worsen premenstrually.
• 7:47
  There's a figure from the large STAR*D depression trial of about 64%, and a systematic review by Nolan and Hughes, which pulled together 35 studies from a starting pool of six hundred and twenty-nine, found that premenstrual worsening is common across a range of psychiatric conditions.
• 8:08
  I'll flag that a lot of those numbers rely on women reporting this themselves rather than prospective daily records.
• 8:15
  So I'd treat them as a rough guide to how common this is rather than a precise rate.
• 8:22
  But even allowing for that, the direction is clear.
• 8:25
  If you're a woman with a mood or anxiety disorder, it's more likely than not that your cycle is influencing it.
• 8:34
  It isn't limited to one diagnosis, so let me take them in turn.
• 8:38
  Depression is the one we have the most data on.
• 8:41
  Many women with major depression notice a premenstrual dip, and it's associated with a worse course overall, more severe symptoms, and in some studies, a poorer response to treatment.
• 8:54
  Bipolar disorder is a really important one.
• 8:57
  Women with bipolar disorder often find the premenstrual phase destabilizing, with mood episodes or worsening in mood symptoms that cluster there.
• 9:08
  The cycle can be one of the triggers.
• 9:10
  It's also a good example of why the way you ask matters.
• 9:14
  When women are asked to look back, around two-thirds report cycle-related mood changes.
• 9:20
  In studies that follow women prospectively, it's lower, somewhere between 44 and 65%.
• 9:27
  Still a lot, but a reminder that memory tends to overcall it.
• 9:33
  Borderline personality disorder shows some of the highest numbers.
• 9:37
  In the work Nolan and Hughes reviewed, premenstrual worsening was reported by around 73% of women with BPD.
• 9:46
  Other reviews find the evidence for BPD more mixed, so I'd treat that number as a signal rather than a firm rate.
• 9:53
  I'll be coming back to it when we look at personality disorders later in the series.
• 9:58
  Anxiety disorders, OCD, and PTSD show premenstrual worsening in a good proportion of women, though the evidence is more mixed here than for depression or bipolar disorder.
• 10:11
  Anxiety and stress are fairly consistently higher across the luteal phase, whereas the data for panic, PTSD, and OCD is patchier, partly because there are fewer good studies.
• 10:23
  And there's evidence in psychosis too.
• 10:25
  In a review of women with psychotic disorders, The risk of symptoms worsening was about one and a half times higher around the perimenstrual phase.
• 10:34
  I'll add ADHD to that list, which links back to the dash MC discussion a few episodes ago, and which I'll cover in its own episode.
• 10:43
  Why would this happen?
• 10:44
  We don't have a definitive answer, but there are some strong candidates, and a lot of them will sound familiar by now.
• 10:51
  The first is the one we keep coming back to.
• 10:55
  If a woman's brain is sensitive to the hormonal shifts of the cycle, then it makes sense that any other vulnerability sitting in a system would be affected too.
• 11:04
  The progesterone, allopregnanolone, GABA pathway, which we've talked about at length, and serotonin, which an estrogen influences and which many of our treatments target.
• 11:15
  Those aren't PMDD-only systems.
• 11:18
  They're involved in mood and anxiety generally.
• 11:21
  So a cyclical wobble in those systems could plausibly amplify whatever's already there.
• 11:28
  I should be clear that this is a hypothesis, not a proven mechanism.
• 11:32
  Researchers working on PME describe it in very similar terms, with the drop in estrogen affecting serotonin and dopamine and allopregnanolone acting on GABA, but nobody has directly tested it in PME.
• 11:47
  It's the natural extension of the model rather than something a trial has shown.
• 11:53
  I'd also point to the idea I raised with dash MC, the hormone sensitivity might be trans-diagnostic, meaning it cuts across diagnoses rather than belonging to a single one.
• 12:06
  PME is, in a way, the clinical face of that idea.
• 12:10
  And there's a trauma thread, which I'm going to leave for the trauma episode because it deserves proper space.
• 12:16
  So what do we do about it?
• 12:19
  The first principle is simple, and it's one I'd like you to hold on to: treat the underlying condition.
• 12:26
  If the problem is a depression that gets worse premenstrually, then the depression needs good treatment throughout the month.
• 12:34
  A woman whose baseline is poorly controlled will have a harder time premenstrually simply because there's less room before things tip over.
• 12:43
  Second, once the baseline is in a good place, we can think about the premenstrual window specifically.
• 12:49
  For women on an antidepressant, one practical option can be adjusting the dose in the luteal phase, taking a higher dose in the days leading up to her period and returning to her usual dose afterwards.
• 13:03
  I'd only do this with a clinician, And I'd be wary of it with anything where abrupt changes cause problems, But it's a reasonable approach for the right person.
• 13:12
  I cover the trade-offs of cyclical dosing in the SSRI episode, so I won't repeat them here.
• 13:18
  For bipolar disorder or psychosis, the equivalent can be reviewing the dose of the mood stabilizer or antipsychotic across the cycle, which is a specialist decision.
• 13:30
  Third, there's the question of hormonal treatments, and I'd urge some caution.
• 13:35
  Everything we've talked about on the hormonal side in this series was largely studied in PMDD we don't have anywhere near the same trial evidence in women whose primary problem is PME, and the effect of hormonal changes on an existing mood disorder isn't always predictable.
• 13:55
  For some women, stabilizing the cycle might help.
• 13:59
  For others, particularly those who are sensitive to progestogens, it might not.
• 14:04
  So I'd treat that as a conversation to have carefully with the whole picture in front of us, not an automatic next step.
• 14:13
  There's some early interest in the pill containing natural estradiol with norethisterone, Zoely, which we talked about in the combined pill episode, but that's tentative, and it hasn't been tested in PME There's one interaction worth knowing about if you're taking a mood stabilizer.
• 14:30
  Lamotrigine, which is used in bipolar disorder, interacts with estrogen-containing contraception because estrogen can lower lamotrigine levels.
• 14:40
  It's one of those practical details that matters a lot if someone on it is considering the combined pill.
• 14:47
  Fourth, psychological approaches.
• 14:49
  Everything I covered last episode, CBT, DBT, ACT, and self-compassion applies here, and one of the most useful things I find in PME is simply having the pattern named.
• 15:03
  Once you can see on a chart that the third week of your cycle is when things reliably get harder, you can plan for it in the way that we've talked about with other conditions.
• 15:14
  One more thing, and I want to say it gently.
• 15:16
  If you do have a pattern where things get significantly worse before your period, and that includes thoughts of harming yourself or ending your life, then please treat the premenstrual phase as a time to have extra support in place.
• 15:31
  Tell someone you trust.
• 15:33
  Make a plan with your clinician in advance for those days.
• 15:37
  Suicide risk and the menstrual cycle is something I'm going to cover on its own later in the series with the care it needs.
• 15:44
  For now, I just want you to know that if this is you, it's predictable, and a predictable thing is something we can plan around.
• 15:53
  If you're struggling right now, please contact your GP, call 111 and choose the mental health option, or call the Samaritans on 116 123 anytime day or night.
• 16:07
  If you're in immediate danger, call 999.
• 16:10
  So to bring today together, PMDD and premenstrual exacerbation are related but different.
• 16:17
  In PMDD, the cycle is the disorder.
• 16:21
  In PME, the cycle is making an existing disorder worse, and there's no symptom-free window to return to.
• 16:29
  It's common across depression, bipolar disorder, anxiety, trauma-related conditions, and more, and is easy to miss if nobody is looking at the pattern.
• 16:40
  Daily tracking is how we find it, and treating the underlying condition well is the foundation for everything else.
• 16:48
  If you've got an existing mental health condition and you suspect your cycle is part of the picture, tracking your symptoms daily for a couple of cycles is a very good place to start, and it's worth taking the chart to whoever is treating you.
• 17:03
  Next time, I want to look at another condition that so often gets entangled with the menstrual cycle, migraine, aura, menstrual migraine, and why it comes up so often in the hormonal treatment decisions we've been talking about throughout this series.
• 17:20
  That's it for today.
• 17:21
  I'm Georgina.
• 17:22
  Thanks for listening.
• 17:24
  A quick note before you go.
• 17:25
  This podcast is for general information, not individual medical advice.
• 17:30
  It doesn't replace seeing your own GP or a specialist.
• 17:33
  So if anything you've heard today feels relevant to you, please do talk to someone.
• 17:38
  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.
• 17:46
  You can find Sirona Health and book your appointment at sironahealth.co.uk.
• 17:51
  See you next time