PMSing through Perimenopause

I wrote before about what’s happening with the two major hormones in a normal monthly menstrual cycle. Estrogen is the Queen of the first two weeks (when the period starts to ovulation), and Progesterone is Queen of the second two weeks leading up to the next period (the classic PMS time). This hormone is the first to get wonky and trigger many perimenopausal symptoms.

Why? Our bodies have a set number of eggs at birth. This number drops steeply at puberty and then decreases each month with ovulation until there are no eggs remaining and a woman is in menopause.

As we age, not only does the number of eggs we have decrease but also the quality of the eggs declines. What does that mean? Remember that we make progesterone after ovulation? If the eggs we are ovulating as we age are less healthy, we make less progesterone. This is one of the first changes in perimenopause. Progesterone levels start to decline in the 2^nd half of the menstrual cycle. This creates a natural state of “estrogen dominance”, something many of my patients are curious about. I tell all women over 35 that they are almost positively estrogen dominant. There’s no need to test this in most women; it’s the natural state of affairs in early perimenopause.

This lowered progesterone during this time translates to heightened PMS symptoms for many women. PMS symptoms vary woman-to-woman in intensity and severity and length of time. Most women think of PMS as being the increased emotional sensitivity right before a period, but PMS technically includes ANY symptom that occurs in that 1-2 weeks prior to a period and goes away once the period comes. Common symptoms are breast tenderness, fatigue, headaches, bloating, cramping, intense cravings, insomnia, night sweats, acne. What an awesome way to feel…

PMS tends to increase in length for many women during perimenopause, sometimes starting immediately after ovulation and lasting the full 2 weeks before the next period.

Many women I work with experience most of the symptoms I mentioned for the full 2 weeks of the month– Yuck! These women feel terrible half of the month. Their period starts and PMS symptoms finally go away (hooray!), but then many struggle with extremely heavy bleeding and intense cramping and more headaches. Lots of women I talk to have a few days after their periods in which they feel their best. This is crazy! Many of us only feel well for 1-5 days per month.

Listen, ladies: This is common but is NOT normal! You do NOT have to live like this.

What to do?

1. Sleep—this is a priority. This is your number one goal. Start your efforts here if you are not getting at least 7 restful hours each night. If so, move on down the list.
2. Manage your stress—you are more sensitive to stress and it’s impact on another hormone called Cortisol. This hormone is HUGE and deserves it’s own post, so stay tuned.
3. Eat well—what does that mean? Well, this is another big can of worms and a big part of my healing philosophy so we’ll spend whole posts on it for sure! The big picture: plant-based diet, lots of healthy fats (think avocado, grass-fed butter, coconut oil, nuts & seeds), whole foods, minimal to no processed foods, minimal to no sugar (right when you want them the most, I know, I’m mean), very little if any alcohol, very little if any caffeine.
4. Are you still reading?
5. Exercise—more is not always better, but try to move your body daily. Walking, stretching and yoga are perfect starts. Try to find a buddy to make it more enjoyable, keep you motivated and committed, and give you some girlie time to get stuff off your chest. This is an important daily routine, but is also SO helpful during those PMS days. You may find it feels best to go for longer & slower walks, jogs and swims rather than shorter more intense workouts during the PMS phase.
6. Keep track of your cycles and your symptoms. There are many, many period tracker apps out there. My favorite for simple tracking (not for fertility purposes) is Clue (it’s free!). Look around, though, and find what works for you. The benefit of these apps is that you can start to see patterns and understand if certain symptoms are cyclical or hormonal. They are also excellent for reminding yourself that when you start to feel the PMS symptoms start, they are temporary and will be leaving soon(ish). Many trackers can send you reminders that PMS may be starting, once the app has a good history of the symptoms you enter each month. I cannot downplay the benefit of this knowledge. Many women tell me they feel crazy for days, they don’t know why, they get their period and feel better and then think, in retrospect, “Oh! I had PMS, that’s why I felt terrible!”. Knowing in advance gives you a little bit more control of the situation; this control and knowledge is very powerful and can prevent the PMS from taking over your decision-making processes.

If you’re doing all of these and feeling confident about your efforts and still struggling, or find yourself so stuck in the PMS haze that you can’t find the energy to make the efforts, it may be helpful to try a few supplemental nutrients.

1. A high quality, food-based multivitamin: All multis are NOT created equal. I recommend the food-based brands like Garden of Life/Vitamin Code, Rainbow Light and New Chapter, because the nutrients are sourced from fruits & veggies (and organic versions are available and preferable). The nutrients from food are readily absorbed and used by the body, minimizing the extra steps needed to activate them or make them useful. This means you actually absorb the vitamins and minerals instead of peeing them out. I recommend finding the Women’s formula specific to your age range, too (that may mean a prenatal).
2. A high-quality fish or krill oil: I recommend we each get a total of 1000mg per day of EPA and DHA combined per day. More may be better, especially if you struggle with more mood change with PMS.
3. Magnesium citrate or glycinate: This mineral is amazing! It is needed to relax muscles, it calms the brain, improves sleep, promotes bowel regularity and decreases PMS symptoms. You cannot get a toxic dose orally. If you take too much, your stools will be looser and you may have some abdominal cramping. I recommend taking this to “bowel tolerance”; in other words, take as much as your body can tolerate without causing diarrhea (the glycinate form is easier on more sensitive bellies). This is usually in the range of 300-600mg. Take it at night to promote a blissful slumber.
4. Vitamin D3: I do recommend having your Vitamin D levels tested. Optimal is to be in the 60-80 range, but normal is above 30. If you live in the Pacific Northwest, I recommend 4000iu daily. You DO want to have levels monitored, as excess levels can increase your risk for kidney stones.
5. Vitamin B6: This B-vitamin is a necessary precursor or ingredient in making many hormones in the body, including serotonin (the happy brain hormone) and progesterone. Levels are depleted with long-term oral contraceptive use and are often low in women with PMS. Start with 100mg each morning with food; better yet, take it with the other B-vitamins as part of a B-complex. I like the B6-Complex from Pure Encapsulations. You CAN get too much B6, so be careful—it can cause numbness and tingling in the hands and feet.

If you are trying these recommendations and not seeing results after at least 3 months, it’s time to get more aggressive. This could mean lab tests for hormones and nutrient deficiencies, or experimental diets to uncover food sensitivities, or the use of more specific herbal therapies, etc. See your local naturopathic physician for more individualized care recommendations! Find a naturopath in your area here.

 

No, I don’t have PMS. I’m just a b*tch

—Michelle Wolf

 I know that’s a racy way to end this post, but I love the subtext of what Michelle is saying here (she’s a very funny comedian I’ve seen periodically on The Daily Show with Trevor Noah). More often than not, girls and women are taught to be kind, sweet and submissive and we are rewarded for being so. Being bold, aggressive and questioning others is not and the thought is that a woman must have PMS when she behaves this way. Let’s all be b*tches, I say!

Advertisement

Biology of a Cycle, the short-short version

There are major hormone changes happening in perimenopause. Let me back up. There are major hormone changes happening constantly in a woman’s body from puberty through menopause. Our bodies get in to a nice rhythm once periods are regular, sometime in our teens to our early 30’s on average. For most women, periods are a monthly hiccup where the daily routine changes a bit for a few days but we march through and go about our business. Please know that I’m talking about the majority of young women who have normal cycles. I see women every day in clinic that struggle with their cycles; they are a huge upheaval in their lives and a major challenge each month. I’m not talking about these women right now. Most young women find their cycles to be an annoyance and nothing more (and that, perhaps, is a topic for another discussion!).

In a normal cycle, you have two distinct phases. The whole cycle lasts on average about 28 days, with each phase lasting 14 days. There is huge variability here. A normal cycle can be anywhere from 21 to 35 days long, which would make the 2 phases more variable in length. Almost always, the second phase is 12-14 days, which means the first phase is usually the one that is longer or shorter. Anyway, the take-home point is there are 2 phases of a menstrual cycle.

The first phase is called the Follicular phase. Day one of your cycle is the first day you have a normal bleed (spotting doesn’t count!) and the first day of this phase. At the same time you have your period, your ovaries begin again to get ready to ovulate an egg. An egg follicle starts to mature and is typically ovulated or hatched around the 14^th day of a normal cycle. Again there’s variability here. A healthy ovulation occurs between days 11 -17 of a cycle and usually depends on how long the full cycle is. Many hormones are involved in the menstrual cycle but the main player here is Estrogen.

Once an egg is ovulated, the 2^nd phase begins. It’s called the Luteal phase. The shell of the egg, called the corpus luteum, sticks around for a while and makes a hormone called Progesterone. It’s the main player of the luteal cycle. If there is no pregnancy, the luteum gets smaller and smaller, the body makes less Progesterone and it signals another period to happen. The whole cycle then begins again.

I’ll come back to this biology lesson frequently in future posts. These two phases and the changes that occur with them as we age are key in understanding perimenopause and its symptoms.

Silver Linings?

I write this at 5am, in our temporarily quiet home while everyone is asleep. I used to get frustrated when I woke up early like this. Now, I relish in the peace and quiet. Before I had kids, I remember talking with a mom-friend who said she recently started getting up at 5am to write. It was the only time she had to herself. A long time lover of sleep, I was disgusted at the thought. I totally get it now…

This isn’t specific to perimenopause, but in my practice I do counsel women on seeing the bright sides of certain negative situations (like when your body wakes up earlier than your soul wants to). In this example, waking early offers an important opportunity for ME-time, something we all have less of as we age and have more and more responsibilities (whether or not that involves kids).

Another example is PMS. Long ago, I read Christiane Northrup’s book, Women’s Bodies, Women’s Wisdom. It inspired me to look differently at the phases of our cycles. She talks about PMS being a time when our bodies are more sensitive to the world around us. This is an obvious statement, I know! I don’t mean sensitive as in emotionally reactive, but sensitive as in more perceptive and more receptive. It’s like the blinders are taken off for a few days. This is uncomfortable.

But Dr. Northrup writes about it being an opportunity for us to receive information, process that information and make decisions. It’s a unique time and an opportunity to be introspective, realize what is and is not working for you and come up with an action plan.

Perimenopause, for many women, feels like PMS on steroids. For many of the women I meet in my practice, I probably wouldn’t recommend taking action based on their PMS experiences (most would end up in jail, I think). I do like Dr. Northrup’s idea, though, that during those days that we are more sensitive, we can’t ignore the daily annoyances of life. Some of these irritations are silly, some are really big and yet we go about our day-to-day lives and try our hardest to push through and not see them. I talk to women who are in unhappy relationships or jobs that are not fulfilling. PMS can be a time to reflect on these areas of our lives and at least set an intention for change.

I would recommend not acting on that plan until the PMS is over, however…And talk to your girlfriends and mentors and therapist to make sure you don’t sound like a crazy person.