I truly wish that I could put billboards up all over the world that read "the solution to women's health concerns is not an antidepressant + an oral contraceptive" because so many of the women I work with have been under the impression that this is the case for their entire lives.
I treat women in their mid 40s who, having decided to not have children, have stayed on the oral contraceptive pill (the OCP, or the "pill") basically all of their menstruating lives (30+ years), and have no plan to come off until after menopause... because they've been told that decision is without consequence. They aren't aware that shutting down ovulation has drawbacks, and they're often afraid that if they stop taking the pill their premenstrual physical and mental symptoms will be untreatable.
You need to know that, firstly, ovulation is incredibly important for your overall health. Ovulation is the only means by which women make any appreciable amount of progesterone - a critical hormone for your bones, your cardiovascular system, your breasts, and your nervous system.
Secondly, you need to know that there are other ways to treat premenstrual syndrome than the pill and an SSRI/antidepressant.
Aside from the fact that the serotonin hypothesis of depression has recently been definitively debunked, the mass prescription of antidepressants and OCPs for all women's health concerns is not only inappropriate, it's almost laughable. "Oh, she's complaining about her moods around her time of the month, let's give her those same two lady prescriptions." Conversation... effectively over.
If you experience changes in your mood that happen predictably around ovulation, or during your luteal phase between when you ovulate and before you get your period, you're not crazy (and you're not SSRI-deficient, either). Irritability, anxiety, depression, and anger are all very common premenstrual mood experiences.
There are many possible causes, and a handful of natural therapeutics that I find to be very effective.
Not all of these causes (and thus the therapeutic strategies that work on them) are necessary for every woman experiencing premenstrual mood symptoms. But each case typically involves at least one of the following four causes:
Mast cell activation: the activation of mast cells, and resulting histamine release, is a major player in premenstrual mood changes. There is an interesting link between estrogen and histamine - estrogen stimulates mast cells to release histamine and also down-regulates DAO (an enzyme that clears histamine). At times of high estrogen (like around ovulation and in the luteal phase) histamine peaks. Histamine also drives higher estrogen. In contrast, progesterone stabilizes mast cells. Many of the "estrogen dominant" symptoms are actually attributable to histamine, and clearing histamine is often an effective PMS-management strategy. For this I use vitamin B6 in combination with magnesium in therapeutic doses, I test and treat for gut health concerns, I support estrogen clearance, and I often use natural progesterone (called 'cyclic progesterone therapy').
Nutritional deficiencies: the nutrients magnesium and taurine are often effective therapies for treating premenstrual mood symptoms. Magnesium helps clear histamine (above) and is also effective for lowering inflammation and supporting a calm nervous system. Taurine is an amino acid that supports the production of GABA when taken along with magnesium. GABA is a calming neurotransmitter. Iron levels are critical to check in menstruating women who experience mood alterations at any time in the menstrual cycle. Zinc is equally important in supporting premenstrual moods - it supports the hippocampus in regulating the stress hormone response, and one study in college-aged women showed significant mood improvements with zinc. Supplementing with calcium has also been shown to improve PMS-related mood disturbances. Another nutrient that my colleague Lara Briden uses quite often to support premenstrual moods is iodine - I find it can be a very helpful therapy, especially when breast pain is also present in the premenstrual phase. High dose iodine therapy should be undertaken with caution and supervision by an ND, as it is only safe if you have recently ruled out autoimmune thyroid disease.
Progesterone insufficiency: if you have a short luteal phase (less than 12 days in length), experience spotting for more than one day prior to the start of your period, and especially if you are not ovulating regularly (whether due to having a high dose hormonal IUD, taking an OCP, having PCOS, or another medical condition like hypothalamic amenorrhea), you're not making enough progesterone. Progesterone is a crucial mood and nervous system-stabilizing hormone that, when lacking, can absolutely exacerbate your moods. In many cases, using prescription progesterone (taken orally) helps to soothe anxiety and stabilize mood in the luteal phase. A small percentage of women actually feel more anxious with progesterone therapy, and if this is the case for you (your anxiety worsens right after ovulation when progesterone rises as opposed to before your period when it falls) you may need a different dose and an alternate approach.
Gut health/microbiome imbalances: as with almost all things in the naturopathic medicine world, we often start with the gut when it comes to mood disorders. The guy/brain connection has been firmly established, and what happens in the gut is also strongly influenced by hormonal changes throughout one's cycle. We have research that links premenstrual mood symptoms to high levels of gram negative bacteria - suggesting intestinal permeability may be at play. Especially if you experience digestive health concerns, incorporating gut testing and a microbiome rebalancing/gut healing protocol can be very effective for treating your premenstrual moods.
There are a few other factors that could be at play: high prolactin, dairy sensitivity, blood sugar dysregulation/insulin resistance, and high stress, to name a few. But these four areas of focus are always worth some attention and investigation if your premenstrual moods are bothersome.
Work with your ND to investigate these causes. Taking a whole-body approach to PMS is critical to address the underlying root cause of your premenstrual mood symptoms. Because the time of one-size-fits-all-womens-health approach of prescription SSRI/OCPs is over, and you deserve better.
In health,
Dr K
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