PMS, PMDD & anxiety - how to take care of your mental health around your period

Premenstrual syndrome (PMS) is a common condition that occurs in the second half of the menstrual cycle (aka, the luteal phase, occurring after ovulation and before our period). Although numbers vary, it’s thought that around 75% of females experience it.

PMS is characterised by a range of physical, psychological, and behavioural symptoms. Each person’s experience of PMS or PMDD is unique and can vary from month to month. Physical symptoms can include cramps, nausea, bloating and body aches. Behavioural symptoms can include difficulty sleeping, food cravings, and withdrawal. Psychological symptoms can include mood swings, irritability, anger, or anxiety. These symptoms typically disappear once our period begins, but can be severe enough to interfere with our daily lives, work, school, or relationships. 

People with more severe PMS symptoms may be classified as having premenstrual dysphoric disorder (PMDD), which is a type of depressive disorder. It’s thought that around 3-8% of females experience PMDD. If you feel like you experience severe PMS anxiety, you may have PMDD.

It’s not known exactly what causes anxiety and other mood changes in PMS/PMDD. One theory is that it's due to fluctuating hormone levels experienced during the luteal phase of the menstrual cycle.

Another theory is that PMS and PMDD are due to our individual sensitivity to oestrogen, progesterone and their metabolites. When progesterone is broken down, one of the substances – called allopregnanolone – affects GABA receptors in the brain, the function of which is associated with emotions such as anxiety, stress, and fear. This theory states that people who experience PMS and PMDD have GABA receptors that respond differently to allopregnanolone compared to those people who don’t experience PMS/PMDD. 

Other research has explored differences in brain structure and found that people experiencing PMDD have different grey matter structure in certain areas of the brain, which has been associated with negative emotions, including anxiety and depression.

PMS anxiety can be hugely challenging to deal with, often having a serious impact on people’s daily lives. For example, anxiety can make it harder to fall asleep, resulting in reduced concentration and productivity at work, university, or school, leading to irritability and fatigue. Anxiety can also cause us to withdraw from social activities, which can subsequently make anxiety worse, leaving us feeling lonely and isolated from others. 

To make matters more tricky, it can also contribute to tensions in relationships, particularly if the anxiety leads to communication difficulties or a lack of emotional intimacy. Anxiety has also been found to exacerbate other PMS/PMDD symptoms, such as headaches and cramps. 

If you or someone you know is experiencing severe PMS anxiety or PMS depression each month, or any other symptoms that are significantly affecting your quality of life, it’s important to seek help from a GP. If you’re having suicidal thoughts and are worried you may act on them, you should call 999, go to A&E or contact the Samaritans.

Many people want to know how to reduce PMS anxiety. Anxiety experienced during PMS or PMDD can be treated a number of ways:

• Non-medical treatments
• Medical treatments
• Drug based
• Therapy based
• Alternative treatments

Non-medical treatments

Some people find that general lifestyle modifications can help mitigate PMS/PMDD-related anxiety, such as exercising regularly, eating healthy and balanced meals, getting adequate sleep, and managing stress. Yoga, meditation and breathwork also help to reduce stress levels and anxiety. Spending time in nature has been shown to have a calming effect on the mind, so if you’re feeling overwhelmed and in need of a quick relaxant, head outside to a green space for a walk or find a bench to sit and take some time out. Many people find that talking to someone you trust about how you’re feeling can also be hugely helpful.

Keeping track of anxiety and other PMS/PMDD-related symptoms is useful so you can know what to expect each month and determine whether these lifestyle modifications are having a positive impact. You can also use these notes if you decide to seek help from a healthcare professional for a diagnosis in the future. 

Medical treatments 

For PMS-related anxiety, there are lots of medical treatment options your GP can offer. These can be split into two different groups: drug-based treatments, and therapy-based treatments. Which your doctor recommends will depend on the severity of the anxiety, any other PMS/PMDD-related symptoms you’re experiencing, and your personal preference.

Drug treatments for PMS anxiety

Combined oral contraceptives (COCs), often called ‘the pill’, are comprised of synthetic hormones that act like oestrogen and progesterone in the body and come in different formulations. COCs control or stop menstruation and can therefore reduce PMS/PMDD-related anxiety and other symptoms. It’s recommended that these are taken continuously (back-to-back packets) rather than cyclically (whereby you have a break from taking the pill and have a period) to maximise the chances of them working. Not all pills can be taken continuously though, so check with your healthcare provider before making any changes to your medication.

New-generation COCs (those containing a type of progesterone called drospirenone) are more commonly prescribed by healthcare professionals. This is because the older-generation COCs can, in some people, reintroduce PMS-like symptoms due to the type of progesterone they contain. New-generation COCs can be taken alone or combined with other non-pharmacological treatments such as cognitive behavioural therapy (CBT). However, COCs aren’t effective for everyone, and it’s not clear exactly why. COCs can also cause side effects and are unsuitable if you’d like to become pregnant.

SSRIs

SSRIs are a type of antidepressant medication and are the primary recommended treatment for PMDD. They can be either taken continuously or just during the luteal phase of the menstrual cycle. When starting SSRI treatment, healthcare professionals will generally suggest a three-month trial to see if it’s effective in reducing your symptoms. Similarly, to COCs, SSRIs can be taken alone or combined with non-pharmacological treatments. Although these can be effective in reducing PMS/PMDD-related anxiety, they can also have side effects including nausea, asthenia/decreased energy, drowsiness, fatigue, decreased libido, and/or sweating.

If you’re planning to become pregnant, discuss your treatment options with your doctor, as they may recommend stopping SSRIs before getting pregnant.

Emerging treatments

Because one of the possible reasons for PMS/PMDD-related anxiety is the action of the progesterone metabolite allopregnanolone, scientists are currently exploring novel drug therapies which target this substance. Although research is in the early stages, there is emerging evidence that such treatments can be effective in improving PMDD anxiety and other mood-related symptoms.

More studies are needed to determine whether these therapies provide sufficient benefits (without negative side effects).

Non-pharmacological treatments for PMS anxiety

Because pharmacological treatments aren’t for everyone, and can cause side effects, some people opt for non-pharmacological treatments instead.

CBT

Your healthcare professional may suggest CBT for PMS. This is a type of talking therapy that can help with a variety of mental health issues, including PMS/PMDD-related anxiety. One of the main benefits of talking therapies compared with pharmacological treatments is that the effects can be longer-lasting and are maintained when therapy comes to an end.

CBT is available in individual, couple-based or group-based formats. It can also be offered in-person or online. CBT helps you to think, feel, and act differently in response to PMS/PMDD-related anxiety and other symptoms. The idea is that you identify unhelpful, negative thought patterns and replace them with more positive ones. Studies have shown that CBT can help to reduce PMS/PMDD-related anxiety and depression, as well as improve the ability to cope with other symptoms. However, research indicates that CBT is generally more effective in reducing the severity of psychological symptoms over physical ones. 

Some research has explored the effects of combining CBT with other types of treatments. For example, studies have been conducted on mindfulness-based cognitive therapy (MBCT), which merges traditional CBT with mindfulness strategies. This therapy involves learning different ways of managing anxiety, such as specific relaxation techniques, and promotes non-judgemental awareness and acceptance of current emotions. Although there is a need for further research on MBCT, existing studies have shown it can reduce PMDD anxiety and other PMDD symptoms, and improve quality of life.

Alternative treatments for PMS anxiety 

A variety of alternative therapies are also available to reduce PMS/PMDD-related anxiety. This includes reflexology, which originates from traditional Chinese medicine.

Reflexology is based on the idea that stimulating specific reflex points on the hands, legs, and ears results in different changes to internal bodily systems. It’s thought that physical and mental health issues are the result of internal blockages, and that reflexology alleviates these by promoting energy flow through the body.

Studies have found that reflexology can reduce the mood-related symptoms of PMS/PMDD such as anxiety. Longer sessions (of around an hour) are associated with more positive effects.

Acupuncture is another treatment derived from ancient Chinese medicine that can be used to manage anxiety. It involves stimulating specific pressure points with fine needles to promote energy flow within the body. Although more studies are needed with larger numbers of participants, existing research has found that acupuncture can reduce mood-related PMS/PMDD symptoms, including anxiety.

Yoga is also an option as an alternative therapy as it promotes relaxation, increased awareness and improved physical health. It’s thought that yoga works by stimulating the sympathetic nervous system, thus regulating the release of stress hormones within the body and reducing PMS/PMDD-related anxiety, anger, irritability, stress and low mood. It has also been shown to improve the quality of life of people with PMS/PMDD.

More recently researchers have begun to explore the potential of Cannabidiol (CBD) to reduce PMS/PMDD-related anxiety. CBD is derived from the cannabis plant, but unlike the cannabis compound delta-9 tetrahydrocannabinol (THC), it does not have any psychoactive properties. CBD stimulates cannabinoid receptors called CB1 and CB2. These receptors affect multiple systems within the body, including those responsible for mood-related PMS symptoms such as anxiety.

Research on CBD and PMS/PMDD symptoms is in the early stages, and that CBD may help reduce PMS anxiety, irritability and stress when taken for an extended period of time. Consult a healthcare professional before starting CBD if trying to conceive, pregnant, or breastfeeding.

There are many supplements and vitamins that are reported to help ease PMS symptoms. Many people like to try these before they try medical treatments. However, evidence for their effectiveness is conflicting, and advice from a healthcare professional should be sought before starting new supplements/vitamins.