Exploring Patterns of Premenstrual Distress

In this episode of The Choice Space, Dr Lee David speaks with Dr Sally Doust, GP and women’s health specialist, about premenstrual distress, including premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD). The conversation explores how hormonal changes across the menstrual cycle can affect mood, energy, sleep and emotional sensitivity – and why these patterns are often overlooked or misunderstood.

They discuss the wider context of women’s health inequalities, including the lack of research and the ways this can affect recognition and treatment. Sally explains how changes in oestrogen and progesterone interact with the brain and body, and why premenstrual symptoms can look very different from one person to another.

The episode also looks at how to tell when symptoms may be cyclical, why tracking patterns can be so helpful and how recognition itself can reduce self-blame. There is thoughtful discussion of PMDD, including the severity of symptoms some women experience and the importance of feeling believed and supported.

Lee and Sally also explore practical support, from cycle tracking and self-compassion to lifestyle changes, supplements and medical treatment options. This is a grounded conversation about understanding patterns, widening choice and responding with more care and clarity.

Key moments
00:37 Introduction
02:48 Women’s health inequalities
04:27 Hormones across the cycle
08:52 Hormones and the brain
11:16 What PMS can look like
14:22 Cyclical patterns and timing
16:42 Choice Pause – changing mood and energy
25:35 Understanding PMDD
31:35 Supportive choices for PMS
35:29 Treatment options
41:52 Cycle tracking takeaway
42:50 The 30 – 30 – 30 approach

About the guest

Dr Sally Doust is a GP with a specialist interest in women's health and medical educator. She works in the NHS, in private practice, and at Brighton and Sussex Medical School. In her GP work she found many women had adverse experiences of healthcare because of gender biases and lack of research into women's health - this inspired her to specialise in this area and remains the key purpose of her career. She holds diplomas in obstetrics and gynaecology (DRCOG) and sexual and reproductive healthcare (DFSRH). She is a member of the Primary Care Women's Health Society and the British Menopause Society. For the past two years she's been a delegate for the United Nations Commission on the Status of Women.

You can connect with Sally on LinkedIn.

Here is a link to the NAPS PMS guidelines

About the host

Dr Lee David is a GP, CBT therapist and author specialising in mental health and wellbeing. Lee has written many books on CBT, mindfulness and teen wellbeing, and speaks regularly at conferences and in the media. Away from work she enjoys running, hiking, singing in a choir and spending time outdoors with her family. You can find Lee through her website and on Instagram, TikTok (@dr.lee.david), Facebook and LinkedIn.  You can find more about her books, wellbeing courses and therapy here:  https://linktr.ee/dr.lee.david 

Transcript

Dr Sally Doust 0:00

Cycle tracking is my one big step. Getting to know yourself, your mind, your body, noticing when changes occur. That way you can build a deeper understanding and you can build that toolbox of all the different strategies and you can take your well-being into your own hands. So this week, if you know that you're in premenstrual phase, cancel that thing in your diary that's going to cause you to feel stressed or move it, move it to somewhere else and share it with your partner and your family so they understand where you're at.

Dr Lee David 0:37

Welcome to the Choice Space Podcast. I'm Dr. Lee David, GP, CBT therapist, and author. Many women notice changes across the menstrual cycle. It might be in mood, energy, sleep, or emotional sensitivity. Sometimes these shifts are mild and predictable. At other times they can feel more intense or harder to understand. Because these patterns unfold alongside busy lives and everyday pressures, it's not always easy to recognise what's happening or to know where to turn for support. In this episode, we explore both premenstrual syndrome, PMS, and premenstrual dysphoric disorder, PMDD, looking at how hormones interact with the brain, with our body and with emotions, and what evidence-based support might look like. I'm delighted to be joined today by Dr. Sally Dust, a GP with a special interest in women's health. Sally, welcome. Could you tell us a little more about yourself and your experience in this area?

Dr Sally Doust 1:39

Thank you so much for having me. It's great to be here. Yeah, so I'm a GP and essentially as soon as I started as a GP, I noticed that women had a lot of unanswered questions. They might feel dismissed, they might have not had conditions diagnosed or not been able to find the treatment that they needed. This particularly stood out one particular patient that I had had PMDD, which is a severe form of PMS, and found that the awareness of that was really low, even though about perhaps 4% of women may have this condition. So that really kind of fired me up. And when I started looking at actually the science behind this, the lack of research into women's health, the gender biases that really contribute to really bad science and bad medicine and that's doing women a disservice, this really drove me to follow women's health as a specialist interest. So I have uh diplomas in obstetrics and gynecology and secular and reproductive health. And I'm a member of the Primary Care Women's Health Society and the British Menopause Society. And nowadays a lot of my clinical practice is in menopause and also how much that overlaps with PMDD and with ADHD as well.

Dr Lee David 2:47

Wow, loads of experience there, Sally. And I just want to start with this idea about health inequalities and women's health in general, because it does feel really relevant. And we know that there's a lack of research, that sometimes research is not applied to women. And then we also know that women's health conditions, like premenstrual distress, and I'm just going to call it distress, to have that umbrella across PMS and PMDD. We know that there is a lack of research, and actually the guidelines do exist, but there's still quite big gaps, aren't there?

Dr Sally Doust 3:20

There are huge gaps in a lot of research across women's health, yes. And this is really from a precedent of animal studies being done mainly on mice, uh, male mice, because scientists felt that female menstrual cycles would disrupt results and data. And then it's only since about some point in the 1990s, I think, that, for example, in America they mandated that women should be studied in clinical research as well. So, yes, we're we're dealing with a precedent of decades of women being left out of research. And yes, with PMS and PMDD particularly, is any areas really where hormones are involved? It seems to be that there's lots of gaps in knowledge when it comes to hormones, particularly.

Dr Lee David 4:02

Let's start with what we know and and also what you have gleaned through your clinical experience, which is also really important, and and what women say to you, which I think listening and actually taking women seriously is is a big part of what we're going to focus on today. Absolutely. So let's think about how hormone changes across the menstrual cycle affect women and let's look a little bit at both physical and mental health, maybe.

Dr Sally Doust 4:27

Yeah, absolutely. So if I break down the cycle a bit and I can describe perhaps what women say through the cycle as we go. And when I'm referring to women, by the way, I guess in this con conversation, I'm speaking to anybody identifying as a woman. And but today, as we're talking about the female menstrual cycle, I guess this would apply to anybody who's experienced a menstrual cycle, no matter their gender identity. And really across the cycle, think of there being two main hormones at play, so estrogen and progesterone. And I suppose an average cycle is thought to be 28 days, but it is actually totally normal to have a cycle between 21 and 35 days. And it might vary month to month as well. So it doesn't have to be spot on 28 days. If we take the start of your cycle as day one, at this point, think of that as a really low hormone environment. So both estrogen and progesterone are really low. And what women say to me at this point is they can feel very tired, low energy, and then about a week into the cycle, estrogen starts to rise. And this can be the best time of the cycle. What's happening there physiologically is it's thickening the womb lining and we're gearing up to ovulate. So we can feel energetic, frisky, sharp, positive, libido comes up here. But actually, even some women will describe that this surge in estrogen can make them feel kind of wired or anxious, like on a bit of a high. And then we ovulate. So this is about halfway through the cycle, so about day 14. And a day or two after that, estrogen drops sharply. And a lot of women can really tell clearly that this is happening. Not everybody can identify ovulation, but literally a day or two afterwards, sometimes women describe like my hormones are dropping off a cliff. Because what happens then is luteal phase is starting or premenstrual phase, and estrogen is dropping sharply, mood is dipping. And so that's when mood can start to really change. We might feel more self-doubt, more anxiety, I guess just kind of like less equanimity in general. And then shortly after this, progesterone starts to rise. And I guess what the body's doing here is preparing for pregnancy. So its progesterone's drop to make the womb really hospitable for implanting an embryo. But this sudden rise in progesterone can make a lot of people feel quite irritable, even sometimes angry, you know, that kind of don't touch me kind of feeling like noises are annoying. And this feeling can peak in the late cycle. So we're talking about maybe a week before your period's due, irritability can peak. Then just before your period, a couple of days before, both hormones drop really low. So each new progesterone dropped really low. We're back into that really low hormone environment that I described at the beginning. And this can really feel like the worst bit for some people, both physically and mentally. So sleeping poorly, fatigued, back to that kind of tearful and low feeling. Um and then the womb lining starts to shed. So you're back at day one at the start of the cycle again.

Dr Lee David 7:25

There's a few things that stand out to me there, and one of them is how for women, the normal is change, isn't it? Throughout. Right throughout the whole of the menstrual cycle, we're experiencing changing hormones and how that will impact different women in different ways. And so actually it's it's all changing all the time, isn't it?

Dr Sally Doust 7:47

Yes, our hormones are in a constant state of flux. And measuring blood levels of hormones, for example, is fraught with problems, and they are quite difficult to interpret because of this situation where we're in flux. And like you said, this has contributed to research being complex, but that's you know, we we need to then up our game with research and be on top of that so that we can provide women with the information that they need about their health. So, yes, we are in constant flux with our hormones, and it does, it does affect some people more than others. And there are clear physiological differences, it's it's incredible. In luteal phase, in this pre-menstrual phase, our body temperature can be a whole degree higher. We can need a couple of hundred extra calories per day, there's more inflammation levels in the body. So the body, the body and the mind are completely different during this point as well.

Dr Lee David 8:37

Yeah, so it's not just about changing hormone levels, I'm hearing there, that there's a lot of other factors at play. Do you think this is about the hormone exactly how much there is, or is it how we respond to it? Is it a combination? What are your thoughts about that?

Dr Sally Doust 8:52

Yeah, so all women are in this state of hormonal flux, and and some feel this more than others. It could also be about how our brains respond to hormones, so we can all be different in that way. Um because estrogen and progesterone, those two hormones that I've talked about in the cycle that are constantly changing, they both have profound effects on the brain. Estrogen promotes serotonin production in the brain. We know that as a happy hormone. So estrogen increases it and makes serotonin hang around longer, which is why we might feel great in that first part of the cycle before we ovulate. Estrogen also increases dopamine, which is involved in kind of motivation and everything. So that motivated part of the month. And then progestos is very interesting because it actually increases what's called GABA, which is a neurotransmitter in our brain that calms brain activity, calms everything down, promotes sleep. So there's normal hormone changes going on. Then women may be having normal levels of hormones that are simply going up and down and creating this profound influence on the brain. And why might we respond differently to this potentially as different women? Because it's so personal and so individual. Probably partly to do with how we develop through our whole lives, really, our genetic makeup, perhaps our early life, whether we've had any stress or trauma, how we form psychologically as young adults in our formative years. So all of this might shape how our brain then responds to our hormonal cycles as adults.

Dr Lee David 10:17

And it really highlights the complexity and all the factors at play, and that might then feed into how to support, in that there may not be a one size fits all, and it may not be one simple answer.

Dr Sally Doust 10:30

Absolutely, yes. I think for women, the approach to hormones needs to be really tailored. So let's take, for example, contraceptive pills. So lots of women will identify with perhaps reacting quite badly with contraceptive pills. Some people feel that they may be very progesterone-sensitive. Progesterone maybe gets a bad rep, though. It may be the synthetic progesterone and contraceptive pills that can really affect people's mood. And it is complex because actually high steady levels of progesterone can actually be really helpful. So progesterone gets a bad rep, but in pregnancy, lots of women say that that's the best time they've ever felt. And actually, in pregnancy, both estrogen and progesterone are pretty high and very stable. It can be so different for each woman and at different times of their lives as well.

Dr Lee David 11:16

So let's think about premenstrual syndrome to start with. What is it and how might someone recognise? We've talked about the fact that it's very normal to have psychical changes in mood, but premenstrual syndrome is a step beyond that, isn't it? It has more of an impact. Yes.

Dr Sally Doust 11:33

So premenstrual syndrome describes a wide range of symptoms or a cluster of symptoms, both physical and mental. And PMS is where women feel that it's impacting on their day-to-day life during their premenstrual phase. So these symptoms occur during premenstrual phase and they disappear by the end of period bleeding. So they may start to lift maybe by day one or two of bleeding. So the cyclical nature of them is really key here. And actually, 95% of women get some sort of symptoms during premenstrual phase. And there's a whole range of them. So it could be low mood, anxiety, irritability, mood swings. So it's all of those mood fluctuations. It could be sleep disturbance, is a big one, and fatigue, just feeling like your stamina is not good. You maybe feel more achy. Other physical symptoms can be breast tenderness, bloating, headaches, and also women will notice changes in libido, changes in sex drive.

Dr Lee David 12:36

And do you find that some women have more physical side and some have more emotional? Or is it just across the board that people can have a mix?

Dr Sally Doust 12:44

Yes. I think that most people have a mix. And when women come to me concerned about hormonal symptoms, it will tend to be the psychological ones that really have the most burden for them. As women, we maybe are used to dealing with pain, with menstrual cramps, and we shouldn't put up with severe pain if we get it during our period. A lot of women will say, I can deal with those, but it's the anxiety, it's the overwhelm, it's the lowness that is really getting to me.

Dr Lee David 13:11

And so there it really highlights the importance of emotional well-being and how to support women to maximize mental health. It's about how do we adapt to our changing hormones and support ourselves in the context of our unique body. We talked about all the different influences which range from our genetics to challenging experiences like trauma experiences, cortisol response, our serotonin levels. There's so much at play. And so we need to find a way to support women to find ways that actually really proactively look after themselves.

Dr Sally Doust 13:43

Yeah, absolutely. The psychological well-being aspect of your cycle, it influences decisions across the board. I've had women describe changes in their relationship or they've changed their job because of how they have felt hormonally. Our hormones are not separate from us. We live our lives in the context of our hormones and it literally shapes women's lives.

Dr Lee David 14:06

So, how would listeners begin to distinguish PMS from stress or anxiety? Because it sounds like there's quite a bit of crossover, but then it is a very distinct issue, isn't it? So, how would we begin to pick that apart?

Dr Sally Doust 14:22

So timing is the most key bit here. So there is always a symptom-free time of the cycle. If it's PMS purely, you will always have a time of your cycle where you feel your normal self, you feel pretty well, and you're free of symptoms. And that may only just be for a week or so. For most women, luckily, they might generally feel okay for most of their cycle and just have a few days of PMS. But for some women, they are having symptoms through their period, and then they have a week where they feel all right where estrogen's high, and then they ovulate, and then the estrogen goes down again, and then they start to feel bad again. So it can vary. But there's always a week where you're symptom-free. Whereas let's take anxiety or depression or low mood, these, of course, can have exactly the same symptoms, so much overlap, but these are present throughout the month, throughout the cycle, or happening randomly at any time. So there's clearly a psychological process going on that's separate from that hormonal cycle. And actually, women can have both. Actually, having an underlying mental health condition can increase the risk of having more severe PMS or your mental health condition flaring up at those cyclical times. We know that women with ADHD, for example, will feel that their ADHD symptoms actually get worse in premenstrual phase.

Dr Lee David 15:42

Yeah, so sometimes it might be a question of has it ever been cyclical? Because maybe there's also a flare-up at the moment of anxiety or depression. And so at the moment I'm getting it all month, but six months ago it was very clearly cyclical. And actually, it's quite important to be able to ask or to think about has it ever been really cyclical so that we can understand are there different components? Is PMS playing a role? Um, and it might be that we need to address both the PMS and the depression or the anxiety kind of hand in hand.

Dr Sally Doust 16:12

Yes, absolutely. I feel in medicine we get tempted quite quite a lot to be black and white about things. Oh, it's depression or it's menopause. No, it's not menopause or whatever. We want to categorize things, we want to make sense of them, of course. But in reality, both both things may be happening and there may be a lot of overlap. So treating somebody holistically is absolutely core to what I would do to work on all of those aspects.

Dr Lee David 16:42

This is the choice pause, a short tool you'll hear in every episode, drawn from my books and therapy practice. Each time it offers a different way to pause, notice, and choose your next step. Today we have a pause for changing mood and energy. Take a slow breath in and a longer breath out. Let your shoulders soften, unclench your jaw, allow your hands to rest. Across the month, many people notice changes in their mood, energy, or emotional sensitivity. Patience might feel shorter. Emotions may feel closer to the surface. Things that normally feel manageable may suddenly take more effort. When this happens, it's easy to question yourself, wondering why today feels harder than it did a few days earlier. Instead of being hard on yourself, see if you can pause for a moment, take another slow breath and allow your attention to widen slightly. Notice your feet on the floor, the support beneath you, the steady rhythm of your breathing, and quietly acknowledge my energy and mood can change. I can meet myself with kindness and understanding right now. And from here, gently ask yourself what would be most supportive for me in this moment? Maybe it's lowering expectations for a while, taking a short pause before responding to a request, getting some fresh air or moving your body, or giving yourself permission to rest and look after yourself. Take one final slow breath and carry the reminder with you that when energy and mood shift, you can pause, check in, and choose your next step with a little more understanding. What point do you think that the symptoms are significant enough that someone might want to seek additional support? Maybe they might go and see their GP and have a bit more input or discussion about potential PMS symptoms.

Dr Sally Doust 18:59

I think this is very individual because it's really about is this something that's impacting on your life? And looking back at other cycles and going, yes, actually, do you know what? Every single month, this has been something that I've been really struggling with, managing day-to-day. Relationships can be impacted or work can be impacted. If you feel overwhelmed each month when PMS is happening, that is absolutely a valid reason to go and speak to a doctor. I find that a lot of women, they feel that they should struggle on or wait till it gets really bad or something until they get help. But you know, if it's impacting on your life and your well-being and you're struggling, there's loads of options to either support your natural hormones or to use hormone treatments to relieve symptoms. And also, I suppose perhaps women may not recognise physical symptoms as easily. We mentioned that with PMS that you can get physical symptoms and that conditions can worsen during that time. So you might get migraine during premenstrual phase or joint pains that actually get diagnosed as something else, or gut symptoms that get put down as IBS. So if you have physical symptoms that have a clear cyclical pattern, that could be PMS too, and it's worth speaking to a doctor about whether hormones are at play here.

Dr Lee David 20:13

Do you think there's value in tracking those symptoms if you suspect that there may be a pre-menstrual component, that there may be a cyclical component, so that there's a bit more data or evidence around the patterns. What's your advice about that?

Dr Sally Doust 20:30

Yes, in general, super helpful because all you're doing there is furthering your own knowledge and, as you said, gathering data, which is so helpful. But I suppose sometimes I hear that women are told to go away for three months and complete a diary. And this can delay diagnosis and leave women without treatment. So especially if their symptoms are severe, this could be really important and it can feel quite dismissive. So if you feel awful and you already know that there's a clear cyclical pattern, then a doctor should be able to gather a clear history from you and ask careful questions to make sure that you are dealing with something cyclical, in which case that might be clear already. But yes, for your own purposes, tracking your symptoms can be really, really helpful. It's really empowering to know what happens at different points in your cycle. I'm sure all of us have had like a terrible week. And then at the end of the week, the penny drops and we go, oh, that's because I'm due on my period, of course. And then you realize. So I guess by tracking, when you feel bad, you can identify what it is. You can anticipate and perhaps adjust your schedule to be kinder to yourself during that time. You can understand that it's not that you're falling apart or not coping or you're not trying hard enough somehow, you can recognize that it's it's your hormone so absolutely valuable.

Dr Lee David 21:49

I think that's really, really important actually is that self recognition of I find that with so many areas of life is that if we're able to understand what's happening to us, if we're able to give it a name and recognise and and create some patterns and create a sense of familiarity even with parts that we'd perhaps prefer not to have but if we can know well that is my pattern and it will pass and it isn't great when it's here but actually yes as you say if I adjust my schedule and I can do this and it might help me. I won't push myself so hard I won't go out as much in the evening maybe I'll do something more gentle and wind down then maybe it just gives us a bit more control and a bit more power to look after ourselves and I think it also takes the kind of anxiety away of what's happening? Like you said that sense of oh does this mean something really bad about me when actually it's like oh no no this is just something and it will pass in its own time.

Dr Sally Doust 22:45

Yes, yeah. As women I think we second guess ourselves so much and we overthink so much and we we have a tendency to be hard on ourselves and yes think that it's something that we've done and I think it can be massively validating to realise that your hormones are having such a profound impact on how you're functioning and how you're feeling day to day and trusting trusting that and not feeling like it's on your shoulders to somehow be better a better person.

Dr Lee David 23:14

I I love that so much. And I think I I'm such a big advocate for the idea of self-compassion and so whenever I see an opportunity to bring it into an episode I I love to do that. And it feels like this is a really great opportunity just to think about the importance of being kinder to ourselves being compassionate and that sort of hand on the heart moment saying this is a tough part of the month for me and how do I look after myself to navigate it as effectively as I can and that doesn't take away seeking support seeking treatment that's that's all absolutely valid as well but as we do it it's doing it without a self-critical tone it's doing it without being harsh to ourselves because I I think often we have this voice in the back of our head saying why is this affecting you so much and there's a kind of blame that can come with it I think that I see in a lot of women and I wonder if that's something that you've observed at all, Sally Definitely I do think there's a stigma around hormones in general and that applies to both women and men.

Dr Sally Doust 24:14

I think even the language around it she's so hormonal or oh it's that time of the month you know as if we're somehow unhinged during that time and and somehow that that is a weakness. And I think that hormones can be the way we live with our female cycles can be a massive strength. A lot of women when we talk about treatments don't want to mask their cycle or stop their cycle say with contraceptives. They want to experience their cycle they feel it's an important part of being a woman and having times of hormonal flux can actually like pre-menstrual phase can actually shed a light on things. It can be a sort of truth teller and you can have these moments of insight because you're heightened and sensitive to what's happening and of course that's sometimes something that can be a real struggle but can also be something that shines a light on perhaps something really important that you need support on or you need to talk to somebody about.

Dr Lee David 25:09

And I think that's really empowering and very important message for people to to hear. Let's move on to think about premenstrual dysphoric disorder because I think that's not very well recognised quite often but yet it's really quite impactful for for the women who experience it. It can have some really severe symptoms and really disrupt people's lives. Can you tell us a bit more about that?

Dr Sally Doust 25:35

Absolutely yes so PMD is premenstrual dysphoric disorder as you said and dysphoric dysphoria means severely affected mood so severely affected mood during premenstrual phase and the word disorder I suppose implies something that is really severe and causing a clinical level condition. So you can feel mentally unwell during this time it's a termed actually as a psychiatric condition in diagnostic manuals. So what can happen is during premenstrual phase, during luteal phase mood can be really marked in how it changes really severe mood swings, totally unpredictable mood, very severe sensitivity to say rejection, very tearful severe anxiety debilitating depression to the point of feeling hopeless. Some women even experience suicidal thoughts and extremely low self-esteem. And there can be some physical symptoms like fatigue and pain but this dysphoria this severe mood change is the key with PMDD and women tell me that they just feel totally out of control and totally overwhelmed. They feel like a different person during premenstrual phase and then it all lifts and you suddenly can see more clearly again you feel a bit more like yourself again. So that's how it's really different from PMS. Of course as I said 95% of us get some premenstrual symptoms. It might be worse some cycles it might be better at others that's normal and PMS can be quite severe and disruptive but PMDD is highly debilitating and it usually needs very strong treatment and support in order to help women live with PMDD.

Dr Lee David 27:18

So there's this real continuum from people who may have some symptoms right up to people with PMDD who have extremely severe symptoms and I'm guessing we'll be likely to need some specialist input if it's severe enough to be causing suicidal thoughts and that crashing low self-esteem that really feels like a group who need a lot of good quality support and recognition. I don't know if that's always the case. Do you think the cyclical nature is also important here? We've talked a bit about that in the context of PMS because it feels to me like there's a risk it could be perceived as non-hormone related condition potentially and I think there is some evidence that it can be diagnosed as as a range of other mental health conditions as well can't it?

Dr Sally Doust 28:03

Yes. In fact most women that I meet who have a diagnosis of PMDD have previously been diagnosed with anxiety or depression perhaps EUPD which is emotionally unstable personality disorder and it's possible that they have those conditions as well but I do meet a lot of women who are misdiagnosed because the cyclical nature of it has not been recognised. So absolutely with PMDD like with PMS the key here is the cyclical nature of it worsening in premenstrual phase and then feeling hopefully mostly a normal self at least some point during your earlier part of your cycle. But yes women get given antidepressants quite often when they actually have PMD and that a focus on hormonal treatment may be much more beneficial for them.

Dr Lee David 28:51

I know when we talked before you told me about somebody who really felt emotional when you recognized and when you named PMD how important is it for women who are experiencing that for it to feel recognized and to be able to get some understanding about what's happening for them?

Dr Sally Doust 29:10

Life-changingly important because they may have gone through a lot of their lives feeling that they've not managed somehow, blaming themselves for how they feel a lot of women feel very guilty about how they've been during their premenstrual phase. They might have had difficulty relating to their partner or shouted at their kids or even broken up from relationships during that time. They may even have had suicidal thoughts unfortunately PMDD is actually associated with suicide risks. So some estimates are that a third of people with PMDD have attempted suicide. It's so impactful and they might have gone through their lives not realizing what PMDD is. I speak to a lot of women who've only just recently heard of PMDD and come forward to consider a diagnosis. Or yes, who have been told that they have depression or anxiety or just feel that there's something wrong with them somehow that they've not managed to function in their life how they should have done been very harsh on themselves. So it's so pivotal and life changing to receive a diagnosis of PMDD. And one of my patients cried when she heard that doctors had been discussing PMDD at a women's health conference because it meant so much to her to know that doctors were recognizing it.

Dr Lee David 30:24

So having this conversation is really important isn't it it's about raising awareness and just normalizing the fact that this is something real. It doesn't affect everybody but for those it does affect it has this enormous impact and it's something that's really important to be recognised and maybe we know somebody maybe it's us maybe it's a friend or a relative or who may recognise that and we're going to come a little bit to what people can do to look after themselves but my feeling is with PMDD it's not trying to do it on our own right it it feels like that will be an occasion when really it's about going to seek the support but maybe also feeling empowered to give the the story in such a way to describe it in a way that makes it easier perhaps for the clinician if they're not as familiar with PMDD to be able to recognise it and then respond appropriately might also be helpful.

Dr Sally Doust 31:16

Absolutely yes knowledge is power isn't it if you if you're familiar with the symptoms of PMDD and you have looked at your cycle and identified clear cyclical changes then you can advocate for yourself and ask about whether this may be the diagnosis and make sure that you get a careful assessment.

Dr Lee David 31:35

So if we think about PMS and perhaps also people who might not have a diagnosis but who have premenstrual changes that are troublesome. This is the Choice Base podcast we love to think about things people can do that care for themselves. And so what kind of choices do people have that might be supportive in the context of premenstrual changing symptoms?

Dr Sally Doust 31:58

Yes so starting with what we could do in our own lives there are lots of things in our lives that will shape how our hormones function on any given month. So for example high sugar consumption is associated with worsening PMS. They also worsen the cravings and appetite kind of swings that happen premenstrually as well. So one easy change is to consider basing meals around protein and fibre and reducing sugar. This is a dietary approach and can make a key difference with hormones. There's a lot of information out there on social media about cycle sinking and eating certain foods for certain points in your cycle this is not evidence based and there's no need to try and follow very specific diets for specific foods at different points in your cycle. So I have found the work of Emma Bardwell particularly useful. So she advocates for 30 grams of protein per meal and 30 grams of fibre per day and 30 plants a week. So quite easy to remember 303030 and is a really good achievable basis for a healthy diet that can support hormonal health and is just generally great for health and a good strategy for weight management as well. It sounds like something that would be quite good for the microbiome and just general health in lots of ways as well absolutely yes there's no need to exclude specific foods or or follow anything that feels very strict. Alcohol unfortunately is also well known to worsen premenstrual symptoms. So of course we might understandably like turn to a glass of wine after a stressful day but alcohol is actually a depressant meaning it lowers mood particularly the next day and increases these blood sugar swings as well and drinking a lot more even like drinking a lot more in the first half of the cycle can actually directly worsen the second half of the cycle probably because of the effect that any lifestyle changes have on the regulatory hormones that dictate how we ovulate and how our ovaries function. And I've talked about avoiding a couple of things but there's also kind of positive things you can include more of and supplements and vitamins that you may want to consider. And in clinic I tend to use the PMS guidelines that were created by Dr. Nick Panay. They're available from pms.org.uk the PMS guidelines mention a few vitamins and minerals and herbal treatments. So some women find that there's a herbal remedy called Agnes castis that can noticeably reduce PMS symptoms. Herbal treatments often have smaller trials than pharmaceutical drugs, but there is some evidence that exists that it's quite helpful. It seems to lower prolactin which is involved in stress which is quite interesting and supports progesterone and sort of slightly lengthens the menstrual cycle. So it's gentle and it does create a noticeable improvement in PMS for some women. It just feels like thinking about these things is really important and that it's not all or nothing that we can do little bits across a number of these areas do you find that they add up rather than there's one thing that's going to fix the problem absolutely yes there's no one thing that's going to fix PMS because we're experiencing hormones influx as we talked about different hormones interacting with each other and interacting with our lives our brains our day-to-day our sleep our diet our physical exercise so yeah absolutely it's having multiple tools in a toolbox to promote hormonal balance and also all of these things also promote general health as well.

Dr Lee David 35:29

So could you give us a bit of an overview about some of the medical treatments and approaches that might be supportive around PMS that somebody might be offered if they did go to see their GP.

Dr Sally Doust 35:43

Absolutely yes the main thing here is I want women to fill in control. How we manage PMS or PMDD is really about whether somebody would like to control their cycle or not. And this is really personal to each woman. I mentioned that some women really like to have their natural regular cycle and that feels really important. Some women really need the relief of getting rid of that hormone roller coaster every month so that they can live with more clarity and more steadiness. So lots of women talk about being put on the pill so I I really want women to be able to feel that they've made a shared decision with their doctor and know why they're doing that. So first of all thinking about hormones that would override the cycle or control the cycle so contraceptives work by stopping ovulation and if you don't have ovulation then you won't have the big ups and downs of progesterone and estrogen in premenstrual phase that can be really difficult to deal with. HRT works by providing higher and steadier levels of estrogen and progesterone over the top of your natural cycle so your mood is steadied out. So we might use HRT if somebody's perimenopausal or actually for PMDD of women at any age we can use HRT as one of the treatment options. There's also a role for antidepressants. So we're not talking about like labeling this anxiety or depression and like I said before many women maybe have been given antidepressants without recognizing the key hormonal element to it here. But in PMS or PMDD we can use antidepressants in a more targeted way so often at a low dose and just in luteal phase. And that way women can kind of have control over when they take them and how they take them and they feel better that maybe they're not using them all the time just when they need to when they're feeling bad.

Dr Lee David 37:29

And that's really good isn't it because we know that prolonged antidepressant treatment can cause challenges and so maybe if you just need it in that one period during the month that feels very positive. And I guess for other women who may have that mix where they've got maybe depression as well as cyclical changes then they may benefit from having longer treatment across the month. So it feels like again there's a little bit of variety there.

Dr Sally Doust 37:56

Absolutely there's different aspects to treatment we could use both we could use a hormonal approach and antidepressants and it's back to that really tailored approach looking personally each woman how they feel with these different treatments and approaching things from all directions.

Dr Lee David 38:10

Yeah I love that. So we've talked a bit about nutrition we've talked a bit about some supplements is there anything about activities maybe exercise or things we can do how we live our lives and how we plan our lives that can also make a difference?

Dr Sally Doust 38:26

Yes I think that it's about recognizing the role that the hormones play but then what do we do with that? We can react each month and feel overwhelmed or we can take it and use it to shape what we're doing. So I guess in Buddhism there's this idea of the second arrow of suffering which is that the first arrow is the unavoidable thing that happens. We can't stop the grief of losing somebody or a health problem happening to us or our hormones changing. We can't stop that. But the second arrow we can make a difference to the second arrow that hits us that really hits us is how we react in the pain that happens as a result. So it could be low self-esteem I talked about women feeling guilty about feeling bad about themselves when they found it hard to cope the anxiety of what the next cycle will bring or how we exist in society this derogatory thinking about hormones and the stigma. So that's really the second arrow of the pain that comes in and that's where we can change things. That's where we can adjust our alcohol or our sugar intake. That's where we can recognize that physical activity does make a big difference. It raises endorphins it increases our confidence I find that strength training for a lot of women massively increases their confidence and their self-esteem so there are things that we can do to change our response to what's happening with our hormones.

Dr Lee David 39:47

Yeah and I think there is some evidence that psychological therapies can help with mood symptoms. We have these very real hormonal shifts in our body and how our body responds to those and then we have how we respond to that and we can do that in helpful ways. We can end up attacking ourselves we've talked a little bit about self-critical patterns and being quite hard on ourselves and maybe feeling guilt and lots of negative feelings and so I'm just I'm wondering if when you're feeling low to make sure we don't get too isolated to keep connected with people who matter to us but in ways that feel manageable so that if we are quite irritable then we don't maybe do something that's too overwhelming or too pressurized but we might lean into well I'm gonna meet a friend for coffee or I'm gonna snuggle on the sofa and watch a movie with somebody where we don't have to talk too much but it still feels like we're together. And I'm just wondering if it does make a difference do you think to lean into positive actions that mean that we're better equipped to cope with the real physical changes that we're experiencing.

Dr Sally Doust 40:50

Absolutely it's the recognition it's the recognition that's so therapeutic tracking your cycle so that you recognise that and can anticipate that telling others so involving others in your life like you said about the therapeutic effect of seeing a friend or saying to your partner no tonight I just need a cuddle I don't need solutions. I don't need you to tell me anything else I just need a cuddle please and so the awareness of others around us about what's happening to our hormones is is so helpful.

Dr Lee David 41:17

So knowledge is power isn't it it's it's having that awareness but I would just add compassionate awareness like kindly awareness and also that question of what do I need? What can I do that would look after myself with this awareness? How can I use this awareness to support myself going forwards? And I think that's a really important part of it. Thank you. It's been so interesting today Sally just to finish we always do a choice space takeaway so for someone who's noticed some pre-menstrual changes might be one practical step that they could try this week something fairly quick and straightforward to start with.

Dr Sally Doust 41:52

Absolutely so cycle tracking is my one big step getting to know yourself your mind your body noticing when changes occur that way you can build a deeper understanding that we've talked about and you can build that toolbox of all the different strategies and you can take your wellbeing into your own hands. So this week if you know that you're in premenstrual phase cancel that thing in your diary that's going to cause you to feel stressed and and or move it move it to somewhere else and share it with your partner and your family so they understand where you're at. And then also with tracking cycle you can go to a health professional with clear information to help guide what treatment you need because knowledge is power and the recognition is so therapeutic. It's life changing to get the recognition that they need.

Dr Lee David 42:37

It is so I'm just going to add because I love this that you've shared with us today the 303030 it's a very broad thing that I can see there'll be so many benefits. So can you just remind us Sally what those 30 things are?

Dr Sally Doust 42:50

So 30 grams of protein per meal 30 grams of fibre per day and 30 plants a week. Amazing thank you so much.

Dr Lee David 42:59

Thanks for listening to the Choice Space podcast. I hope this conversation has offered a little room to pause and choose your next step. We've linked the ways that you can connect with Sally in the show notes as well as the PMS guidelines. If this episode has been helpful please download and share with someone else who might value the conversation as well. And if you have a moment please consider leaving a rating or a review on whatever platform you're listening on. It really does make a difference to help people find us. This episode was edited by Elle Dixon