Some women respond adversely to hormone fluctuations by developing symptoms of anxiety or depression. These mood change symptoms can be arranged into two categories — one consisting of symptoms relating primarily to anxiety or heightened (negative) affect; the other to the more classical depressive symptoms, when withdrawal and fatigue predominate. Most women will not fit neatly into one category or the other, and a certain amount of overlap can be expected in symptom reporting and in the menstrual symptom questionnaire. The grouping of symptoms establishes an overall impression of either anxiety or depression so that treatment can be directed at the relevant presentation.
Increasing levels of oestrogen in the luteal phase are thought to inhibit the deactivation of noradrenaline and influence serotonergic pathways, thus contributing to symptoms of heightened mood such as aggression, irritability and anxiety (category A). Treatment for this group concentrates on moderating the effects of increasing oestrogen levels by encouraging improved entero-hepatic recycling and improving progesterone levels.
Women who are peri-menopausal often experience more category B depressive symptoms, which might be triggered when low levels of oestrogen adversely influence serotonin. Those women who report having premenstrual mood changes at any time during their life are more likely to present with similar symptoms at the time of the menopause. Depression and withdrawal can also occur if oestrogen levels are inadequate when a woman has diminished ovarian reserve, is breastfeeding, over-exercising or underweight (see ‘Too little oestrogen’).
Another group who also experience category B symptoms are those women who are generally depleted and who are described by natural therapists as suffering from adrenal exhaustion. The treatment for premenstrual syndrome in conjunction with either low oestrogen or adrenal exhaustion is outlined in the section below on ‘PMS with depletion’.
Premenstrual Syndrome With Mood Changes: Symptoms
• Nervous tension
• Irritability and angry outbursts
• Increased sense of vulnerability
• Social withdrawal
• Lack of interest in daily life
• Waking through night
Premenstrual Syndrome With Mood Changes: Treatment
Hormone modulation will need to either reduce adverse effects of increasing oestrogen, address problems associated with declining oestrogen or rectify adrenal exhaustion. This should be combined with:
• Dietary changes to increase the serotonin precursor tryptophan, such as increased frequency of smaller volumes of food; no sugar or refined carbohydrates; regular protein intake at each meal with increased consumption of fish, legumes, egg, lean meat and/or low-fat yoghurt.
• Reduced intake of caffeinated drinks and alcohol.
• Herbal anxiolytics may be indicated for the increase in anxiety and/or irritability. These herbs are usually commenced in the luteal phase of the cycle, just prior to the expected onset of symptoms and include: Lavandula officinalis, Valeriana officinalis, Scutellaria laterifolia or Eschscholzia California for anxiety.
• Witbania somnifera for anxiety with exhaustion.
• Anemone pulsatilla tincture for tension headache with nervousness, especially when combined with Passiflora incarnata.
• Betonica officinalis is used for headache and anxiety states, especially in combination with Scutellaria laterifolia.
• Hypericum perforatum may be indicated in category B symptoms but, unlike anti-depressant drugs which are often used during the luteal phase of the cycle only, Hypericum should be taken all month for best results.
• Psychotherapy and counselling have been shown to improve mild to moderate depression and anxiety as effectively as anti-depressants. Various types of counselling and psychotherapy techniques are theoretically useful for women with premenstrual syndrome (PMS), although there have been few suitable studies to evaluate these techniques. One study looked at the effectiveness of cognitive behavioural therapy in premenstrual syndrome and found that it was useful in improving symptoms.