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Premenstrual Dysphoric Disorder (PMDD) and Integrative Mental Health by Les Cole, MD & Delene Cole, LMFT

How do you know if you have PMDD? Is it the same as PMS, just worse?

Premenstrual Dysphoric Disorder (PMDD) affects approximately 5% to 8% of cycling (pre-menopausal) women. Amazingly, there are still many medical practitioners that don’t believe PMDD is a real condition. If you have PMDD, it must feel crazy making to hear someone say they don’t believe it exists. We recommend you walk away from that person and seek help from someone who understands your suffering and frustration, how to diagnose PMDD and separate it from Premenstrual Syndroma (PMS), and how to treat it!

 

If you have PMDD and sought help, you may have wound up in the Psychiatrist’s, Psychologist’s or Therapist’s office as either your first stop or through referral. You may have been told that you are depressed, are bipolar or have a mental health problem. Your primary care practitioner may have even given you one of these diagnoses. This is not true, even though these may be your symptoms or behavior. In these circumstances, it is likely you have been treated with anti-depressants, anti-anxiety or other psychiatric medications and found inadequate benefit because PMDD is not a Psychiatric disorder. Even most practitioners who believe in PMDD are likely to treat you with these medications with the same inadequate results, because they do not understand the cause of PMDD.

 

If you have severe “Psychological” (Emotional) symptoms such as

  • Depression
  • Anxiety
  • Irritability
  • Feeling overwhelmed or out of control
  • Mood Swings
  • Sensitivity to rejection
  • Social withdrawal
  • Sudden sadness or tearfulness
  • Seizure disorder
  • Panic attacks
  • Agoraphobia
  • Eating disorders
  • Various personality disorders
  • Bipolar disorder
  • Obsessive Compulsive disorder

that are only present or significantly worse during the 2nd half of your cycle – whether you have any or no physical symptoms – then you likely have PMDD. These symptoms most often last the entire or majority 2 weeks of the 2nd half of your cycle (following ovulation).  Because of the cyclic nature of PMDD – it may especially be mistaken for bipolar disease unless the physician or therapist specifically asks you if your symptoms are related to your cycle. The symptoms tend to be severe, overwhelming and disabling.

 

Most practitioners, who acknowledge the existence of PMDD, believe this to be the same process as PMS, just worse – like “PMS2″ or “PMS on steroids”. It is not the same condition. It is a different condition altogether and requires a completely different treatment. Since PMDD is not PMS (the hormone imbalance of Estrogen Dominance) balancing Estrogen and Progesterone won’t help here. If you have PMDD and someone puts you on Progesterone your symptoms won’t improve and may actually worsen. Also, most Ob-Gyns will prescribe birth control pills (BCPs), however, there is only one BCP indicated for treatment of PMDD but often is of little use and some birth control pills, shots, creams and patches may actually make things worse. Please See PMS for a better understanding of this condition and treatment.

 

For most women, symptoms are so disabling that they cannot function. School, work, relationships, home and personal care may be impossible to manage. All to often, symptoms are so severe and hope for relief so devastated, they choose total hysterectomy or even suicide. There is a profound hopelessness associated with this condition because there appear to be so few answers.

 

There is good news, however. Now PMDD can be treated easily and successfully. This is done by regulating the neurohormone – GABA receptor imbalance that contributes to it. Yes, the cause of PPMD is now understood. It is caused by a genetic mutation in your GABA receptors making them react abnormally to the neurohormone allopregnanolone. Allopregnanolone normally helps keep you calm, cool & collected, but in PMDD it has the opposite reaction – depression, anxiety, irritability, anger, confusion, inability to think clearly and cope – due to your GABA receptor mutation.

 

Allopregnanolone comes from progesterone, which is produced during the last 2 weeks of your cycle. This is why your symptoms are so pronounced during that time. If you were given progesterone during that time, your allopregnanolone levels would increase and your symptoms would worsen or simply not change. This is why BCPs and treating PMDD like PMS doesn’t work. So, we could reduce your progesterone to reduce your allopregnanolone, but we also don’t want to reduce your progesterone because that would cause infertility, cycle irregularity (length), and cause the physical symptoms of PMS – bloating, heavy periods, cramping, breast tenderness, etc. (Estrogen Dominance). We can’t change the GABA genetic defect because that is hardwired into your DNA (genetic mutations are for life). So, that leaves us with lowering your allopregnanolone and that can easily be done without affecting your progesterone.

 

So how do we treat PMDD?

With 5-alpha-reductase blockers (1). They block the conversion of progesterone to allopregnanolone thus decreasing your allopregnanolone and its negative effects on your abnormal GABA receptors and greatly decreasing your symptoms. Finasteride is the 5-alpha-reductase blocker most appropriate for treatment of your PMDD.

 

(1) Martinez PE, et al, “5α-Reductase Inhibition Prevents the Luteal Phase Increase in Plasma Allopregnanolone Levels and Mitigates Symptoms in Women with Premenstrual Dysphoric Disorder.”  Neuropsychopharmacology. 2016 Mar;41(4):1093-102. doi: 10.1038/npp.2015.246. Epub 2013 Aug 14.

 

Finasteride has been around for a long time and has been used to treat male baldness and benign prostatic hypertrophy. It does this in men by blocking the same enzyme 5-alpha-reductase  conversion of testosterone to dihydrotestosterone. It has also been used in women to treat female baldness by lowering women’s conversion of testosterone to dihydrotestosterone.

 

The PMDD study (1) used Dutasteride as the 5-alpha-reductase blocker showing good results, however its half-life in the body is 5 weeks meaning it takes 5 weeks for half the dose to leave your body, leaving 50% the original dose in your body at 5 weeks. An additional 5 weeks would leave you with 1/4th  the original dose in your body. Another 5 weeks would leave you with 1/8th and so on.

 

Finasteride, on the other hand, has a half life of 6 hours, meaning that it is completely gone from your body in less than a week! This is important because 5-alpha-reductase blockers will also block the conversion of testosterone to dihydrotestosterone in a male fetus. That conversion begins at 7 weeks pregnancy and is important for forming your male fetus’ male genitalia, so if you are taking Finasteride for your PMDD, we want it completely out of your system by then. At St. Petersburg Health & Wellness we ensure this is the case with our treatment protocol.

 

Here’s how it works.

We have you use birth control to prevent pregnancy. We prescribe a 1 month supply of Finasteride with no refills. Each month you will perform a pregnancy test. If it is negative, we will give another months prescription. If you should have a positive pregnancy test, you would at that point be between 2-3 weeks pregnant and off your Finasteride. The Finasteride in your body would be cleared completely by the next week (since it has a 6 hour half-life) giving you a full 3 weeks of safety before your male fetus would begin converting his testosterone to dihydrotestosterone.

 

If you have symptoms associated with your cycle, call St. Petersburg Health & Wellness – 727-644-9639 – and make an appointment. We can Help! Also, read the section on PMS to help you understand the difference. At times it is difficult to tell the difference between the two because the symptoms overlap and sometimes you can have both PMS & PMDD because they are due to 2 different causes. At. St. Petersburg Health & Wellness, we can sort this out through a careful history and appropriate specialized hormonal testing.

 

Les Cole, MD practices Functional, Anti-Aging, Integrative & Preventive Medicine and is certified by the American Academy of Anti-Aging Medicine in Functional, Anti-aging and Regenerative Medicine and by the American Board of Integrative and Holistic Medicine. Delene Cole, LMFT is a Marriage and Family & Integrative Mental Health Therapist with additional certifications in Hypnosis, Internal Family systems Therapy and Soul Collage. To learn more about PMS & PMDD and other topics to improve your Health and Wellness, visit stpetehw.com, Like us on Facebook, or call St. Petersburg Health & Wellness for an appointment 727-202-6807.