A case in learning more about PMDD

As a naturopathic doctor, I treat various kinds of female hormone conditions ranging from dysmenorrhea, polycystic ovarian syndrome to menopause-related concerns.  

I have treated many cases of PMS (premenstrual syndrome) as part of one’s health concerns; however, this patient’s case demonstrated to me that sometimes female hormone imbalance can be difficult to detect and also challenging to treat.  I’d like to present to you the case of  34 year old “Rachel”.

Rachel first presented to my office complaining of digestive issues, including gas, bloating, constipation and reflux. Starting her on a modified diet, I prescribed her digestive bitter herbal formulas that helped resolve her long-standing GI complains.

Then two years ago, Rachel started to complain of sporadic mild anxiety, palpitations and mood changes. Originally, these were attributed to a high stress job.  She  attended counselling and started a meditation and yoga regime, which helped reduce the intensity of her symptoms.  After a few months, these symptoms became more intense and lasted longer in duration.  Over the period of 6 months, Rachel’s anxiety became extreme at which time, she noticed that this occurred clearly and consistently after ovulation and then peaking in intensity in the days pre-menstruation.  After menses would start, her anxiety & palpitations would subside and often resolve until the following month around mid-cycle.  At the time, she felt that her symptoms were manageable and didn’t feel that she required any treatment.  

After a few months, Rachel began to  experience sleep onset insomnia concurrently with her anxiety & palpitations. This began  around ovulation lasting until the onstart of menses.  She’d feel physically tired but unable to fall asleep because her brain was fully alert.  I recommended many supplements for her which unfortunately, were ineffective in addressing her issues. These supplements included high dose Magnesium glycinate, L-Theanine, GABA (amino acid), Melatonin, “Cortisol Manager” (a formula to reduce nighttime overexcitation), chaste tree herbal tincture.  

Rachel contacted me several months ago to report that she heard about a condition called “pre-menstrual dysphoric disorder” and believes that she met most of criteria for this diagnosis.  PMDD is considered a more severe type of PMS. Symptoms are as follows: anxiety, emotional sensitivity, sadness and insomnia during the premenstrual phase of the menstrual cycle.  This condition is conventionally treated with either anti-depressant medications or birth control pills. This patient is currently waiting to see a specialist for this condition.  

In this case, Rachel’s continuous search led her to finding this possible diagnosis.  I believe this condition is associated with a suboptimal production of endogenous progesterone, resulting in over stimulation of the nervous system,  secondary anxiety and insomnia.  What makes this working theory challenging to treat is related to age. Because Rachel is 34 years old, the possibility of low progesterone level is unlikely if viewed through the conventional perspective based on the diagnostic guidelines.  Having said that, a growing number of young women experience hormonal imbalance starting in their 20’s associated with deficiency of progesterone, relative to estrogen.  Conventional doctors will probably prescribe her birth control pills to suppress her hormone levels throughout the month in order to prevent fluctuating hormone levels.  This will likely not be an effective long-term strategy.  

My suggestion to this patient was to measure her progesterone level in the luteal phase and consider low dose progesterone replacement therapy should her levels be low.  Currently, this  therapy is put on hold while the patient is waiting to see a hormone specialist.