Session 5 PMS - Menopause Swings 5 PMS.pdf · Session 5 ‐ Living with Hormone swings ‐ 1 PMS...

Session 5 ‐ Living with Hormone swings ‐ 1 PMS

Welcome

Introductions If Appropriate

Name stickers and felt pens “ “

Icebreaker “ “

Groundrules and confidentiality

Time 10 ‐ 20 mins depending if new or on‐going group

Refreshments – at start or half way through

Aims of the session To understand how monthly hormone swings can affect us physically, emotionally and in our mental performance.

To learn how to reduce the effect of our symptoms by self‐help measures ‐ and the medical or complementary therapy options for treatment that there are.

Introduction to the PMS session We are going to start the session with a brainstorm about what you feel about PMS or PMT.

Activity AFlipchart or A3 pad for feedback

Brainstorm ‐ PMS

• Ask the group – “What comes into your head the moment you hear the initials PMS – or PMT?”Ask them to feed back their answers onto the flipchart ‐ just as they first thought of them – not censoring their first thoughts – even including swearwords if you feel they are acceptable to the group!

• When they have finished, comment about the wide range of symptoms and experiences they will have given you and explain that PMS can affect people in 3 main ways – physically, emotionally and in their mental performance.There will probably be examples of each ‐ if not, ask for an example of the type they have not given. Allow for some discussion as you go along

• Ask if there are any positive words about PMS on the feedback.

• Explain that for some women “PMS time” can be really traumatic ‐ for themand for those around them! It can become a time to dread and fear. PTO

Menopause - what you lose on the swings you gain on the roundabouts!

Dr Althea de Carteret

• If handled differently however, “PMS time” can be used to withdraw from the world for short spaces of time and learn more about how you really tick – and what you need to do in order to enjoy your life more throughout the whole month. Time 30 mins

What is PMS?Read out to group or put into your own words

PMS or Pre‐menstrual syndrome is a collection of unwanted physical and emotional changes occurring in the second half of the menstrual cycle ie. pre‐ menstrual, coming just before the period.

We use the term “syndrome” now instead of PMT or pre‐menstrual tension because PMS includes a lot of changes rather than just an increase in tension.

PMS symptoms vary between women and often vary in the same women in different monthly cycles. This can be very confusing and can delay the diagnosis of PMS.

Symptoms lasting more than two weeks before the period may be the result of coming near to the menopause ie. peri‐menopause (whatever the actual age of the patient) – or may be due to other medical or psychological problems.

PMS and your hormones

Many women experience a change in themselves, both physically and emotionally, each month during the huge swings in blood levels of oestrogen and progesterone hormones – though some women feel no different at all.

It’s accepted that women may feel big emotional as well as physical changes during or just after pregnancy, or around the menopause ‐ when hormone levels are changing quickly. Research has also shown that 10‐20% of women are sensitive to monthly hormone changes, though only 5% have really severe symptoms.

Using the MOOS Menstrual Distress Questionnaire it is apparent that the charts of PMS symptoms in the “sufferer” group follow a similar curve to that of the monthly rise and fall of the hormone progesterone, whereas the control group showed minimal symptoms, which usually occurred over the time of the period itself.

Many PMS specialists accept now that PMS symptoms occur in a situation where the blood levels of progesterone hormone are rising, or are high – at a time of low oestrogen . This is borne out by the common finding in HRT users, that PMS symptoms can be produced for the first time in a patient when the HRT



progestogen is added to the oestrogen, before the oestrogen levels have built up to an effective dose.

Damping down the monthly hormonal swings, by preventing the egg being released, has been shown to relieve symptoms in PMS patients ‐ but no single treatment seems to work for all patients.

Giving a man PMS!

Research in the 70s showed that if you keep a man awake for 48hrs with very little food he would experience all the symptoms of PMS except for the breast tenderness! (Unfortunately I can’t trace this research which I first read in the 70’s and is now lost in the mists of time!)This is a good way to try and explain to people how bad you feel when you are pre‐menstrual, as most people have had some experience of missing a night’s sleep, though not necessarily 48 hours ‐ and they won’t know what it feels like to have this for 2 weeks out of each month!

This finding suggests that you can tackle PMS by working on Stress, Tiredness and Eating patterns – and these Self Help options can make a huge difference to how women feel during their PMS time.

Time 5‐7 mins

Activity BPMS Quiz Worksheets for the groupPMS answers and Self‐help solutions sheetPensFlipchart or A3 pad for feedbackPost‐it notes for Thorns and Roses evaluation

• Ask the group to fill in the quiz sheet – not spending too long on any question if they’re not sure of the answer. It may be good to offer for people to work in 2’s if they want to, so any difficulty with literacy won’t be so obvious ‐ but they are likely to discuss their different viewpoints which might take up a lot of time so you’ll need to keep them focussed.

• When they have finished, go through the answers on the answer sheet with them getting them to volunteer answers before you give the ones on the sheet. The more they get right as a group the higher their confidence will be.

• As you go through each question put the answers on the flipchart if they agree with the answers given.



• Discuss the Self help solutions as you go through the answers getting the women to volunteer things that they have found helpful – and add any they don’t give, from the Solutions on the answer sheet.

• When no more answers are forthcoming read out the self‐help information for each section as you get to it. There is a fair amount of “teaching” in this session as there is very little written information about PMS that combines the physical, emotional and mental performance effects of PMS.

• Watch the time – and take a short break halfway through the session if needed.

Time 1 hourMain points to be learned about PMS

Check that each idea has been dealt with during the activity or session.Read out a selection, in these or your own words, as a way of reminding people of the most important points and rounding off the activity or session. Include any new points the group has made which you know to be relevant and accurate.

• PMS is a real hormonal effect which only affects about 10‐20% women and only 5% severely.

• It must be confined to the 2 weeks before a period ‐ and there must be at least a week free from symptoms before the next period.

• If symptoms last longer that that they may be due to coming near the menopause (whatever your age) or to other physical or psychological problems.

• It can be confirmed by keeping a daily symptom chart for 3 months

• It can affect a) your physical body

b) your mental performance

c) your emotions

• Women do not become crazy irrational beings during PMS time!

You can learn to observe and understand what triggers your bad feelings ‐ and sort things out after the period is finished. If this is difficult, counselling can help you change how you react to trigger situations in your lives.

• The following can help reduce the misery of PMS

Self help changes a) with patterns of eating and drinking

b) with combating tiredness

c) with keeping stress to a minimum



• Women who spend time regularly with other women live longer, healthier, happier and less stressful lives that those who don’t! Making time to spend with our women friends isn’t a luxury ‐ it’s essential to our health and happiness. (See References)

• If none of the self help measures work you could try complementary therapies or ask your GP for advice or for referral to an NHS PMS/Menopause clinic. Take your symptom charts with you when you go to see someone about your PMS as it can save a lot of time and backs up what you are saying about your experience.

Time 2 mins

Other issues that might come up

Difficulties with children or partners

Problems at work

Carers needs

Physical or Mental health problems

Domestic abuse

Coping after losing someone ‐ through death, separation or divorce

Becoming more assertive – knowing what we want – and saying it

Knowing we have a right to a fulfilling life

Learning to organise our time and make the choices we want

Being honest about long term emotional or family problems ‐ and thinking about using counselling to help sort things out if stuck

Other services or agencies that might be relevant ‐ read the list out to the group without contact details so they know what help is available if they ever need it.

If you can’t locate some of these ask for suggestions from the group. Say you can give out details 1‐1 after the session is over. This maintains confidentiality

Local PMS and Menopause clinic

Assertiveness classes

Local counselling services – individual, relationship, alcohol, bereavement,

sexual preference, sexual and relationship etc.

Leisure Centres ‐ for exercise classes, T’ai Chi, Yoga, and ? relaxation sessions

List of Helplines for Carers, Domestic Abuse, CAB, ‐ or whatever may have special

relevance to your group



Adult Education Centres

Local Complementary Therapy Centres

Women’s Massage practitioners

Time 2 mins

Handouts PMS leaflet “Sorting things out” 7 pages

Symptom charts

Thorns and Roses evaluationSee Running successful Group Time 2 mins

Time for short 1-1 discussions



Session 5 PMS Quiz

1) What time of ‘the month’ (menstrual cycle) does PMS occur? – and how can you know if you really have PMS?

2) In what ways can PMS affect you?

a) your physical body?

b) your mental performance at work or at home?

c) your emotions?

3) Bearing in mind the research in the 70s that showed that if you keep a man awake for 48hrs with very little food he would experience all the symptoms of PMS (except breast tenderness!) – how might you help a woman with PMS cope better with her days?

a) with eating

b) with tiredness

c) with stress



4) Many people with PMS can find their worst times are when they haven’t eaten for a long time ie. first thing in the morning and while cooking the evening meal after collecting the kids from school. What advice might you give them so that they can keep their blood sugar steady during these times – and throughout the day?

5) As stimulants usually make things much worse – what advice could you give about caffeine (in tea, coffee, cola drinks, chocolate) and nicotine?

6) How do you think alcohol should be used during PMS time?

7) Do you know of any Herbal treatments or other Complementary therapy that has been shown to help with PMS – or that has helped you?

8) As PMS is due to the huge hormone swings that happen after the egg is released each month ‐ can you think of any Medical treatments that could prevent PMS?



Session 5 PMS ‐ Answers and Self Help Solutions

The large variety of symptoms have been shared with me by the women in my PMS/Menopause clinics and workshops over 20 years.

Q1) What time of ‘the month’ (menstrual cycle) does PMS occur? – and how can you know if you really have PMS?

• PMS starts any time up to 2 weeks before the period in a 4 week monthly cycle. It is triggered by the release of the egg.

• There must be at least a week of feeling completely well between the end of the period and the beginning of the next bout of PMS.

• If it lasts longer than 2 weeks it may mean that you are nearing the menopause – or the symptoms may be due to other medical or psychological problems.

• You can only know if it’s PMS by keeping a daily symptom chart for 2‐3 months and taking this to discuss with your GP, practice nurse or PMS clinic.

Q2) In what ways can PMS affect you?

All these symptoms must be intermittent and confined to the time before the period and disappear for at least a week after the period is finished.


• weight gain, bloating and breast tenderness• tiredness • craving sweet things – especially chocolate! –this may be because chocolate

also contains a caffeine‐like substance and a chemical which gives you a “feel‐good” boost.

• fuzzy heads, headaches and migraines• clumsiness – may put things down on the edge of a table or may drive badly


Intermittent • poor concentration • poor memory• difficulty making decisions• difficulty coping with problems• lower confidence sometimes, because of this



c) your emotions?

Intermittent • mood swings • weepy• more tense and irritable• anxious and panicky• feel “out of control” at times• aggressive verbally – and maybe physically• change in sex drive ‐ usually lower, sometimes higher• feel unable to cope at times. If you are waking every day feel very low and weepy this may be depression and you should see your GP to discuss this ‐ and discuss seeing a counsellor and taking antidepressants.

“Teach ‐ in on emotional symptoms in PMS”

Women often complain of an upsurge of emotional feelings premenstrually which seem to come from nowhere ‐ and are often described as a “Jekyll and Hyde” experience.

It is often easier for us to label our problems as having a physical cause eg. PMS ‐ than to accept that the physical and emotional parts of ourselves interact and that each affects the other.As women are usually conditioned to put other’s needs before their own it is often difficult for them to express their boredom, misery or anger with their particular life experience ‐ and to say when they need to stop and relax. They may also see this as being a failure.

Women may be genuinely unaware of feelings of frustration or lack of fulfilment in their lives or of an ongoing problem in a relationship, or at work. They may be successful in keeping their problems “under wraps” for most of the time. It may only be during the stress of the large hormone swings premenstrually, that these feelings emerge, and they often surface with a vengeance, with outbursts of weeping, irritability or aggression, which feel “out of control” and frightening to the woman and her family or colleagues.

Women almost always blame themselves for these incidents ‐ and do not look at the external trigger which has led to a particular outburst.If the woman is encouraged to describe exactly what led up to an outburst there is always a reasonable explanation for her anger or upset feelings! ‐ usually in respect of her unmet and often unspoken needs ‐ or people’s expectations that she is always there to care for others.



Some “very supportive” partners focus on the woman as “the problem” and don’t look at aspects of their behaviour which are provoking their partner’s reactions.

Women do not become crazy irrational beings during PMS time ‐ though that is the popular myth!If a woman can think about specific examples of recent PMS outbursts, discussion of real incidents can help her to acknowledge her feelings ‐ and plan changes in her life, so that her needs are made clear to others and cared for.

Counselling can help women to change their ‘Downward spiral of negative thinking’ in the premenstrual phase, to

• being able to see things clearly and understand themselves better

• problem solving

• and building up self‐esteem ‐ until the PMS is seen as “ a challenge to work out” rather than “an overwhelming problem”.

Q3) Bearing in mind the research in the 70s that showed that if you keep a man awake for 48 hrs with very little food he would experience all the symptoms of PMS (except breast tenderness!) – how might you help a woman with PMS cope better with her days?

a) Self help with patterns of eating and drinking

Many of the common PMS symptoms eg. feeling tired, irritable, anxious, dizzy, weepy or headachey are similar to the early symptoms of low blood sugar ‐ and the frequent chocolate craving in PMS patients supports this link.

Ways to deal with this and other PMS symptoms include:‐

• eating three or four separate meals a day including protein in each (fish, eggs, beans, cheese,nuts or meat) ‐ without skipping meals or snacking ‐ can dramatically relieve PMS symptoms!

• eat food which takes time to chew and digest to allow a slow release of sugar into the blood rather than a sudden sugar surge eg. plenty of fresh vegetables and fruit, whole grains, oily fish, and nuts. Bananas release endorphins ‐ the “feel‐good” hormones, as well as sugar ‐ but can release sugar too quickly if eaten on their own.

• don’t eat chocolate or sweet snacks instead of meals as this produces a sudden rise in blood sugar. The body responds by releasing insulin which pushes the blood sugar down again. This usually goes too low, producing



cravings for something sweet about an hour and a half later. This can produce a sugar craving cycle which can go on all day ‐ may produce energy dips or outbursts and doesn’t help the waistline!

• if it’s a “chocolate or die day” have a small amount of, preferably dark, chocolate at the end of a meal or healthy snack ‐ so the sugar is absorbed slowly.

• some foods aggravate PMS eg. animal fats and refined white flour and sugar and it’s best to reduce all foods made from these in your diet.

• as caffeine makes PMS symptoms worse use decaff versions of coffee, tea and cola drinks ‐ or change to herbal teas.

• drink plenty of fresh tap water to detox naturally. Choose low calorie drinks rather than canned or bottled fizzy drinks which can have up to 6 teaspoons of sugar per can. Fresh fruit juices may also contain lots of sugar.

• fluid retention and bloating can be minimised by reducing salt intake ‐ and by herbal or natural diuretics eg. melon, cucumber. Medical diuretics don’t usually help.

• keeping to your recommended weight also reduces the risk of fluid retention.

• cooking meals for the family, after a busy day at work, can be the last straw in PMS time ‐ so discuss who else in the family can share the cooking (and tidying up afterwards) or plan around freezer meals or take‐aways, premenstrually.

• teenagers need to learn to cook for when they leave home, so teach them how to cook in your non‐PMS time ‐ and get out of the kitchen and leave them to it in your PMS time! ‐ but make sure they or your partner tidies up afterwards!

One patient told me that when she was premenstrual she would never stop in the kitchen, as she would always interfere in what her family were trying to do to help her. She learned to walk straight through the kitchen when she got in from work, and would go and do something relaxing, until the meal was ready.

b) Self help with the tiredness

• going to bed really early after a hot bath can often help ‐ or having a short nap in the day. Women often have some sleep disturbance before a period ‐ and may not get enough dreaming sleep to feel refreshed in the day.



• using a deep relaxation method ( eg, from Yoga, T’ai Chi or relaxation programme ) before bedtime may also help you get a better night’s sleep.

• 10 ‐ 15 minutes deep relaxation in the middle of a busy day can make all the difference to how you cope ‐ and it’s good to learn a method of relaxation while sitting in a chair that you can use anywhere. Your local Mental Health team or MIND may have suitable tapes or relaxation courses on offer.

• massage, even just hand or shoulder massage, can be relaxing and refreshing when exhausted and can be learnt in a group and shared with others.

• Complementary therapies eg aromatherapy/massage, yoga, T’ai Chi etc. or visiting a spa can make you feel energised and much better in yourself so book your favourite in your PMS time. If money is tight ask for these instead of presents from your family and friends.

• moderate exercise 3 times a week can reduce fluid retention and weight gain and give an increased feeling of well‐being. Doing this out in nature can add greatly to the experience and the relaxation. You need to choose something you enjoy and maybe go with a friend or partner ‐ unless you want this time for yourself.

c) Self help with the stress

Women can be encouraged to Keep stress to a minimum wherever possible when they are premenstrual.

• Mark “PMS” time on your calendar or work diary for several months ahead – and refuse to book work meetings, or even social engagements, during the PMS weeks wherever possible. Even something social can be too demanding at this stage of the month and could end in tears or a fight! ‐ so stick out for what you really want to do. Let the family do things without you sometimes.

• Learn to say “NO” ‐ during your premenstrual time

• cut down your workload ‐ where possible

• refuse extra demands at home or at work

• leave things until you can manage them more easily

• Being a “martyr” doesn’t help you or anyone else in the end. Book “time out” on your own or with friends, regularly, during PMS time.



• Research shows that women who spend time regularly with other women live longer, healthier, happier and less stressful lives than women who don’t! This is not a luxury ‐ it’s essential to our ability to cope and be happy.

• Talk about how you feel with someone who cares about you. Many women feel more vulnerable, and less able to control expression of their feelings premenstrually ‐ but WHAT they feel is really important and it may only come to the surface in their PMS time ‐ so learn to listen to your PMS self!

• “PMS time” may be the only time the needy child part of you gets heard. We all have a child still inside us ‐ which probably needs more care and nurturing than the competent cheerful self we usually show to the world.Listening to that part of you allows you to take your normal needs as a human being more seriously ‐ and to care for yourself as you would your best friend

• Write down every situation in which you feel upset or angry premenstrually ‐ who was there, what happened, what triggered your tears/outburst etc. ‐ but wait until the period is over before talking to those involved in the incidents, to sort out what is going wrong.

• If you are unable to do this comfortably, in your home or work‐place ‐ a self‐assertiveness course, individual counselling or Relate counselling might help

Q4) Many people with PMS can find their worst times are when they haven’t eaten for a long time ie. first thing in the morning and while cooking the evening meal after coming home tired from work or collecting the kids from school. What advice might you give them so that they can keep their blood sugar steady during these times – and throughout the day?

Eat before getting the kids up in the morning – and in the afternoon before leaving work or collecting kids from school .

It’s best to eat three or four meals including protein (fish, eggs, beans, cheese, nuts and meat) each day ‐ without skipping meals or snacking as this will keep your blood sugar steady through the day.

Carry nuts and dried fruit or a whole food sandwich and salad with you if you will be out over a meal time.



Q5) As stimulants usually make things worse – what advice could you give about caffeine (in tea, coffee, cola drinks, chocolate) and nicotine?

Stimulants will usually aggravate PMS symptoms, after the buzz has worn off, so women can often reduce their PMS symptoms markedly by

• cutting right down on caffeine from all the above sources , cigarettes and chocolate – though a couple of squares of dark chocolate at the end of a meal is actually good for you!

• Use decaff versions if you don’t want to give them up altogether ‐ try different brands until you find ones you like.

• There are many herbal teas and infusions which are caffeine free.

• Cut right down on cigarettes before the period. Stopping smoking is the single most important health change you can make – so contact your GP to see what help is available when you are ready to try. You have a much better chance of stopping, and staying off cigarettes, if you access some of the support on offer.

Q6) How should alcohol be used during PMS time?

Although alcohol might make you feel better briefly it is actually a depressant, so it’s best to limit it to small amounts in the evening when you have finished all you need to do for the day.

If you know you are drinking too much – do think about contacting your local Alcohol Advisory Service before it causes you real problems.

Self‐help suggestions as above really can reduce the effects of your PMS but if that doesn’t work after a few months try complementary therapies, counselling or ask your doctor for one of the other treatment options ‐ or a referral to a Specialist PMS/Menopause clinic.

Q7) Do you know of any herbal treatment or other complementary therapy that has been shown to help with PMS – or that has helped you?

HerbalAgnus Castus Vitex or Agnacast.This has been shown to help significantly with the PMS symptoms and can also be good for heavy periods etc. in women with no gynaecology problems.It can be used off the shelf, as stated on the pack ‐ or see a qualified Medical Herbalist. If taken after 5 pm it may cause insomnia. (See References)



St John’s Wort can be effective at relieving weepiness but can interfere with uptake of Oestrogen (eg. in the Pill) and other prescribed drugs, so check with your pharmacist or GP before using it if you are on regular medication.

Gingko Biloba can lighten mood and may be helpful for some women

Food supplementsGamma linoleic acid ‐ in Star Flower Oil or Evening Primrose Oil Can be good for breast tenderness and general wellbeing in some women – but not all. Must try a full dose for at least 3 months eg.1500 daily – and this can be increased premenstrually ‐ and reduced after the period. GLA can reduce absorption of some Epileptic drugs

Multivitamins and minerals ‐ especially those containing Magnesium, Zinc and Selenium also help some women.High dose of Vit B6 not now recommended

Complementary Therapies

Many patients have reported that various Complementary Therapies have increased feelings of well‐being and reduced their PMS symptoms. This may be partly due to the support and counselling aspects of Complementary Therapy consultations ‐ which can also be found in women friends or groups.

Q8) As PMS is due to the huge hormone swings that happen after the egg is released each month ‐ can you think of any medical treatments that can prevent PMS?

Any hormonal treatment that prevents the egg being released can prevent PMS, so some contraceptives that do this can be helpful but don’t work for all women.

1)combined contraceptive pills with a relatively higher oestrogen balance and a modern progestogen ‐ and this can be taken continuously for three months at a time to reduce the number of periods a year.

2) progesterone‐only methods• modern progesterone‐only pill prevents ovulation in many women

though it is not licensed for PMS. (The older ones do not prevent the egg being released) Although it can make some women feel worse some women have much less of a PMS problem while taking it.

• injection• implant

However, as progesterone imbalance causes PMS in the first place, any progestogen ( including that in the combined pill) may make some woman feel as if they have PMS all the time.



If you want to try hormones it’s probably better to try a pill version first before going for the injection or implant which are long term contraceptives and will continue to have an effect for 3 months in the case of the injection ‐ or 3 years in the case of the implant.

HRTA 100mcg oestrogen patch is used with a progestogen which doesn’t cause many side effects (eg. 10 mg dydrogesterone or MPA) ‐ or a Mirena coil can be fitted to protect the womb lining. The Mirena coil can give PMS like side effects in a few women, who can use prescribed Natural Progesterone instead. The creams sold without prescription do not contain enough progesterone for this use.HRT patches can be very effective in severe PMS and is unlikely to cause any serious long term problems as it is taken below the average age of menopause of 51.There are other medical treatments which suppress the normal hormonal cycle too but they need to be prescribed and supervised by a specialist NHS PMS/Menopause clinic or Gynaecologist.

SSRI antidepressants These may be effective for PMS in women with marked mood disturbance ‐ but counselling is useful alongside them. Using an SSRI antidepressant for only the two weeks before the period works just as well as continuously and is much less likely to cause dependancy.

Counselling can be very helpful in changing behaviour patterns and learning to see PMS as a challenge that can be overcome ‐ not an overwhelming illness.

Surgery

Hysterectomy on it’s own has never been an option for PMS as it is the swing in hormones from the ovary, when the egg is released, that causes the symptoms – not the womb itself. A few women after having the ovaries removed for severe PMS can’t tolerate HRT and find they have exchanged PMS for menopause ‐ so it’s always worth trying really hard with the self‐help measures, complementary therapies, medication and/or counselling before going for surgery, unless there are other major gynaecology problems too.

Useful resources for PMSwww.menopauseswings.org Website for free PMS and perimenopause info and leaflets

Royal College of Obstetrics and Gynaecologists www.rcog.org.ukExcellent free PMS patient leaflets ‐ and advice on PMS for doctors in the Green Top Guideline 48

National Association for Premenstrual Syndrome NAPS www.pms.org.ukInformation and activities for women with PMS



http://www.menopauseswings.org


http://www.rcog.org.uk


http://www.pms.org

http://www.pms.org

PMS Leaflet ‐ sorting things out!

Women do not become crazy irrational beings during PMS time ‐ though that is the popular myth!

What is PMS?Many women experience a change in themselves, both physically and emotionally, each month during the huge swings in blood levels of oestrogen and progesterone hormones – though some women feel no different at all.It’s accepted that women may feel big emotional as well as physical changes during or just after pregnancy, or around the menopause ‐ when hormone levels are changing quickly. Research has shown that 10‐20% of women are also sensitive to monthly hormone changes, though only 5% have really severe symptoms.

PMS or Pre‐menstrual syndrome is a collection of unwanted physical and emotional changes occurring in the second half of the menstrual cycle ie. pre‐ menstrual, coming just before the period. We use the term “syndrome” now instead of PMT or pre‐menstrual tension because PMS includes a lot of changes rather than just an increase in tension.

PMS symptoms vary between women and often vary in the same women in different monthly cycles. This can be very confusing and can delay the diagnosis of PMS.

Although some women find their mood swings in PMS distressing, others have learnt that these can make them aware of feelings that are normally buried, but are really important clues as to how they feel about some aspects of their lives ‐ and which of their normal human needs are not being met.

Symptoms lasting more than two weeks before the period may be the result of coming near to the menopause ie. peri‐menopause (whatever the actual age of the patient) – or may be due to other medical or psychological problems.

Giving a man PMS!Research in the 70s showed that if you keep a man awake for 48hrs with very little food he would experience all the symptoms of PMS ‐ except for the breast tenderness! This is a good way to try and explain to people how bad you feel when you are pre‐menstrual, as most people have had some experience of missing a night’s sleep, though not necessarily 48 hours. They also don’t know what it can feel like to have these symptoms for 2 weeks out of every month!

This finding is also useful in that it suggests that you can tackle PMS by working on Stress, Tiredness and Eating patterns – and these Self Help options can make a huge difference to how many women cope during their PMS time.

How can you know if you really have PMS?

• PMS starts any time up to 2 weeks before the period in a 4 week monthly cycle. It is triggered by the release of the egg.

• There must be at least a week of feeling completely well between the end of the period and the beginning of the next bout of PMS.

• If it lasts longer than 2 weeks it may mean that you are nearing the menopause – or the symptoms may be due to other medical or psychological problems.

• You can only know if it’s PMS by keeping a daily symptom chart for 2‐3 months and taking this to discuss with your GP, practice nurse or PMS clinic. See attached chart



In what ways can PMS affect you? (PMS leaflet)

All these symptoms must be intermittent and confined to the time before the period ‐ and disappear for at least a week after the period is finished to be called PMS.


• weight gain, bloating and breast tenderness• tiredness • craving sweet things – especially chocolate! – this may be because chocolate also

contains a caffeine‐like substance and a chemical which gives you a “feel‐good” boost.• fuzzy heads, headaches and migraines• clumsiness – eg. may put things down on the edge of a table or may drive badly


• poor concentration • poor memory• difficulty making decisions• difficulty coping with problems• lower confidence sometimes,

because of this

c) your emotions?

• mood swings • weepy• more tense and irritable• anxious and panicky• feel “out of control” at times• aggressive verbally – and maybe physically• change in sex drive ‐ usually lower, sometimes higher• feel unable to cope at times

If you are waking every day feel very low and weepy this may be depression – and you should see your doctor to discuss how you are feeling ‐ and discuss seeing a counsellor or taking antidepressants.

Understanding emotional symptoms in PMS ‐ crazy or what?

Women often complain of an upsurge of emotional feelings premenstrually which seem to come from nowhere ‐ and are often described as a “Jekyll and Hyde” experience. It is often easier for people to label their problems as having a physical cause eg. PMS ‐ than to accept that the physical and emotional parts of ourselves interact and that each affects the other.As women are usually conditioned to put other’s needs before their own it is often difficult for them to express their boredom, misery or anger with their particular life experience ‐ and to say when they are exhausted and need to stop and relax.They may also see this as being a failure. Women may be genuinely unaware of feelings of frustration or lack of fulfilment in their lives or of an ongoing problem in a relationship, or at work and may be successful in keeping their problems “under wraps” for most of the time.



It may only be during the stress of the large hormone swings premenstrually (PMS leaflet) that these feelings emerge, and they often surface with a vengeance, with outbursts of weeping, irritability or aggression, which feel “out of control” and frightening to the woman and her family or colleagues.Women almost always blame themselves for these incidents ‐ and do not look at the external trigger which has led to a particular outburst.If the woman is encouraged to describe exactly what led up to an outburst there is always a reasonable explanation for her anger or upset feelings!This is usually in respect of her unmet needs, often unspoken, or people’s expectations that she is always there to care for others.If a woman can think about specific examples of recent PMS outbursts, discussion of real incidents can help her to acknowledge her feelings ‐ and plan changes in her life, so that her needs are made clear to others and cared for.

Counselling can help women to change their “downward spiral of negative thinking” in the premenstrual phase, to

• being able to see things clearly and understand themselves better

• problem solving

• building up self‐esteem ‐ until the PMS is seen as “ a challenge to work out” rather than an overwhelming problem.

Listening to your “PMS self”It’s really good to learn to listen to your “PMS self” ‐ as that may be the only time the needy child part of you gets heard. We all have a child still inside us ‐ which probably needs more care and nurturing than the competent cheerful self we usually show to the world. Listening to that part of you allows you to take your normal needs as a human being more seriously ‐ and to care for yourself as you would your best friend

How might you cope better in your “PMS time”? - bearing in mind the research in the

70s that showed that if you keep a man awake for 48 hrs with very little food he would

experience all the symptoms of PMS (except breast tenderness!)

a) Self help with patterns of eating and drinkingMany of the common PMS symptoms eg. feeling tired, irritable, anxious, dizzy, weepy or headachey are similar to the early symptoms of low blood sugar ‐ and the frequent chocolate craving in PMS patients supports this link.

Ways to deal with this and other PMS symptoms :‐

• eat three or four meals including protein (fish, eggs, beans, cheese, nuts and meat) a day without skipping meals or snacking. This can dramatically relieve PMS symptoms!

• eat food which takes time to chew and digest to allow a slow release of sugar into the blood rather than a sudden sugar surge eg. plenty of fresh vegetables and fruit, whole grains, oily fish and nuts. Bananas release endorphins ‐ the “feel‐good” hormones, as well as sugar ‐ but can release sugar too quickly if eaten on their own.



• if you will be out over a meal time take nuts and fruit or a whole food (PMS leaflet) sandwich and salad with you.

• don’t eat chocolate or sweet snacks instead of meals as this produces a sudden rise in blood sugar. The body responds by releasing insulin which pushes the blood sugar down again. This usually goes too low, producing cravings for something sweet about an hour and a half later. This can produce a sugar craving cycle which can go on all day ‐ may produce energy dips or emotional outbursts, and doesn’t help the waistline!

• if it’s a “chocolate or die day” have a small amount of, preferably dark, chocolate at the end of a meal, so the sugar is absorbed slowly.

• some foods aggravate PMS eg. animal fats and refined white flour and sugar and it’s best to reduce all foods made from these in your diet.

• as caffeine makes PMS symptoms worse use decaff versions of coffee, tea and cola drinks ‐ or change to herbal teas.

• drink plenty of fresh tap water or low calorie drinks rather than canned or bottled fizzy drinks which can have up to 6 teaspoons of sugar per can. Fresh fruit juices may also contain lots of sugar.

• fluid retention and bloating can be minimised by reducing salt intake ‐ and by herbal or natural diuretics eg. melon, cucumber. Medical diuretics don’t usually help much.

• keeping to your recommended weight also reduces the risk of fluid retention.

• cooking meals for the family, after a busy day at work, can be the last straw in “PMS time” ‐ so discuss who else in the family can share the cooking (and tidying up afterwards) or plan around freezer meals or “take‐aways”, premenstrually.

• older children and teenagers need to learn to cook for when they leave home, so teach them how to cook in your “non‐PMS time” ‐ and get out of the kitchen and leave them to it in your “PMS time”! ‐ but make sure they or your partner tidies up afterwards!

One patient told me that when she was premenstrual she would never stop in the kitchen, as she would always interfere in what her family were trying to do to help her. She learned to walk straight through the kitchen when she got in from work, and would go and do something relaxing, until the meal was ready, so that she and her family could enjoy the evening together.

b) Self help with the tiredness• going to bed really early after a hot bath can often help ‐ or having a short nap in the day.

Women often have some sleep disturbance before a period ‐ and may not get enough dreaming sleep to feel refreshed in the day.

• using a deep relaxation before bedtime may also help you get a better night’s sleep.

• 10 ‐ 15 minutes deep relaxation in the middle of a busy day can make all the difference to how you cope ‐ and it’s good to learn a method of relaxation while sitting in a chair that you can use anywhere. Your local Mental Health team or MIND may have suitable tapes or relaxation courses on offer.

• massage, even just hand or shoulder massage, can be relaxing and refreshing when exhausted and can be learnt in a group and shared with others.



• Complementary therapies eg aromatherapy,massage, yoga, T’ai Chi (PMS leaflet) or visiting a spa can relax you and give you energy ‐ so book your favourite in your “PMS time”.

• moderate exercise 3 times a week before the period can reduce fluid retention and weight gain and give an increased feeling of well‐being.Doing this out in nature can add greatly to the experience and the relaxation.You need to choose something you enjoy and maybe go with a friend or partner ‐ unless you prefer this time on your own.

c) Self help with the stressYou need to keep stress to a minimum wherever possible when you are premenstrual.

• Mark “PMS” time on your calendar or work diary for several months ahead – and refuse to book work meetings, or even social engagements, during the PMS weeks wherever possible.Even something social can be too demanding at this stage of the month and could end in tears or a fight! ‐ so stick out for what you know you can handle at this time.Encourage the family do things without you sometimes.

• Learn to say “NO” ‐ during your “PMS time”

• cut down your workload ‐ where possible

• refuse extra demands at home or at work

• leave things until you can manage them more easily

• Being a “martyr” doesn’t help you or anyone else in the end.

• Book “time out” on your own or with friends, regularly, during PMS time.

• Talk about how you feel with someone who cares about you.Many women feel more vulnerable, and less able to control expression of their feelings premenstrually but WHAT they feel is really important and it may only come to the surface in their PMS time ‐ so learn to listen to your “PMS self”!

• Write down every situation in which you feel upset or angry premenstrually ‐ who was there, what happened, what triggered your tears/outburst etc. ‐ but wait until the period is over before talking to those involved in the incidents, to sort out what is going wrong.

• If you are unable to do this comfortably, in your home or work‐place ‐ a self‐assertiveness course, individual counselling or Relate counselling might help

• Watch out for your worst time of day. Many people with PMS find their worst times are when they haven’t eaten for a long time ie. first thing in the morning and while cooking the evening meal after coming home tired from work, or collecting the kids from school.

• Keeping your blood sugar steady during these times – and throughout the day can make all the difference ‐ so eat before you get the kids up in the morning – and in the afternoon before leaving work or collecting kids from school. Carry nuts and raisins etc. with you when you’re out of the house



• Stimulants ‐ ie. caffeine (in tea, coffee, cola drinks, chocolate), nicotine (PMS leaflet)

Stimulants will usually aggravate PMS symptoms, after the buzz has worn off, so women can often reduce their PMS symptoms markedly by • cutting right down on caffeine from all the above sources , cigarettes and chocolate

– though a couple of squares of dark chocolate at the end of a meal once a day is actually good for you!

• Use decaff versions if you don’t want to give them up altogether ‐ try different brands until you find one you like.

• There are many herbal teas and infusions which are caffeine free.• Cut right down on cigarettes before the period to reduce PMS symptoms.

Stopping smoking is the single most important health change you can make – so contact your GP to see what help is available when you are ready to try. You have a much better chance of stopping, and staying off cigarettes, if you use some of the support on offer.

AlcoholAlthough alcohol might make you feel better briefly it is actually a depressant, so it’s best to limit it to small amounts in the evening when you have finished all you need to do for the day. If you know you are drinking too much – do think about contacting your local Alcohol Advisory Service before it causes you real problems.

Treatment options for PMS

Herbal treatment Agnus Castus Vitex or Agnacast. This has been shown to help significantly with the PMS symptoms and can also be good for heavy periods etc. in women with no gynaecology problems. It can be used off the shelf, as stated on the pack ‐ or see a qualified Medical Herbalist. If taken after 5 pm it may cause insomnia.

St John’s Wort can be effective at raising mood and relieving weepiness but can interfere with uptake of Oestrogen (eg. in the Pill) and other prescribed drugs, so check with your pharmacist or GP before using it if you are on regular medication.

Food supplementsGamma linoleic acid ‐ in Star Flower Oil or Evening Primrose Oil Can be good for breast tenderness and general wellbeing in some women – but not all. You need to try a full dose for at least 3 months eg.1500 daily This can be increased premenstrually ‐ and reduced after the period. GLA can reduce absorption of some Epileptic drugs

Multivitamins and minerals ‐ especially those containing Magnesium, Zinc and Selenium also help some women. High dose of Vit B6 not now recommended

Complementary TherapiesMany patients have reported that various Complementary Therapies or going to a spa have increased feelings of well‐being and made their PMS symptoms much easier to live with ‐ so put some money aside for this or get friends or family to treat you in your “PMS time”.

Counselling can be very helpful in changing behaviour patterns and learning to see PMS as a challenge that can be overcome ‐ not an overwhelming illness.



Medical treatments (PMS leaflet)

HormonalAny hormonal treatment that prevents the egg being released can prevent PMS, so some contraceptives that do this can be helpful ‐ but they don’t work for all women.1) combined contraceptive pills with a relatively higher oestrogen balance and/or a modern progestogen. These are more effective for PMS if used for 3 months continuously followed by a week’s break. This is sometimes called tri‐cycling.2) progesterone‐only methods

• modern progesterone‐only pill prevents ovulation in many women though it is not licensed for PMS. (The older ones do not prevent the egg being released) ‐Although it can make some women feel worse some women have much less of a PMS problem while taking it.

• injection• Implant

However, as progesterone imbalance causes PMS in the first place, any progestogen ( including that in the combined pill) may make you feel as if you have PMS all the time.If you want to try contraceptive hormones it’s probably better to try a pill version first before going for the injection or implant which are long term contraceptives and will continue to have an effect for 3 months in the case of the injection ‐ or 3 years in the case of the implant.3) HRT using 100 mcg oestrogen patches with 12 days oral dydrogesterone 10 mg or the Mirena

coil ‐ to protect the womb lining. This can be very effective in severe PMS and is unlikely to cause any serious long term problems as it is used below the average age of menopause ie. 51. A few women need prescribed Natural Progesterone instead. The creams sold without prescription do not contain enough progesterone for this use.

There are other medical treatments which suppress the normal hormonal cycle too but they need to be prescribed and supervised by a specialist NHS PMS clinic or Gynaecologist.SSRI antidepressants These may be effective for PMS in women with marked mood disturbance ‐ but counselling is useful alongside them. Using an SSRI antidepressant for only the two weeks before the period works just as well as continuously and is much less likely to cause dependancy.

SurgeryHysterectomy on it’s own has never been an option for PMS as it is the swing in hormones from the ovary, when the egg is released, that causes the symptoms – not the womb itself.A few women after having the ovaries removed for severe PMS cannot tolerate HRT and find they have exchanged PMS problems for menopause ‐ so it’s always worth trying really hard with the self‐help measures or medication before going for surgery, unless there are other major gynaecology problems too.

Self‐help suggestions as above really can reduce the effects of your PMS but if that doesn’t work after a few months try complementary therapies, counselling or ask your doctor for one of the other treatment options ‐ or for referral to a Specialist PMS/Menopause clinic.

Useful resources for PMSwww.menopauseswings.org Website for free PMS and perimenopause info and leaflets.Royal College of Obstetrics and Excellent free patient leaflets ‐ and advice on PMS for Gynaecologists doctors in the Green Top Guideline 48 www.rcog.org.ukNational Association for Info and activities for women with PMSPremenstrual Syndrome NAPS www.pms.org,uk © Althea de Carteret 2011







http://www.pms.org

http://www.pms.org

S 5 What women shared about their experience of living with PMS

“If only it was widely known that it really is REAL!Tell everyone!

“I found the “Living with hormone swings” session very comforting and enlightening ‐ lots of practical advice and support

“I think it should be possible to perceive PMS as a positive, insightful experience rather than something always to be fought and battled against.I suppose I mean “Embrace” rather than “Endure”.I find this almost impossible myself, but I do realise I am starting to perceive it differently as I understand it more and observe what is happening emotionally, deep inside.

“My own experience of PMS feels that what is being required of me is to work through the shit at its root. To face it full on, at its full depth to create genuine change.

“PMS can be experienced as being the most important time of the cycle, a reliable and powerful up‐welling of all the unresolved, unprocessed feelings that persistently come up to the surface until you genuinely face them and address them.

“PMS can be a time when you are deeply connected to your truth, and if we could perceive this time differently, and care for and nurture ourselves, really listen to the stirrings and calls inside ourselves, it would create a holistic attitude to caring for ourselves and others at this time of the month.



Session 5 PMS - Menopause Swings 5 PMS.pdf · Session 5 ‐ Living with Hormone swings ‐ 1 PMS...

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Transcript of Session 5 PMS - Menopause Swings 5 PMS.pdf · Session 5 ‐ Living with Hormone swings ‐ 1 PMS...