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Root Cause of PMS

Q:  Hi Tracy, why are some women’s PMS experiences so much worse than others?   I’ve read that diet is a big deal, but that can’t be all that matters.  I am sure there are a lot of reasons but what are the biggest drivers?  I get this question a lot and obviously it’s a big concern for women clients for all of us.


A:   It’s all a matter of how quickly things go downhill – literally!   Generally speaking PMS (pre-menstrual syndrome) refers to a group of symptoms (mild, moderate, or crazy) which women can experience  in the week or so leading up to the beginning of her menstrual cycle (when she starts menstrual bleeding).   Technically, this is the time from a woman’s mid-luteal menstrual peak and the end of the monthly menstural cycle.  During this time, her progesterone and estrogen levels are both falling.  Please reference the diagram below; this fall-off begins around day 21 (the mid-point of the luteal phase and the typical start of the “PMS” window).  The question is (1) how quickly estrogen and progesterone are falling and  (2) if progesterone is falling more rapidly than estrogen.  Generally speaking levels of progesterone in the body protect us from feeling symptoms of “estrogen dominance”.  These symptoms include the puffiness, bloating, mood swings, breast tenderness, weepiness, and weight gain we associated with PMS.

There are three typical imbalances involved here.  (1)  PMS may be severe because a woman has relatively high estrogen levels all the time, so as progesterone falls, estrogen continues to dominate (this often has environmental roots).   (2) Or PMS may be severe because a woman’s baseline estrogen levels are normal but her progesterone levels are on the lower side; thus, as progesterone falls, it drops lower than what is needed to “buffer” her body from estrogen.  (3) PMS may also be severe because a woman’s body is poor at detoxifying and ridding itself of estrogen in the liver (often due to poor methylation in the liver or issues in the GI tract such as estrogen binding and/or reabsorption due to constipation).  The common element is this:   temporary (or ongoing) estrogen dominance yields what we call “PMS” symptoms.

High and/or ongoing stress will also exacerbate PMS.  When we are stressed, our adrenal glands secrete large amounts of a stress hormone called cortisol (to protect the body from the affects of short-term stress). Cortisol, however, competes with progesterone for receptor sites in our cells.  So even with normal progesterone production, high levels of cortisol can prevent a women from benefiting or “feeling” the benefits of having healthy progesterone levels (and estrogen dominance will occur anyway).

Realize that lifestyle choices can also make PMS worse.  In particular, a diet that includes

  • a lot of hormones (e.g. dairy foods, conventionally-raised beef),
  • exposure to many xenoestrogens (e.g. BPA in canned foods, triclosan in many antibacterial hygiene products, many pesticides used in conventional food farming or home gardening)
  • high amounts of sugar, refined carbohydrates, and/or caffeine.  Unfortunately the mood swings caused by estrogen dominance often cause our clients to eat even more of these foods, sending their symptoms on a downward spiral.

Realize too that our “fat cells” (adipocytes) generate their own estrogen.  Thus women with excessive amounts of body fat often struggle with estrogen dominance and worse PMS (keep in mind that even individuals with normal weight may still have an excessive percentage of body fat) .  This is one reason why overweight, postmenopausal women are several times more likely to develop breast cancer than postmenopausal women of normal weight.

If you’re passionate about hormones, you may be a perfect fit for our Hormones Demystified clinical course!  It’s self-paced and available to practitioners at any time.



(Diagram from Wikipedia)

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4 Questions for “Root Cause of PMS”

  1. 2
    Terrie Pugh says:

    Great info thanks. What is the best test for checking if there is estrogen dominance and the levels of other sex hormones? And if possible, if a client is perimenopausal?
    The hospital hormone blood test was ‘normal ‘


    • 2.1
      SAFM Team says:

      Please keep in mind that ‘perimenopausal’ is a very broad term that may mean a woman in her thirties, mid-forties or close to fifties – all these women may have a different hormonal balance and all be classified as perimenopausal. What is notable is that typically 5-10 years prior to actual menopause progesterone production starts declining and this often results in relative, low-grade estrogen dominance, which can be a source of PMS for many women. Other factors that contribute to this dynamic at any age are stress and insulin resistance.
      To gain insight into the hormone balance and metabolism we typically recommend DUTCH Complete test:

  2. 1
    Anne Markt says:

    Hi there- I have a female client, late 20s. She’s estrogen dominant due to very low progesterone. An FM practitioner gave her bio-identical progesterone cream to use twice a day. She started a week ago, and is doing this in conjunction with other supplements including Estro-DIM 2/day. She has a solid diet and lifestyle already. Her issue is bad PMS, erratic cycles, and severely heavy periods that led to low ferritin. After starting the cream, she became severely moody/mildly depressed 3 days in, so they reduced to 1 dose of progesterone per day. Then on day 17 of her cycle, 7 days in using progesterone, she had very severe cramping which isn’t normal for her. I’ve read somewhere before on the Q&A that initial use of progesterone sometimes worsens symptoms before it gets better, but how bad? Compounding Pharmacist advised her to push through and do the full 2-weeks of progesterone cream, and wants her to add Vitex twice per day on top. He mentioned femenessence maca harmony to boost progesterone as well, but client has tried it and became severely irritable and emotional on it, so stopped. In your experience, is depression/major cramping on progesterone cream normal initially? Does it take a full month for symptoms to subside? Or is there a better way to boost her progesterone without side effects so she’s compliant? I’m trying to set the right expectations and alleviate her fear of continuing the protocol. Or, could Vitex taken twice a day be enough and she could stop progesterone? Thank you! I’ve taken the hormones demystified course. So valuable for this case.

    • 1.1
      SAFM Team says:

      Indeed, progesterone (P) is critical for sensitizing estrogen receptors. If this person’s progesterone was extremely low, it should be increased very slowly and gradually to allow the body time to adjust. Otherwise, as you say, the effects of estrogen are dramatically worse. She probably should have started on just one dose (or even half dose) daily to begin. In my experience, it can take 1-2 mos for the transition period to pass. However, given this person’s age, I do agree that (unless there are rare, dysfunctional reasons for the low P), a vitex and inositol combination instead of the P cream would likely be a better choice (there is a great Q&A post in the internal treasure chest on the latter; I recommend you search for it). I recommend evening primrose oil daily to counter the cramps (which are caused by the prostaglandins). But overall, I would *always* using progesterone cream only in combination and concert with multiple agents to counter the estrogen dominance (e.g. repleting magnesium, dairy food removal, ground flaxseed, B-vitamins, DIM). Most low progesterone at this age in an otherwise healthy woman is caused by insulin resistance or over exposure to xenoestrogens – again, both of which need to be addressed as root causes for long-term relief and hormone balance.

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