Moody Bitches: The Truth about the Drugs You’re Taking, the Sleep You’re Missing, the Sex You’re Not Having and What’s Really Making You Crazy.... Julie Holland

I’m not typically a dessert person, but if I find myself scrambling through the cabinets for leftover Halloween candy, I know my period is exactly two days away. There are studies that claim that craving chocolate during PMS is specifically American and therefore a learned cultural phenomenon and not related to anything physiological. The theory is that we have been taught that it’s okay to eat chocolate during PMS and we’re taking advantage of that accepted behavior by indulging when it’s our time of the month. I don’t buy that for a minute. First, your body requires more calories when you’re premenstrual, and sweets and carbs can provide them quickly. Second, your magnesium levels are low (premenstrual migraines are a reflection of this), and chocolate can boost magnesium levels.

      The most important piece of the puzzle is again serotonin. In depression and in PMS, when serotonin drops, your body tries to fix that imbalance. It begins to want carbs, specifically sugar, and particularly chocolate. Eating carbs is known to boost serotonin levels, but try to stick with complex carbs like whole grains instead of sugary concoctions to avoid the insulin surge and crash of blood sugar levels that follow. Tryptophan is the amino acid your body uses to create serotonin, so it makes sense to eat foods high in tryptophan specifically, instead of carbs in general. One thing I tell my patients about chocolate cravings is that they can sometimes be satisfied by eating bananas, which are high in tryptophan. Milk, lentils, and turkey are also high in tryptophan, especially the dark meat, so the truth is, you’d be better off pulling a King Henry and munching on a turkey leg than scarfing down all those Oreos.

      Here’s an even lower-calorie way to boost serotonin levels: the amino acid supplements L-tryptophan and 5-hydroxytryptophan (5HTP), the building blocks for making your own serotonin, are available in any health food store. Nutritional supplements, vitamins, minerals, and amino acids can offer significant symptom relief, but you’ll need to do more legwork to educate yourself about what’s recommended and how to take it. Because of aggressive lobbying, these supplements are not regulated by the FDA to the same extent that prescription medicines are; there can be tremendous variability among brands and even within brands. Enlisting the assistance of an herbalist or naturopath would be wise in many situations.

      Vitamin B₆ is also helpful for PMS, as it is a cofactor for serotonin synthesis. Adding a magnesium supplement, which can lower anxiety and prevent insomnia, is also a good idea in the days leading up to your period. Magnesium is a diuretic, so it’ll also help with your swollen boobs and bloated pelvis. Calcium can also lessen irritability and help with insomnia, so a calcium-magnesium supplement would work nicely. Sometimes caffeine (or pineapple or asparagus, natural diuretics) can help to get rid of some degree of the bloating and fatigue. Omega-3 fatty acids found in oily fish or fish oil supplements may also help cut down on reactivity and irritability.

      Here’s the biggest tip I can give regarding PMS: regular exercise. Cardio, in particular, can help to reduce many symptoms of PMS and moodiness in general. It has been shown to be as effective as antidepressants in improving mood and energy level and reducing feelings of malaise. In many situations, daily cardiovascular exercise can do as much for you as SSRIs, without the weight gain and deadened libido.

      Your diet also matters. Estrogen dominance can lead to heavier periods. Hormones in processed meat and certain chemicals in plastics, soaps, and pesticides can mimic estrogen, as can soy, which is added to many processed foods. If you do eat meat and poultry, make sure it’s organic, or at least labeled “hormone-free,” as the hormones used in the meat industry can potentially cause heavier periods. My patients who have switched to a vegetarian or vegan diet are enjoying lighter, less crampy periods. Also, keeping your weight at an optimal level can make a big difference in your monthly symptoms. The more body fat you have, the more estrogen your body is going to make, so aim for a leaner frame if you have significant PMS symptoms or especially heavy periods.

      Timing is everything. When you do and don’t have sex can affect a slew of things. For instance, when you started having sex, and how often you have it, can affect fertility. If you started earlier and engage in it weekly, your cycles are more likely to be regular. Weekly sex, with its regular dose of pheromone exposure, also means you’re less likely to have heavier, painful periods, your fertility will more likely stay on track, and your menopause may even arrive later. One more important timing tip: abstaining from intercourse and from orgasm may be just what your uterus needs during menstruation. In a group of women with heavy periods, 83 percent reported sex during menses, compared with 10 percent in the group with lighter periods.

      For severe PMS that affects functioning (missing work or school, being unable to perform household chores, having huge, regular blowups with everyone around you), there are prescription medication options. Psychiatrists will commonly prescribe SSRIs or SNRIs (serotonin and norepinephrine reuptake inhibitors like venlafaxine, desvenlafaxine, and duloxetine; see the appendix for details). You can take these pills all month long or just during the week before your period. The shorter-half-life medicines, like paroxetine and venlafaxine, are not good choices here, as coming off them tends to be uncomfortable; you don’t need to deal with antidepressant withdrawal every month. I prefer to use escitalopram, which starts working quickly and is easier to taper. I have quite a few patients who used to take antidepressants every day but now take only 5 milligrams of escitalopram for the four to seven days before their period every month, and this can be perfectly effective.

      Another treatment option is to go on oral contraceptives, which create steady hormone levels. For many women, PMS is markedly reduced, as are cramping and heavy bleeding. Often, the longer you’re on the Pill, the lighter your periods are. There is also the option of taking oral contraceptives continually, where you stop the hormones only three or four times a year to have withdrawal bleeding. More gynecologists are recommending continual use of the Pill, especially in patients with endometriosis (a condition that causes extremely painful menses). Just how often you need to come off the hormones in order to shed the uterine lining is a subject of some debate, but the FDA has approved the use of Alesse and Levlen, which allow only four periods a year. And I certainly have patients who are enjoying fewer than that.

      However, I have a few complaints and caveats about oral contraceptives, so I’d prefer that you don’t rush to use them to treat PMS until you read on.

      The Pill’s Dirty Little Secrets

      Using oral contraceptives to manage PMS is not an option for everyone. Flatlined hormone levels have the potential to throw things off dramatically; it’s not what’s natural for us. It is extremely hard to predict who is going to do well on the Pill versus who won’t. I have some patients who are typically very moody and erratic, seemingly tossed about on a stormy sea of hormones throughout the month. Those patients often do better on the Pill, having fewer mood swings and minimal PMS once they get past the first few months of taking oral contraceptives. For them, the Pill ends up being stabilizing, providing steady levels of the same hormones day in and day out, which is what they need to manage their moods and minimize PMS.

      But many of my patients find that they cannot tolerate how emotional the Pill makes them, and after trying several different brands over the years, they abandon the idea of using oral contraception for birth control. For these patients, the Pill is destabilizing. I have heard this sentence countless times when first meeting a patient and asking about contraception: “The Pill made me crazy.” Those exact words. It’s not clear why so many women in my office are reporting this phenomenon, except that many are coming to me for complaints of depression, not just PMS. In one study of women who started oral contraceptives, 16 percent noted that their moods had worsened, while 12 percent noted improvement in their moods and 71 percent had no change in their moods. Women who had PMS prior to the Pill reported significant improvement in their PMS on the