Life Uncut - Do You Feel ‘Crazy’ Around the Time of Your Period? Unpacking Premenstrual Dysphoric Disorder (PMDD) with Dr Izzy Smith

Episode Date: June 4, 2024

There’s a huge amount of stigma associated with anything to do with our periods and for a lot of people, they may have spent years being told that they are dramatic, moody and irrational around the time of their period. As it turns out, it may not have just been ‘that time of the month’. They may experience a condition called PMDD or Premenstrual Dysphoric Disorder.  As for any invisible health condition, having a name for it can be really validating and give you a sense that you’re not crazy and you’re not alone. It also helps people around you understand what might be going on so this episode isn’t just for the girlies who experience extreme mood shifts like depression, irritability, anger and hopelessness around their period, it’s also for those of us who don’t so that we can be more supportive for a loved one who does. Today we have Dr Isobelle Smith, an endocrinologist with over 10 years of experience in hormones, joining us to unpack the ins and outs of PMDD.We chat: What PMDD is and how it differs from PMS The stigma of ‘erratic’ moods and emotional dysregulation The possible causes of PMDD PMDD being listed as a mental disorder Treatment and management for PMDD How PMDD changes over the course of your ‘reproductive’ years PMDD in perimenopause and menopause  Medical misogyny and advocating for your own health   You can find Dr Izzy Smith here Izzy mentioned the International Association for Premenstrual Disorders here And the resource that the Queensland Government put together here   You can watch us on Youtube Find us on Instagram Join us on tiktok Or join the Facebook Discussion Group Tell your mum, tell your dad, tell your dog, tell your friend and share the love because WE LOVE LOVE! xxSee omnystudio.com/listener for privacy information.

Life Uncut acknowledges the traditional custodians of country whose lands were never ceded. We pay our respects to their elders past and present. Always was, always will be Aboriginal land. This episode was recorded on Gadigal land. Hi guys and welcome back to another episode of Life Uncut. I'm Laura. I'm Brittany. And on today's episode, we are having a very important conversation about something you may have never heard about before, and it is called PMDD. That is premenstrual dysphoric disorder, PMDD. Now, I'll be honest, I had never heard of what this was until recently, Bridget Hussway,

she actually shared an Instagram photo of herself describing this disorder and how she experiences it. And I mean, imagine around your period how there's always the jokes about how we are a little bit crazier, how we are more emotional. Oh, is it that time of month you're crying a lot? And you're like, well, yeah, actually. So where is the fine line, I guess, is what this conversation is between it just being a normal emotional reaction to the fact that you had the flood of hormones, that your periods are coming, and something that is far more impactful to your ability to live a normal life. Those who suffer from it have a one to two week period just before their period comes. And during the first couple of days of their period,

where their emotions, their mood, their happiness are so deeply affected that it makes it almost impossible to function normally. Well, their extreme feelings, like extreme mood shifts, depression, irritability, anger, that feeling of hopelessness, like these are all words that are used to describe PMDD and are used in the diagnosis of PMDD. And I think more people are talking about it now. It's funny, Laura, you said, you know, I just recently heard about it. I had heard about it a little while ago. I remember Angie Kent talking about it on Instagram. Well, she actually spoke about it on our podcast, but I didn't click to it because at the time we were talking more about PCOS and endometriosis. So for me, I didn't really take on board this

conversation around PMDD. And it wasn't until recently that I think I've been seeing far more conversation about it. So we wanted to talk to an expert today. We got a friend of the podcast. She's been on the podcast before talking about PCOS and endometriosis, funnily enough, Dr. Isabel Smith. She's an endocrinologist. She's so well-versed in unpacking what PMDD is. So we wanted to talk about what PMDD actually is and how it differs from PMS, which I think is really important, and the stigma of these erratic moods that people feel, and also just trying to educate not only people that might have it, but those surrounding them that might not have it, but it impacts them. And I'm talking about your friends and family and even your partners. I think it's

really important for partners to listen to this, especially men who have never had to experience the feelings of a period. Yeah, I totally agree. But even when we say, if it's not something that you experience, it's something that's relevant to everyone. I would guarantee that some of you listening to this will have never heard of what PMDD is, but you will identify with so many of the symptoms and so many of the key indicators that actually would suggest that potentially you do have PMDD. And I think that there are a lot of people who struggle with really severe mood swings around their period, really severe depressive episodes around their period. I don't think I have PMDD, but I myself know that for those like four to five days prior to getting

my period, I am so low. I'm so low to the point that it's often like a bit of a joke in our household that Matt knows my period's coming because I'm so not myself. And a part of me hates that stereotype. Like I hate the idea that that happens to me, but I think we have so much more ability to understand and to also to have control over our lives when we know what it is that's happening. You know, when we actually can put into words the things that we're experiencing and that's what this episode will give you. It gives you the tools to understand what's happening in your body. Also just talking about the fact that it's listed as a mental disorder. So it's not like PCOS or endometriosis, even though you are having physiological effects

on your body, the way to diagnose it is in a mental health journal. That's what they do. They go through a criteria and it's listed as mental health diagnosis, which I don't know how I feel about it. I guess it is in a way, but it's a really fine line with the diagnosis. I find the episode absolutely fascinating. I know you guys will too. We hope you enjoy. Yeah, let's get into the chat with Dr. Izzy Smith. I feel like there's so much stigma surrounding women's periods. For so many years, we were told that you don't talk about it. You shouldn't talk about it. It's gross. we were invalidated in our feelings when we feel emotional or a bit upset or you know like whenever anything goes wrong around that time Laura you've spoken about it someone goes oh are

you on your period but so many women experience symptoms around their period and before their period pre-menstrual so differently like some people get no symptoms some people get severe symptoms and it plays havoc with not only your body but mentally because you're like I don't understand what's happening. I don't usually react this way. But if you've had these feelings and I'm ashamed a little bit to say I'd never even heard of this before, but you might have a reason for feeling that way because there's something called PMDD or premenstrual dysphoric disorder that I've only recently started to hear some people talk about. And I thought, oh my God, there'd be so many women that are experiencing PMDD that didn't know what it was

or anything about it. So we wanted to do an episode on it today, but not just with Laura and myself, but with somebody who knows absolutely what's up, Dr. Izzy Smith, who we have had on the podcast before. We did an episode with Dr. Izzy on PCOS. She's been an endocrinologist working for the better part of 10 years. We thought who better to come on and talk to today. So Dr. Izzy Smith, welcome. Thank you for having me back. I feel like this conversation around PMDD though, it's been picking up a bit of steam From a medical specialist, like what is PMDD and what does that really stand for? Just firstly, Laura, I think you're spot on about we're hearing more about women's health.

You know, endometriosis is so much better understood and known by the general population. Polycystic ovarian syndrome, the menstrual cycle, even menopause, we're talking about more. Perimenopause though, it's been a really big talking point, not just in the media, but like across pop culture, you know, Mama Mia has spoken about perimenopause so much recently. And I think the pendulum is definitely shifting in how we have these conversations. Well, medicine historically has had a terrible reputation of invalidating women's experience with healthcare. I always mention, you know, a hysterectomy is called a hysterectomy because it was thought, you know, women who probably had a severe mental illness, such as schizophrenia,

it must have been their uterus that made them hysterical. So they would have a hysterectomy to improve their mental health. Izzy, you actually taught me that years ago and I tell everyone that that's like my fact of when I want to drop a fact and impress on a dinner party. Trivia. Yes, I say, yeah. That's your feminist trivia. I hope I am quoted, Britt. But to get back to what PMDD is. So premenstrual dysphoric disorder, I'm going to just call it PMDD from now, essentially is really severe premenstrual syndrome. So as Laura said, you feel pretty crappy a couple of days before your period. Your mood might be a little bit irritable, a little bit sad, a bit doom and gloom. Hopefully you can still function in your day-to-day life. You can go to

work. Your relationships don't completely fall apart. In saying that, I've had many fights with people, not many, but I'm definitely more sensitive as well before my period, but it doesn't have a major impact on my ability to function. If those symptoms get much more severe and, you know, there's specific criteria to diagnose this, it's in the DSM, which is the kind of mental health criteria, you need to have around five of these and they are having really severe kind of mental health symptoms. So anxious, depressed, irritable, then sometimes some physical symptoms, severe fatigue, people can't get out of bed, muscle aches and pains, joint pains. And it has to be in the week before your period and then the symptoms resolve after the period. As you can see, some

of those symptoms could be sound like depression, could be anxiety, and some of the more physical symptoms can be similar to endometriosis or menstrual migraines. So it is quite important someone gets the correct diagnosis. And sometimes it's a diagnosis of exclusion, making sure there aren't those other conditions. And then if someone meets those criteria, the symptoms really do get better after the period. That is what we think is most usually PMDD. How long after your period are you talking? Because I'm just doing the math in my head. That means the week before, the week of your period and then what like a week after that's three weeks of the month that you that these women are experiencing people's symptoms generally should be better within

a couple of days within their period and that's related to the underlying cause of pmdd which is generally interestingly though they're still not completely sure on the science of what causes pms and what causes pmdd it's not actually abnormal hormones so someone often comes to me and says I want you to test my hormones because I feel really bad before my period. And it's actually a response to normal hormones that is causing the symptoms. And some people get really severe symptoms and some people are totally fine, as you said, but usually it's the progesterone, which only happens in your menstrual cycle after you've ovulated. And as the progesterone gets higher, the, you know, PMS symptoms or PMDD symptoms start to occur and then the hormones

rapidly drop. So the main two theories are a kind of metabolite of progesterone. So one of our main female hormones interacting with our neurotransmitters in a kind of abnormal way and also their rapid change in hormones just before the period. And some people's PMDD might be almost straight after they've ovulated. So they're really, really sensitive to progesterone versus some people's PMDD might just be a few days before their period. And maybe it's more the rapid decline in hormones that they're more sensitive to and just in general talking about hormones there's so much individual variability of how we're impacted by our hormones and not just our reproductive hormones I have some people who see me who are so hypothyroid you know the markers are

almost off the charts and they're still doing their job and they're like oh I'm a little bit tired but not too bad and some people might have just slightly low thyroid hormones but feel rubbish or people with PTSD, we know if they're exposed to adrenaline or stress hormones, they might have a very different response to someone that doesn't have PTSD. So we're so individual with our hormones and not just our reproductive hormones. And that's why, you know, PMS and PMDD impacts everyone differently. When you say progesterone, you're still talking about the reaction that someone has is still a reaction to what would be considered a normal amount of progesterone in the system. Just some people's reactions are way more adverse, which may be what

classifies or someone can be diagnosed with PMDD, rather than it being an issue where there's too much progesterone or not enough progesterone to cause this sort of reaction. Exactly, Laura. It's a clinical diagnosis. So that means I'm not doing blood tests to diagnose it. I might do blood tests to exclude other conditions or refer them to a gynecologist to screen for endometriosis. But once everything else is ruled out, it's a clinical diagnosis based on the history. There's a little bit of some very small studies maybe suggesting naturally higher levels of progesterone could be associated with worse PMS, but the data is not strong and it's not a problem with your hormones. It's so interesting. I made the joke at the start, which Matt, and he knows, he sees it in me. He's

got a good gauge for when I'm about to get my period, probably because he's mentally tracking it as well. But he sees the difference. And sometimes I will be way more reactive to things that I wouldn't be had I not be, you know, having my period in two days. Usually for me, it's like two days before and I am in a hole. What about, are you sensitive to, more sensitive to criticism? 100%. That's one of the big diagnostic criteria. Yeah. I am like. I will second that. Criticism, but like genuinely I feel as though I am depressed for a couple of days beforehand. Do you track your cycle, Laura? No, I like to wing it. Also, So we do the pull-out method.

So I am not the right person to have that. Let's not go there. If you're using withdrawal method of contraception, I would definitely recommend tracking your cycle, 100 PMDD. Guys, I want a third child. So like we're hoping. Yeah, but you can't trick Matt into doing it. Okay, he knows what he's doing.

The guy is well aware how babies are made. He made two of them. But what I wanted to say is off the back of that is it is such a sometimes frustrating invalidation because this is what women deal with, that often their very real frustrations in life are reduced down to this idea that it's because you are hormonal or you are about to get your period. And that's what I think a lot of women have experienced at some point, a guy or a friend being like, are you getting your period? And I can only imagine though, for people who have PMDD, who have been struggling with these

highs and lows in the volatility around how they feel, that this would be a very frustrating thing because it comes with the invalidation from other people around you that when you're struggling with something, they're like, oh, you're just getting a period. But Izzy, how do you differentiate between someone that's just experiencing shitty feelings and somebody that's experiencing shittier shitty feelings? Because if there's no blood tests and nothing that's actually physiologically being tracked, how do you as the doctor say, oh, okay, you're worse than Sally? I think we'll go back to what Laura says and then answer that question because in some ways saying, you know, you are being hormonal, there is validity to that. We tick off those criteria,

like increased sensitivity to criticism, labile moods. These are real symptoms that people are experiencing due to hormonal changes. Your boyfriend or husband saying, oh, you're just being hormonal, of course, is completely invalidating how you're feeling. But there is truth to our mood, how we feel can be impacted by our hormones. And we need to respect that and give it the validation it deserves rather than brush someone off and not make them feel listen to, but it is legitimate. And that's why I think we really, you know, tracking how can we know what's normal, what's a little bit blue and what's really bad. And I often think about this because I track my cycle very tightly. I know when I'm going to ovulate. I know, you know,

I'm like, oh, I've got my ovulation breasts are a bit bigger. So do I. Yeah. Do you know, actually just, I thought, I'm sorry, I'm interrupting you there, but I can now that I'm off the pill, cause I was on the pill for my whole life. Now that I'm off the pill, I can tell you the exact second that I feel like I'm ovulating literally I go oh there it is I feel I'll open my I won't know it's that day and I'll open my tracker and it's exactly and it can be really empowering just understanding our body like why do we have this type of discharge sometimes and other types of discharge why am I a little bit sorry demeter so I'm using medical language why I'm a little bit puffy at different times of the month so one tracking your cycle is just

critical irrespective of if you're using the pull-out method for contraception I think which is not contraception of whether you're being irresponsible we understand I would say there's um no I'm not going to talk about my personal life that is completely unprofessional I just had a thought coming to my head and then thankfully another thought so not talking about my sex life on a podcast no so we need to track our cycle and I always find it funny because I don't think I have PMDD, but I definitely get PMS. And sometimes in that few days before my period, I need to consciously tell myself, do not give the thoughts you're having or the feelings you're having very much emphasis right now. Be aware of them, notice that you're

feeling this way, but know that you will feel better in a week or two. And then sometimes it'll be a week after my period and I feel really sad for no reason. I'm like, huh, I would have put this down to PMS if it was two weeks ago. Totally. So that's where you need to track your cycle over you know, multiple menstrual cycles. There's lots of different apps, you know, the Flow app. I actually use the Femi app, which is the female running company I work for. The Garmin app's not too bad. And then there are the specific criteria. If you also think you could have PMDD, I really like a website called the International Association for PMDD. And they've actually got a little, you can go on and it says like, do you think you can have PMDD? You can go on, you can answer

questions. That's a really good resource is the Jean Hales website. If they're having an impact on your function is really what we talk about with mental illness. You know, this is a kind of combination of a physical mental illness condition, but it does fall under a mental illness. It's in the DSM. We all get anxious sometimes. We all have a low mood sometimes. It's when it's consistent, prolonged, interfering with our functionality when we call it a disorder. So PMDD does in fact fall under a mental health condition. Yes, it does fall into the mental health condition, but I'm an endocrinologist and PMDD is a funny one because it falls into different specialties. You can have an

endocrinologist involved because we're good at hormones. We're good at prescribing hormonal treatments or turning off hormones. You can have a gynecologist involved because for some people, they end up having their ovaries removed because this condition is making them stay in bed for two weeks of the month. They can't have a job. Their relationships, especially it seems as women get older, the PMD can get worse. They can't function. And that might sound really extreme. And so I'm going a little bit off topic, but I'm always asked, what can you do for PMDD? I don't want to take an antidepressant. I don't want any hormonal treatment. And I talk about, you know, well, let's track your cycle. Let's journal. There's a few supplements. They don't have much

evidence, but if you have severe PMDD, I would recommend the best evidence-based treatment, which is fluoxetine or other antidepressants. And people often, they don't want to take that medication but then it's really impacting their their day-to-day life and function so it's hard as a doctor I'm torn because well the best evidence-based treatment I can offer you is you know turning off ovulation is an antidepressant and so if it is so severe I think we need to validate that this is a really serious condition for some people and supplements are great but it's not always going to cut it as is journaling as is sleep as is cutting out alcohol as is tracking symptoms so for PMDD it's not just bad PMS for some people it's really disabling

and quite full on treatments are needed. And that's why gynecologists involved, psychiatrists are involved, sometimes even in urologists to make sure it's not a menstrual migraine. For some people, it is a really severe condition. I have two questions. Firstly, like how common is it, I guess, because I think everyone can identify with aspects of this that you're talking about. And I know you say once it's gotten to a point where it's really impacting people's life, but what does that look like in terms of the amount of women who might suffer from it? So different statistics, you look at studies and, you know, look at the population and see how many people have PMDD. It quotes around two to 5% of the population. So that's

quite a lot. Probably a lot of people don't know they have it. They have a week or two of the month, especially one week where they just feel absolutely terrible. Also, it can be associated with other mental health disorders. So if you have underlying depression, it can then be exacerbated in that week before the period, but around 2% to 5% is what we quote. It's really interesting with PMS because depending on where the study is done, really influences the percentage of the population that identify with having PMS. So maybe to some degree, there are some cultural aspects. In some countries, it's as low as 10% and some countries as high as 70, 80%. But around 20% of the population is what is quoted generally. When you say that it can be controlled by either antidepressants or

turning off ovulation, can it be controlled by going on birth control and just staying on the active pill so that you're not actually going through ovulating? Yes, that is one of the treatments. The most evidence-based treatment generally is an antidepressant and that can be just in the luteal phase, so from between ovulation to the period. Fluoxetine is what's generally used because it stays in the body for a long time. So if you do just take it for two weeks a month, you don't have a rapid drop of the antidepressant. So you don't have that withdrawal syndrome. And that's effective in around 70% of people. The pill also, generally the evidence shows for people who take the pill, they feel better in the premenstrual part, but their mood

in the other parts of the menstrual cycle is not as good. Isn't really evidence that one pill is better than the other. I often now prescribe a pill with the body's natural estrogen, like a 17 beta estradiol, as there's some data showing that might have better impacts for mood. We do know the pill can have a negative impact on mood, especially when prescribed in adolescence. And when I give advice as well, it's always about the individual in front of you. And that's why I never say medication is all good or bad. It's all about the context. Would I give chemotherapy to everyone to prevent cancer? Of course I wouldn't. For someone who's got cancer, of course it's great. You know, the pill, is it appropriate for everyone? Of course it's not, but for some people it is

effective and yeah, it can be used for PMDD. So PMDD, is that something that will, if it's going to affect you later in life, it'll affect you from your very first menstrual cycle, or is it too highly related to a period of your life? And I guess what I mean by that is people that suffer PMDD, do they suffer it from when they start their period or do you heavily link it to mental health issues so that maybe when someone's in, they've never had it before, then they're in their mid-20s or their 30s and they start to experience extreme symptoms because of other things going on in their life? Usually the first one. So people will generally say they've always had challenging, not very good symptoms before their periods, but we do seem to find it gets

worse as people get older. Sometimes people actually find with PMDD, their mood was quite good in pregnancy. And then after pregnancy, once they get their menstrual cycles back, the symptoms come back and yeah it does seem to be whether it's coming towards the perimenopause time it is worse but yeah it's not just like a i've now got a period of depression now i feel worse between my period it's often you know someone's always had this kind of not very good response to changing hormones and the progesterone the other kind of theories of what caused pmdd as a woman working in the medical industry and especially in the field in which you work in there is a lot of conversation that's happened over the last couple of years around medical

misogyny and like around even for women who go and maybe present to the doctor with all the signs of PMDD might be like highly dismissed. How prevalent do you think that is in your experience? Yeah, this is such a tough question for me because it kind of drags at my heartstrings because in some ways medicine has been my entire life. I started medical school when I was 18. I have grown up in hospitals and treating patients. Also, my first experience that made me want to be a doctor was I had kidney failure as a teenager. And I went to my GP, not my regular GP. And she told me, oh, you're just a bit puffy because you've started the pill. I went on and ran a half marathon in kidney failure. And I come from a non-medical family. I'd been told the doctor

says it's probably nothing, you're fine. And I had kidney failure and I knew there was something wrong with my body. But I think when you're non-medical, when a doctor says, oh, it's probably nothing, you're just like, well, that's what the doctor says. And you're young. So you believe They're the adults. They're the doctors. They're the smart people. Yeah, and you don't really know how to advocate for yourself. And then I had some really amazing experiences with the healthcare system

and it taught me the doctor I want to be and the doctor I don't want to be. I now work in quite a style. I work in private practice. I don't work in the hospital anymore. But I have seen terrible communication and it's all about the communication. Generally, medicine has amazing treatments. It's part of why I love it. like, it's like science is magic. That is not magic, it's science. And I love that. It's so

exciting. And so that's why I get so sad when people have these really negative experiences with their healthcare system and it's due to poor communication. I will say in some ways, it is the system that doesn't support good healthcare all the time. Also, I think there's a really big expectations on GPs to be experts in everything, which, you know, they just can't be. and you come in and you've got 15 minutes with someone you've never met. So I always say have a regular GP, build up that rapport and the relationship to have good healthcare experiences. But I do have people that come to me and they've had really, you know, not very good experiences and just not being validated. And even if I might not necessarily agree when a patient says I did

this and I think it gave me this condition, I'm not going to invalidate their experience. I'm not going to say, you know, that's not right at all because I just don't know. We can never really prove something, what someone's experience was. So that's a really chitty chatty way of me saying it's real, it's disappointing, we need to do better. And part of why I do like a rise in some of the kind of alternate health medical misinformation is because it's making doctors have to be better because patients are having such negative experiences with their healthcare system that they are going and seeing someone probably giving them some pretty expensive non-evidence-based treatments because unfortunately that is better than some of the health care they

have access to yeah or even just like the idea of what we were sold for so long as women just being told that periods are supposed to be painful well that's normal like periods are painful for some people they're really painful and now all the conversations that have come out around endometriosis and so many people who have been missed it's not until they're in their late 30s that they're being diagnosed with something or mid-30s because they've gone through fertility or whatever it is. I talk about when I do public speaking there is a culture of women enduring young girls enduring really heavy menstrual bleeding because they're having you know cycles where they're not ovulating yet then people having to suffer with PMS, PMDD, painful periods

then pregnancy you know you're supposed to go to work when you feel I know Laura you would know this you're not allowed to tell anyone because it would be shameful to have a miscarriage and share publicly. So, you know, I just think it's ridiculous that, you know, don't say anything until 12 weeks and then you give birth and it's a badge of honor to not, you know, to be working straight away, to do it with no drugs and not complain. There's just a culture that women should endure and not complain about it. And I think that's, you know, a lot of women's health in the healthcare system. And I hope that that is improving. Is there a higher correlation of people with PMDD that have PCOS, endometriosis, other conditions? So in terms of the association

there's definitely a genetic association we know if you have a family member who has PMDD you're more likely to have it there is actually also an association with childhood trauma and I find that really interesting because this is a really a problem of your neurotransmitters because your hormones are okay it's the response to the hormones an abnormal neurotransmitter response so when our young brains are developing and in trauma responses and responding to stress there's a strong association and you know the Queensland government website has some education on that so you sorry just to like let's just break this down a bit because there'll be a lot of people at home that won't understand neurotransmitters and hormone fluctuations no i'm one of the people

that would like to know more because i think the first thing that we say even to each other as women is you know someone says oh i'm feeling really shitty they're like you probably have your period you're like yeah but a lot of people don't understand what that actually means in your body so what actually happens with the hormone fluctuations and the neurotransmitters let's do like a 60 second menstrual cycle tutorial. Yeah. So when you have your period, your hormones are actually the lowest. Then you start making estrogen and you've got your little follicles in the ovary developing and making estrogen. Then one lucky follicle is the chosen one that ends up being ovulated. After you ovulate, your estrogen levels go back down and then progesterone

comes into the picture. Progesterone is the main hormone in the second part of the cycle. So after ovulate, that prepares the lining of the uterus for a implantation of an embryo. If there isn't an embryo, so the egg wasn't fertilized, the progesterone goes up, up, up, up, and then it will start to drop. And then when the progesterone dropped the lining of the uterus, the endometrium falls away and that's the period and the hormone levels are low and the cycle starts again. What I said about neurotransmitters, back to the underlying kind of cause of PMDD, The main theory is a metabolite of progesterone called allopregnanolone interacts with GABA receptor.

So GABA is one of the receptors in our brain and it's like an inhibitory receptor. So you've kind of got excitatory and inhibitory receptors in the brain and that has like an abnormal response when it binds. That's the main theory. Also, we know our reproductive hormones interact with serotonin, dopamine and other hormones that are involved in our mood. When you're saying that childhood trauma can have a link, you're saying because the neurotransmitters when you're a child are sort of trained not to fire off the same way? I don't think I can, you know, say that there's any hard evidence or research, but we do know there is association with childhood trauma and your risk of PMDD.

Of course, that doesn't mean everyone who has childhood trauma would get PMDD or people that have had no childhood trauma, of course, still get PMDD. It's an association. I think that's something to really important to understand. When you look at risk factors for a condition, it doesn't mean that it's necessarily going to happen. I have every protective factor to not get asthma. I was born vaginally on a farm. I went to childcare.

The house definitely wasn't overly hygienic. I had pets. I had siblings. I get asthma, eczema, dermatitis, allergies. I get all of these things, even though I had every protective factor. Some people would have had none of them and don't get any of them. so you know risks cause risk association it's not as simple as like cause and effect but that is a risk factor we do know there is an association with other mental illnesses so depression you

are more likely to get pmdd and then there's sometimes a little bit of overlap between endometriosis and pmdd as well you mentioned that the associated factors that might indicate someone could be more likely to get pmdd aren't necessarily something that's like there's not the research on there's not like there's you know an unequivocal research study the way you go okay here it is this is what it looks like but what is the research in terms of how much attention PMDD gets as a topic for research or even women's issues in general I feel like it's just such an area that is under-resourced in terms of what we actually do know about it so so much of it is like subjective or it is um what's another word for it it's theories I guess yeah based on like

the information that's coming in rather than it being from a broader study now this is almost a big question where you could talk about the complexities of medical research and cause effect and I think sometimes in the community we think finding a solution is as simple as just we'll do a study or you know put some money towards it look at conditions like dementia all cancers in general neurodegenerative conditions they have so much money in research put into them we just don't really completely understand the cause of motor neurone disease so it's not always as simple as there hasn't been enough funding in saying that women's health has definitely been underfunded and especially conditions that aren't fatal so you know there's lots of money in breast cancer

endometriosis is only finally starting to get funding and that's not to say breast cancer isn't important but research costs so so so much money and that's why researchers are constantly trying to get grants it's really difficult and to find something which isn't like this condition and mental illness and mood disorders in general, we still don't have a really good understanding of the pathophysiology of depression, how the antidepressant medications work. We know they can increase serotonin, but has there been much data to show it's low serotonin that causes depression? Not really. So I would say we do need more research into the understanding of this condition. There is pretty good data that's related to this allopregnenolone.

They've done studies where you can give a medication called like a 5-alpha reductase inhibitor, which is, if anyone knows, it's the same medication as like finasteride that men take to, you know, prevent hair loss or for prostate medication growth. That actually stops the conversion from progesterone to that metabolite. And that has a beneficial effect for symptoms for people in PMDD. So I think there is pretty good evidence that it is related to this metabolite. But of course, we need, you know, better treatments. I think the fact that our only treatments are an antidepressant and turning off ovulation, really, it would be better to have a more targeted treatment that had less side effects. How does PMDD affect relationships and friendships and people with their work relationships?

I think the best person to ask would be someone who has the condition, in honesty. But what I hear my patients say to me, they'll come in crying saying, I'm yelling at my kids or my husband and I'm not being myself. and I don't want to be this person and they often have quite a lot of kind of guilt and sadness of part of this month I'm not myself and then I go back to feeling great the other side for some people it's really physical symptoms severe fatigue can't get out of bed joint pain muscle aches so it will be different for different individuals I don't think I experience extreme PMS symptoms at all like I think I've been really good but I I'm just trying to think about it now

I'll get on the phone to my partner Ben sometimes and I'll be like I'm so sad I'm so upset and he's like what's wrong babe and I'm like I don't know and at the top hopelessness a hundred percent and I'm like I don't want to get out I don't want to get up today I don't know what it is and then I'm like oh my god maybe I have depression and then I'm like hang on a minute open my app and I'm like I'm about to get my period this is often misdiagnosed as depression and although some of the treatments might be similar it's really important to understand the diagnosis and that's again, why the tracking your cycle is so critical for anyone who thinks they could have PMDD. What is the benchmark for criteria? So how do you actually like, what do you work through as a list

to say, okay, tick, tick, tick. So you need to have five criteria and the first three ones are kind of mood related. So it's irritability and it's kind of our feelings of hopelessness and feeling sensitive to criticism. Then are the symptoms often more physical symptoms, but you need to have five of those symptoms. If anyone is listening, like I said, that website, you can go through if you think you have it. It's also just to do with the timing. Do the symptoms improve after the period? And that's it. And then once that's been... And other conditions have been excluded. Right. Okay. When a woman goes into perimenopause and menopause, and obviously hormones are completely out of whack, does PMDD get better or worse? So after menopause,

it will get better in perimenopause the symptoms can often get worse yeah because it's just trying to work out what the hell's going on perimenopause just perimenny is that what we call yeah perimenny perimenny oh my god you can call it perimenopause next time i see a patient i'll be like i think you have the perimenny laura from life on cut so she's like what i need a manicure yeah a pedicure petty meddy oh my goodness so perimenopause is the highest mental health risk time for a woman in her life. So Australian data from 2021 showed women between 45 to 49 had the highest suicide risk or completed suicide. And I think that's a difficult time for women in their life. Generally, often they have aging parents, adolescent children, often high stress periods

of their career, but then perimenopause with crazy hormonal fluctuations, hot flashes, physical and emotional changes adds to that. So when we talked about kind of medical gaslighting, perimenopause is one that women really are dismissed they get their thyroid function checked they are told they're not in menopause and you know that's it always misdiagnosed as depression yeah and i love treating perimenopause because people come in often feeling so sad and crap and crying and i you know i put them on hrt and they come back being like thank you so much it's really easy for me that's a little bit off topic but yes pmdd often does get worse in perimenopause but after menopause it should improve completely as what would you say to

someone who's listening to this, but they have dealt with, basically they've just dealt with like the highs and lows of their mental cycle. And for them, it is completely normal. Not something that they love, not something that they enjoy dealing with, but they are used to having this period where every couple of weeks they feel absolutely fucking down and rotten. And then everything goes back to normal. What would you say to people who think that that's a normal reaction to ovulation? I would first again I really sound like a broken record track your cycle and see the pattern in behavior then there's lots of things that we can do that are good for our mental health that are just generally good for our mental health so regular exercise not just at that time but in

general has good data for improving mental health and PMS symptoms then you know avoiding not too much alcohol and things like journaling all of those positive things we can do for our mental health. Specific to PMS, we do know some supplements do have a little bit of benefit. So magnesium has a little bit of data. Vitamin B6 has data for improving PMS symptoms, also has some data for morning sickness. It can cause neurotoxicity if taken too high. So B6 neurotoxicity, you know, tingling in fingers and toes. And it's very easy to get too much from being like, oh, vitamin B6 is good. I'll take three times the amount. You can get toxicity quite easily. yeah then omega-3s also have a little bit of evidence then there is like another herbal

supplement like a vertex also so there are some supplements that we can do and if someone finds they have this difficult month it's not you know their mood is impacted but they're functioning okay they don't feel like it's impacting their quality of life maybe someone a little bit like me who says i'm aware of this i don't give that time too much emphasis i'm gentle with myself in that time I'm a very enthusiastic runner but I will back off at that time because I know my body just can't perform at high intensities in that week before my period so I might adjust some of my lifestyle factors around my menstrual cycle with kindness and you know that is what works for me I don't have PMDD I have PMS for people if it is really catastrophic in that they're having

two weeks of a month that they can't function I would say that definitely deserves treatment and of course you start with the lower grade things and if they're not helping then maybe it is time to consider something like a you know fluoxetine for two weeks a month seeing and making sure it's not something else as well so who is the best person to see with PMDD is a little bit hard because it's kind of managed by lots of different people but always a GP with an interest in women's health would be your first stop and the thing is like don't go to a bulk billing clinic to a doctor you've never seen before. And sometimes I say, you know, GPs often have special interests. If it's a doctor who wanted to do plastics, but decided they didn't want to be a plastic surgeon,

but they're going to be a GP and specialize in minor surgeries, skin cancer removals, probably not the best person to talk to about your periods. So look on the GP website. Often it will say this doctor has special interests in X, Y, Z, I think is a really good place to start. We're going to put all those links that Izzy did mention throughout the episode. We'll put them in the show notes that you can go and have a look if you think this could affect you or someone you know. And at the end of the day, this affects so many people. If you have a friend or a family member that you think this could be affecting, please send to them, show your boyfriend, show your partner, because it's really important for the men to understand. I really like the trend of,

I think I like the trend unless it could be used against them, but the partner having the menstrual cycle tracking up in their phone as well. I could see it could be used to be like, you're just being difficult because you're about to get your period it could be maybe a little controlling but maybe in some relationships I can see Laura raising her eyebrows at me no because I think it depends on how your partner approaches I mean a big part of you if you guys came to the live show you know it was like one of my stories was me getting really angry at Matt about something and him being like you are absolutely getting your period and I was like don't you fucking gaslight me and then I stood up and I had my period the thing is is like he knows and he does it with such kindness like

he's not using it as a weapon to be invalidate me but often I will act in a way that is absolutely not congruent with the person I am normally and that's what my patients come into me sometimes saying and being sad about because they're not themselves one week of the month yeah and I think that's why men should listen to this episode because I think a lot of men don't understand what a period is and what happens to a woman's body like that is out of our control it's not us just feeling and pretending to be emotional and hysterical. There's physiological changes that we can't control. And I think the more men that understand that, the more understanding and caring they'll be in a relationship. 10 million percent. And I do some public speaking now and I've almost

said, I'm not going to do corporate public speaking. I'm not going to come to a law firm and only talk to the women. The men can sit and listen about fertility periods, PMS, because it just seems pretty, I don't know, old fashioned that this stuff should only be women's business because you know 50% of the population are women. Absolutely and how do you support your partners when that's what they're going through and you don't have any understanding? Izzy thank you so much for coming being part of the podcast again and for sharing all of your knowledge around this for anybody who wants to find you or who wants to know more where can they find you? So they can have a look at my Instagram I think I have some posts on PMDD if not I probably should do one.

We'll whack one up before then. You can have one after this. At Dr. Izzy K. Smith, I also look after patients with PMDD at private practice, you know, at a few places around Sydney as well. But, you know, really my Instagram is where I like to give people some information that might hopefully be useful. Thanks so much for coming, Dean. My absolute pleasure.