The Food Medic - Breaking the Silence: Why PMDD Needs More Attention? | With Dr Milli Raizada

Episode Date: May 28, 2025

Is PMDD the Hidden Struggle Behind Your Mood Swings? In this episode of The Food Medic Podcast, Dr Hazel Wallace, a women’s health nutritionist, sits down with Dr Milli Raizada, a GP, hormone expert and author of Happy Hormones, Happy You. Together, they unpack the realities of premenstrual dysphoric disorder (PMDD) -  its severe symptoms, how it differs from PMS and why diagnosis can be such a challenge. The episode covers: What are the key differences between premenstrual dysphoric disorder (PMDD) and premenstrual syndrome (PMS)? How has Dr. Raizada's journey with PMDD influenced her approach to treatment and advocacy for women's hormonal health? What challenges do women face in obtaining a diagnosis for PMDD? What strategies and treatment options are suggested in the episode for managing PMDD, including lifestyle changes and supplements? How should women seek appropriate care for their hormonal health? The episode aims to raise awareness and empower women to seek appropriate care for their hormonal health. So, could PMDD be the missing link behind symptoms you’ve been struggling to explain? — If you have a question you'd like us to answer on the podcast, simply send a voice note to [e-mail] – we'd love to hear from you! Stay up to date with the latest health advice, recipes, insights, and updates from Dr. Hazel Wallace and The Food Medic community. Dr. Hazel Wallace Instagram: https://www.instagram.com/drhazelwallace/ The Food Medic Instagram: https://www.instagram.com/thefoodmedic/ Facebook: https://www.facebook.com/thefoodmedic/ Twitter: https://twitter.com/Thefoodmedic Explore More from The Food Medic Not Just A Period – New Book A groundbreaking guide to understanding your cycle, hormones, and health. Coming 22nd May 2025. Pre-order now: https://linktr.ee/notjustaperiod The Food Medic App Learn more: https://www.thefoodmedic.co.uk/about-the-food-medic-hub Weekly Newsletter Subscribe here: https://view.flodesk.com/pages/62b5a28d76b1bf772c403012 Get in Touch For inquiries or collaborations: General: [e-mail] Partnerships: [e-mail] Learn more about your ad choices. Visit podcastchoices.com/adchoices

Hello everyone and welcome back to the FoodMedic podcast. I'm Dr Hazel Wallace, a women's health nutritionist and former NHS doctor. And I'm back for a special women's health series of the FoodMedic podcast. In this mini series, we're diving into all things women's health, from expert insights and myth-busting chats to mini Ask Dr Hazel episodes, where I answer questions submitted by you. Expect accessible evidence back tips to help you feel empowered, not held back by your menstrual cycle and more. Today I'm joined by Dr. Mili Reisada, a GP, hormone expert and bestselling author of Happy Hormones, Happy You. With her background in clinical medicine, lifestyle health and medical education, as well as her own experience with author of Happy Hormones, Happy You. With her background in clinical medicine, lifestyle health and medical education, as well as her own experience with premenstrual dysphoric

disorder or PMDD, Dr. Millie brings both clinical expertise and real empathy to this conversation. If you're enjoying these conversations and want to go beyond just understanding your hormones and your menstrual cycle and actually learn how to work with them, my latest book, Not Just a Period, is available to pre-order now. It's a practical science-backed roadmap that helps you align your cycle in every area of your life, from nutrition and mood to body image, skin, hair and more. If you're ready to feel more in tune with your body and supported by your hormones, rather than confused by them, I'd love for you to check it out. You might notice a QR code floating around if you're watching the video, free to scan, or if you're

listening to the audio version, you can find the link at the bottom of the episode show notes. Dr. Millie, welcome to the Food Medic podcast. Thank you so much for having me, Hazel. It's lovely to see you. Yeah, you're so welcome. So I would love to talk all things mood and the menstrual cycle, specifically PMDD. And I think it's best that we start there. So when it comes to PMDD, I think, first of all, it's not talked about very much. And second of all, it's often just like confused or related to PMS or we talk about it as a

worse form of PMS. Yes. Can you talk a little bit about exactly what PMDD is and how it differs from PMS in terms of maybe symptoms and its severity? Absolutely. And it's topically timed because it's PMDD Awareness Month this month. So PMDD is premenstrual dysphoric disorder. So it's a long-term chronic condition that people suffer with and it happens where people suffer with symptoms in the luteal phase, which I'm sure your listeners will know is in the two weeks typically before your period. And in that time people struggle

with quite severe physical symptoms, but also psychological symptoms. And the difference really between PMDD and premenstrual syndrome, PMS, is the severity of the symptoms that people suffer with and how it impacts their kind of functioning in daily living, how it affects their work life, the relationships, their abilities to kind of function. So the features needed to be having a diagnosis of PMDD relationships, their abilities kind of function.

So the features needed to be having a diagnosis of PMDD would be the fact that it's recurrent in the fact that it happens over more than one cycle. So there's different criteria which I'm sure we'll talk about later, but over two or three at least cycles, people suffer with these symptoms. But it can be really, really severe, really, really, really affecting people's physical and mental health. And it's the mental health aspect which can be so devastating in people. Yeah, absolutely. And I think not many people know that it is a diagnostic mental health

disorder. And I think that just really illustrates like how much of a syndrome this is. Absolutely. Can we talk a little bit about what would be the core symptoms perhaps that people might experience in those two weeks before their period? Absolutely. So, I mean, there's over 150 documented symptoms people can suffer with. So if we look at physical symptoms and if we start from our head and go all the way down, you know, it can affect the brain health significantly. So low mood, anxiety, it can affect your sleep, insomnia, it can make you feel very angry, a lot of rage, feeling overwhelmed. Inability to cope

is a very common symptom. I hear a lot of my patients talk to me about just feeling like there's no way out. And a lot of people describe it as just the hell week or the couple of weeks before the period. So then you can suffer with hot sweats. A lot of the symptoms are related to being sensitive to hormones. So it's a hormone sensitivity condition. So they mirror a lot of symptoms people might get perhaps in the perimenopause. So hot flushes people might get, they might get palpitations, they

might get breast tenderness as well. They might get bloating, weight gain, increasing appetite. The physical symptoms are so huge that the typical four effective symptoms that people struggle with the most, I would say, is low mood, anxiety, overwhelm as well, and the rage. They're the typical symptoms. And like you've mentioned already, the is a mental health disorder. It is listed in the DSM-5 criteria. And to get that diagnosis, you need at least five symptoms. One of those needs to be a core effective symptom. So you need to have the problems with low mood or anxiety or at least one of those four core symptoms with four of the others that are kind of badged up into PMDD. Yeah, in terms of how the awareness around PMDD, it's not very well known.

It's not even spoken about within medical communities very often. I don't really recall touching on it very much in medical school or even throughout like my clinical practice. And now it's getting a little bit more airtime, but still we're really lagging in research. And one of the common things I'm hearing is how hard it is to get a diagnosis. Can you talk a little bit about why it's so difficult and maybe what people can do if they are feeling like this might be what I'm experiencing, how can I advocate for myself in the doctor's office?

I think like you've even just mentioned, I mean, when I was at medical school, we didn't cover PMDD within the curriculum. So I think one of the key issues is that GPs are uneducated around this topic. So the first port of call when we want to see someone for help, perhaps would be your GP. And so they're not recognizing the condition. So because a lot of the symptoms are related to low mood anxiety and a lot of effective kind of mind symptoms, we're attributing it to perhaps depression or anxiety. Now those conditions can actually coexist with PMDD which is why it makes it very

difficult to diagnose but the difference there would be that the PMDD is very cyclical in nature as opposed to potentially depression and anxiety which would affect you throughout your cycle. So I think lack of education, lack of awareness, but then also lack of research. I've started my PhD in women's health hormones because I'm really passionate about the fact that there's such limited research out there

and we utilize that research. It can take five to 10 years to be part of guidelines but without that research we can't inform management and how we manage patients and from an evidence-based point of view. So I think and there's so little funding available as well. You know a lot of big pharmacy companies will fund a lot of research available on SSRIs and the pill which is commonly used treatments for PMDD. But what about all the other treatments that are potentially available that aren't a big pharmacy kind of approach? So I am hugely passionate about research and kind of advancing conversations and that's why we're here today.

Yeah, absolutely. Absolutely. So for, in order to get a diagnosis, you've mentioned we need to have evidence of maybe like three cycles of having these symptoms. I'm a huge advocate of tracking your cycle. I guess that's the best way to gather information. And I think typically when we think about tracking cycles, people think, well, we're just tracking the period, but it's so important to be tracking everything else. Like if your mood is changing, if your cravings are changing, if any physical symptoms are changing, that will allow us to piece that puzzle together. And so then you can go along to your doctor and it should be a GP who can then tell you

what would happen next. But for people who are maybe struggling, even getting that step done, so they're going to the GP and maybe they're not able to voice their concerns or they don't feel like they're being listened to, what would be the best kind of piece of advice you could give them? My biggest advice would be that if someone knows that there's something not right, you know, they will know their body and their symptoms better than anybody, that they should advocate for themselves and not feel like there's a stigma attached to the way that they're feeling. So there's lots of support out there, which I'm sure we'll go over, but it's being able to piece things together for themselves and educate themselves.

And once they're educated, they can advocate for themselves. I would say that would be my biggest advice. Once people understand and become hormone intelligent and understand what's happening in their body, they can start thinking, well, that's not normal. And when they start noticing a pattern and piece the puzzle together and join the dots, they can then start being able to articulate that to the GP.

But perhaps if they've not really, if the penny's not dropped with them before, they're not able to do that. So you know, and I've come from a perspective where I've, even as a doctor, I've suffered with hormonal dysfunction and having those conversations with my GP, I struggled with. So it is very difficult. But going back, if I was to do it differently, I actually do think tracking would have been something that would have validated the way I was feeling a lot more because there's something

concrete to say, look, it's happening at the same time of my menstrual cycle. And there's actually a very interesting article a few months ago in the BMJ that talked about having your menstrual cycle and what phase you're in as a sixth vital vital sign that's something we should always be asking patients about instead of just looking at the blood pressure, looking at temperature, what about, where are you in your menstrual cycle? Are you having a menstrual cycle? And having that conversation started. Yeah, yeah I'm a big believer in that and I think the best piece of evidence is what comes from you. Absolutely.

So if you're able to gather that information, because we have textbooks and we've got papers and things, but they're all averages. And I think, you know, not every woman has the same menstrual cycle, not every cycle is the same, not everyone has the same experience. So when you are able to track it, then you identify what's not right for you, what's not normal anymore. So I love that. And you told what's not right for you, what's not normal anymore. So I love that. And you told me before the podcast that you've experienced PMDD yourself. And if you're happy to, I'd love to talk a little bit about how that was for you and

maybe what were some of the symptoms that you were experiencing and how that conversation went with your doctor. With myself, from memory, I've always been on the contraceptive pill for a long long time from when I was younger for acne control, for period control and so it was only when I was trying for my children when I'm coming off the pill I had the children and I vividly remember when I had my children feeling the best I've ever felt and a lot of patients with PMDD do have that have that feeling

where they feel the most stable during a pregnancy because of the lack of fluctuations of the hormones. So after the pregnancies, really suffered with postnatal depression, really undiagnosed, but very, very anxious, very low in mood in both of the pregnancies. It was after my son was born and I came off all contraception. That's when I really, I kind of remember having my own cycles without any, without any pill.

And so I started getting used to having monthly cycles and starting to see a pattern there. I mean, I was working a stressful job to young children. It was a very stressful time. And so when I approached my GP to discuss the way I was feeling, there was that, well, you're just doing too much. You're just stressed. And I still vividly remember having that conversation

with my GP, who was lovely, who knew me quite well, knew that I was type A personality, always doing a lot of things. And I think they attributed it to me rushing around rather than could it have been something else? Could it have been a hormonal problem? Things kind of got worse over the months, years. It had an impact on work, relationships.

And my husband at the time said to me, you need, he knew there was a cyclical kind of variation. He knew that it was hormonally related, but no one seemed to be acknowledging that. So I actually booked a private appointment with a gynaecologist and I just, I remember walking into his room, I still remember exactly what I was wearing.

I walked into the room and I just burst into tears. Straight away I think he kind of, because he, I did know him in that line of field, working locally, everyone seems to know everyone. And I explained within a couple of sentences of how I was feeling. And then he said straight away, it's PMDD. And you know, I was a GP at the time. And I thought, PMDD, what's that? You know, and this was quite a while ago,

but I still remember thinking, what is it? I've heard of PMS, but what's PMDD? And he kind of taught me through what it was, discussed some options with me. And it was at that visit that we decided to have the GNRRH analogue injections, which I had Zolodex injections for. Yeah, I think I just needed to have something to help.

And off-license and off-label, that can be given as a diagnostic assessment so you can track your symptoms, but actually giving this off label can actually, and if people improve, is a way of diagnosing it as well. And so I had that for, I think it was short of a year, and I was just, I was back to being how I felt when I was pregnant. It was the most stable I have ever been. Yeah, and then I came off the injections, but then my came off the injections, but then my symptoms started coming back, and that's when I started doing a lot more research

and reading papers and thinking, why is there such limited research? We need to be doing more. Started looking at supplements that I could take, for example, and you know, as GPs, that's not something we really talk about. And so I started looking at lifestyle medicine, did further qualifications, looking at what the root cause was really was my kind of main aim.

And I do manage my symptoms. I'm not on any treatments at the moment. And that's not to say that everyone's in that situation because everybody's individually different. But I've been able to manage it through lifestyle and through targeted supplementation And on the whole I can manage my symptoms in that luteal phase There will be times where I will fire off emails that I shouldn't send and think maybe I should have sent that in my follicular phase or and so I've

Kind of developed ways and my husband's very much aware of ways, he's like, just wait. Or you know, I've handed my notes in for numerous jobs in my luteal phase, that's another common thing that people do because they just, they feel very overwhelmed, out of control, and the rage can be quite severe. Yeah, thank you for sharing that. When you were going through your diagnosis, was there any situations where you were potentially misdiagnosed with anything or did you think it was something else? I think it was attributed

to stress and just doing too much and rushing around. I was never offered an SSRI by my GP, so there was no real diagnosis. I think they thought it was all social. It was all working as a junior doctor, you know, marriage, young children, busy job, elderly parents. They never really suggested it was even a mental health condition at the time. And because I felt like they were absolutely lovely when I spoke to them, but just because I felt that I was being slightly dismissed really, I felt like the way I felt wasn't being validated. And I felt embarrassed really. I felt embarrassed that as a doctor, I should be able to cope with these symptoms.

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It's a sweet summer twist on iced coffee. Your cold brew is ready at Starbucks. And it made me feel quite weak, to be honest. And so I didn't go back. I just kind of carried on with things. And that's why I had to book the appointment privately, which was the best decision I ever made, to be honest, because I got my diagnosis.

I was able to trial treatments but then there's so many treatments out there and I only did try the Zolodex, that was the only treatment I actually did try and it was coming off that that I realized well I don't want to be on this for a long term or then have any surgical operation. Because obviously it's inducing a medical menopause having the injection. I just still remember having the hot sweats and taking layers of clothes off. And it was, it didn't really understand that that was going to be happening at the time. It was only after a couple of months, I realized what was happening and what was the fact that my cycles had stopped.

It was all in that moment. All I wanted him to do was stop the way I was feeling. So I just said yes to having the injection. But thinking back and looking back, I think it was the most appropriate thing at that time for me. Whether I'd want that again, probably not. But that was just my own personal experience. Yeah, absolutely. And as you mentioned, we have such limited research in women's health in general,

but especially when it comes to things like PMDD and also PMS. I guess my next question is, do we know why some women experience PMDD and why some women don't? Because I think the prevalence is about 3 to 8% of women experience that. And that's not low, you know, that's still quite high. But why is it that some women, you know, I think most people listening to this podcast, you have a menstrual cycle, will experience some change in mood before their period. But that doesn't mean that they have PMDD or even PMS. But what happens to the women who get such severe mood shifts that's diagnostic of PMDD? Do we know why? It's a million dollar question. I think it's very interesting because I think there's been such limited research. There

are some postulated theories that we talk about that can be contributing to people's symptoms. So with hormones, we've got in a part of the brain called the limbic system, which is really important for emotion. There's lots of hormone receptors for estrogen and progesterone. If you were to look at a picture on the internet and have a look, there's so many receptors in those areas for estrogen and progesterone. Now we know that those hormones have a positive impact on certain neurotransmitters such as dopamine. We know progesterone stimulates or will get converted into allopregnenolone which has a positive influence on GABA. GABA is really important for calming. So the couple of theories that are talked about,

one of them is a problem with the way that estrogen and serotonin operates. So in that luteal phase, when you're just about to come on your period, your estrogen drops for you to then enable you to have a period. Now, if that shift in hormone causes a drop in serotonin, serotonin is what we typically call the happy hormone.

It can influence your mood. So that's one of the reasons and thoughts of why SSRIs, antidepressants, work because they try and boost that serotonin. So that's one of the theories. The other theory is related to issues with the way that the brain is sensitive to changes and fluctuations in progesterone and working along that progesterone allopregnenolone GABA

pathway. And it's actually a very interesting area because some people say that PMDD is people being sensitive to progesterone. However, I know a lot of people with lived experience and particularly even myself where progesterone has been transformational for them as well. But the current evidence base out there doesn't have progesterone, well for PMS, cyclogest is licensed in the BNF, but there's a long way to go in terms of how we understand what exactly it is, but because we're all so different,

genetically we're all different, so potentially what is one of the root causes for one woman might not be the root cause for another. And I think this explains why some people are treatment resistant to an SSRI. And the way that we try and treat it basically is to stop those fluctuations by stopping ovulation. So me having that injection induced a medical menopause, stopped ovulating, giving people the combined oral contraceptive pill, for example, it will stop ovulation and they'll have less cycling of their symptoms. So when people have that pill, it's better to take it either 24 days on and four days off or even just continuously for a few cycles so they're not getting those fluctuations.

So that's how that's thought to work by stopping that ovulation. But the people who, when you give progesterone to some people, they're very sensitive to it, but then some people it can be very beneficial. I mean, there's that many treatment options available which we can go through. And people have started from the top and worked the way down.

And you know, at the end, last resort, people do resort to having the womb removed and having their ovaries removed because it's affecting their life so significantly. Yeah, absolutely. And that's, I mean, that's last resort. But let's start up at the top in terms of like treatment options and where we can start and what we could layer on top of that and what's available. I mean, I'm a huge advocate of lifestyle and in clinic to be fair, that's probably the most foundational thing we discuss. Now, at the moment in the evidence base, lifestyle

medicine has weak evidence for its benefit because of the severity of PMDD. However, I think if it's done very well, and we look at stress, which is a massive factor in worsening a lot of PMDD symptoms, I really do think that can be quite transformational. I think in a GP setting with limited time to discuss things with the GP, it's very difficult to explore social circumstances, and that's why I see patients for over an hour because you need to understand what's going on in their social circle. So there is lifestyle,

factors, so nutrition, you know, just even what people are eating can have a massive impact. A lot of people I see when they're eating very processed foods, very inflammatory processed foods, very inflammatory processed foods, and you'll know more about this, that it can be negative on the mental health. It's going to affect gut microbiome and that will impact, there's lots of ways in which it can impact your mental health, but it will impact the mental health. So I think with lifestyle, because there's not just nutrition, there's exercise, then there's sleep and there's mental health, there's toxic substances and then there's positive psychology. And if there's a problem in each of those areas, the compound effect of that is huge.

It's the same as saving money. If you do a little bit over time, it can be quite large. It's the same if you have problems in each of those six areas, over years, that can be very, very impactful and negative on your mental health. So one of the big things I do is really educate people on the importance and power of lifestyle changes. And that might not work for everybody

because people say they've already tried that, but even just exercise, I mean, obesity, for example, increased risk of insulin resistance. Obesity also increases activity of an enzyme that's involved in the progesterone metabolism pathway. And so there's so many reasons why losing weight through eating well and moving more, and I know losing weight is not just those two factors but

by able to doing those things it can have such a positive influence because of the mechanisms underlying what's driving that PMDD process. We could talk about lifestyle in a whole podcast. Yeah, no, absolutely. But I do think it's so important even if it's adjunct to the medical side of things. And, you know, in my practice, I would kind of support the nutrition and lifestyle element alongside what people are doing with their GP. And I go into nutrition and supplements a little bit in the book in terms of what can help with PMDD, but I completely agree with you. In terms of the evidence base, we are really like stretching and working hard here,

but I feel like there's a lot of promising supplements maybe coming out. I say that really cautiously because I see a lot of supplements come out in the women's health space that aren't evidence backed. And I just feel like we're maybe preying on a really vulnerable community, but I do see some great supplements and I see potential there. And I think if we can offer something that women can do at home, outside of the doctor's office, that can be really empowering. I say that with a pinch of salt because I often find when you're speaking to women with

PMDD, because they have that hell week, and for some women it's two hell weeks before their period, the motivation to want to eat healthy, to want to take your supplements, to want to get outside can be really low. And I've often speaking to clients and they'll be in bed doing their FaceTimes with me because they just don't want to speak to anyone. So I think like from a practical element, sometimes it's the basic things, it's just getting the basics right, like meal prepping ahead of your hell week, making sure that you're just getting simple, good, nourishing foods, getting out for a walk, taking your supplements.

I would love to talk a little bit about what supplements are maybe showing some promising results in women who have PMDD. Yes, so there's some key ones that I look at in clinics. So again, very limited evidence base, but then there are lots of things that we do in medicine in conjunction with a patient. And as long as they're aware of what the evidence base is in the shared management there, and it helps them, and they're aware of the benefits and the risks. I think it's acceptable to try those. So vitamin D is very important for multiple bodily processes, immunity, hormonal health is a hormone, it's not a vitamin. So it's very important. So I think vitamin D

can be very important, especially in the pathways I've talked about in terms of the way that progesterone is metabolized, the way that estrogen is metabolized. A lot of those processes can involve vitamin D, for example. So having adequate levels of vitamin D, especially in this country with, you know, poor weather and, you know, exposure. So vitamin D, Chasterberry, so Vitex, Agnes, Castis, that can be beneficial. And the way that it's thought to work is by balancing out hormones. Now, on social media, there's a lot of people that are very vocal who say, oh, there's no such thing as an imbalanced hormones. Whereas I kind of disagree. I mean, balance is a word in the medical dictionary.

And if there's always too much of one thing, it's never a good thing. Whereas I kind of disagree. I mean, balance is a word in the medical dictionary. And if there's always too much of one thing, it's never a good thing. So we do need our hormones to all of them be in perfect balance and harmony for them to all function. So chastaberry can, it can be useful for reducing prolactin, improving progesterone and boosting that, which can be beneficial

to some women. There's also, there's some studies that have looked at calcium as well to see whether that would be beneficial. There's also some studies that have looked at vitamin E, EPO, so evening primrose oil. There's also some supplements that have looked at omega-3s, you know, just to try and reduce inflammation because I think really the root cause of a lot of PMDD symptoms are like multiflatorial. It's never usually going to be just their genetic risk. It will be the way that their lifestyle plays out in conjunction with that genetics that's going to make them how they are and how they present. So it's usually numerous things that can be helpful.

But I suppose it's always working with someone really, a healthcare professional, to see what's appropriate and what's not because you can get over-faced sometimes with trying so many different things and thinking, oh, this isn't working. And they can get quite costly as well with supplements. So I think it's targeted supplements, but I think there's a lot of people doing genetic testing to see where their weaknesses are. And a genetic test is not diagnostic. But if you can see that the people are struggling producing allopregnenolone because of enzymatic deficiencies in micronutrients. And if they then try a supplement and it improves the symptoms,

I think really that's the way that the future of medicine is going to be going, especially with, because there's some people who don't want to go down a combined or a contraceptive pill route, that they don't want the SSRIs. That's not something I wanted. But it was never explored to me about what supplements were available. And you know, it's very weak evidence in the evidence base. If we look at the guidelines and what they say, CBT, lifestyle medicine and supplements are very, very low down. And it's the conventional medical drugs that are kind of the core of what we offer. But a lot of patients that I'm seeing aren't wanting that.

A lot of patients aren't wanting to get to the extreme of having the Zoladex injections and having the womb removed and the ovaries removed. So a lot of women are actually, what I'm finding is a lot of women are coming to me, buying things off the internet to try and help me, buying things off the internet to try and help, buying prescription medication off the internet to try and help, because of support groups suggesting what they should do, but they're struggling and the healthcare professionals aren't listening. Yeah, I completely agree with you.

And I think you raise a valid point in that like, you know, with supplements, they're also not inert. And like, you know, supplements are regulated like food supplements. And so we don't have to prove efficacy, we don't have to prove safety. And it's not always helpful to just take a heap of supplements and hope for the best. So I do, I am a big believer in like food first approach. And I I think like the calcium research is interesting, but maybe we start with can we optimize calcium in the diet? Vitamin D is like another story because in the UK we don't get enough vitamin D anyway. So I think really most of us should be taking vitamin D, all of us should be taking vitamin D between October and March. And then, you know, with some of the other supplements like Chesapeake, not everyone

can take them because they may be on medications that prevent them from doing that. But I think it is something that we should be providing to women. Here are your options, have a conversation with your GP, make sure it's suitable with you or your pharmacist or nutritionist, dietician, whatever is available to you. And then let's look at what else we can do. So you mentioned a few of the different medications like the pill and obviously you were on the GNRH analogs, which is probably a bit when symptoms are a bit more severe or if the other options haven't worked because you induce medical

menopause. So what would be like first line medication maybe? So first line medication would probably either be an SSRI. This is if you were to go, this is what the evidence base shows, an SSRI. So citalopram, acetalopram, peroxetine. And then if contraception is needed, then a combined oral contraceptive pill, if there's no contraindication, so if the woman doesn't get severe migraines and they're able to take it, there's no other reason why they can't, then they're the first line options, I would say, medication-wise. Second line, people can increase their SSRIs, and there's lots of different ways of taking that SSRI.

Some people find it benefit to taking it just in that luteal phase, but the studies that have been done have shown that taking it throughout the whole month, you know, it can be up to 60% effective. They can be quite effective for some people. Then the pills, in terms of the contraceptive pills, it's the drosperinone

Which is the progestin that seems to have the most evidence behind it So certain pills such as Yasmine and there's a lot more newer ones that have come out with varying doses of synthetic Estrogens and progestins but it's that base of progestin that some people find useful. However, some people are very sensitive to those progestins as well. So then further down the line there are some people are using, which is not a contraception, but some people are using hormone replacement in

terms of estrogen patches with some micronized progesterone. And then further down the line really would be looking at your GNRH analogues and then the last treatment would be removal of room and ovaries. But there are a subset of women that are utilizing body identical progesterone on its own and there's been, well there's been no study, hardly any studies looking at that and but like I've said it can be very useful for people with PMS and it is licensed in the BNF for PMS, but for postnatal depression, some people can use, utilize it off license.

So it's interesting because there's this argument, is it progesterone? Is that the problem or is, do we need, do we need progesterone? And it's quite an interesting area because a lot of the evidence base and what people currently work on is actually progesterone is the problem. And so a lot of the therapies out there and a lot of the novel therapies coming out, such as Suprenolone, they're looking at antagonizing progesterone and there's some selective progesterone receptor modulators being used, such as Eulapristol that are being used and researched by the pharmacy companies. And they're all working to antagonize that progesterone

and allopregnenolone pathway. Whereas some people really find benefit from having progesterone. So it's very, very interesting, but that's not part of the evidence base. That's very off-license. Yeah, absolutely. So what I'm hearing is we're not really sure

why some women respond to certain treatments and why some women don't. But there are an array of different medications out there and it's worth kind of, it might require trial and error to find what works for you essentially. Absolutely, yes. And some supplements we didn't mention actually, apologies, before. So vitamin B6 can be quite useful and magnesium. And again, that's very important in the progesterone pathway and metabolism. We need those nutrients to help with the enzymatic processes.

So they can be useful, but with B6, again, it's knowing the correct dose because high doses can cause problems with nerves. So it's always better to have like a healthcare professional where you're sounding out of these kinds of ideas problems with nerves. So it's always better to have like a healthcare professional where you're sounding out of these kind of ideas because we need to make sure it's safe what we're offering because you might be on medication and they might all interact together. There might be problems in your past medical history that stop you going on certain medications.

But yeah, it is very nuanced. But I think a multifaceted approach is important. I see a lot of people who have got really poor gut health, and so we do metabolize our hormones within our gut as well, and if there's problems in the gut, in our nutrition, people aren't sleeping enough, they're very stressed, cortisol and progesterone share very similar pathways, we really need to be looking at the whole picture. Yeah, yeah. And I guess one thing that we didn't mention is the kind of psychological CBT talk therapy, which is another thing and sometimes difficult to get access to, but

some women respond to it quite well. Absolutely. Again, for PMDD, it's got weak evidence for it. For PMS, it's quite high up there on the treatment algorithm. It can be useful just so that people can cope with the way that their thoughts affect their behavior and so having some pathways and coping mechanisms of how we can change that can be very important and it's the same with menopause. You know, CBT is an option on that treatment algorithm because it's how they cope and deal with those symptoms. So there are lots of ways people can approach it.

Some people really do want to take a very holistic route. Other people really do want to try SSRIs and the pill. And that's all very individualized, what people's preferences are and what people's wishes are. Yeah, absolutely. You mentioned before we started the podcast that PMDD is quite controversial. I'd love to explore what you mean by that. For me, I would say what I think is controversial about it and what I am seeing at the moment

is that a large number of women are wanting to try progesterone therapy. I'm really struggling to access that from their GPs. So at the moment there's a lot of discussions around menopause, which I think is great. And when people are having hormone replacement therapy, it's usually in the form of, depending on circumstances, estrogen with progesterone. But progesterone only therapy is not something that's, even as GPs, it's not something that they're familiar with or educated about because of the lack of research,

because of lack of involvement and inclusion within that evidence base. And I think it's because of the controversies of whether that's helpful for PMDD or whether it's attributable to it. So a lot of women are wanting to try cyclogest, for example, trying it vaginally, rectally, as a suppository. We know that it can be beneficial for people with PMS.

So it is a spectrum disorder with PMS and PMDD. Yes, I know people say it's not a severe form, but it's still on that same spectrum. There are different symptoms that can present with PMDD and it severely affects functioning, but it's a spectrum disorder. And so I think that's what I would say one of the biggest problems is at the moment is just the lack of understanding and the lack of choices being given to women. I think if people understand that if something is off license and off label and they understand the risks to try something, I think they should be given that opportunity

to. But that's my own personal opinion. And we do that with HRT at the moment because there's limited randomized control trials looking at body identical HRT, yet women are still offered it because on balance of risk and benefit, it will benefit the woman. So if, you know, depending on their history, so it has to be individualized, but I think what I'm seeing a lot of women struggling to be even able to try an option because it's not typical, it's, it doesn't fit the pill SSRI, HRT route. So I think a lot of work needs to be done around progesterone therapy and supplements as well, rather than just looking at the SSRIs and other big pharmaceutical kind of names out there. What do you think are some of the biggest myths and misconceptions maybe when it comes to PMDD?

That I think it's just a woman just being hormonal and not able to cope. I think people just... And even, you know, people even do say still, oh, they're just being hormonal. It's a common statement that people do say. And that when people are struggling with the mental health, that judgment of just the gym on the period, they'll be fine. And yes, the sensitivity of those hormones will improve

once they've started the period, but it's that misconception that people can just battle through it without support, when actually there is no stigma in needing help and support and being heard. When someone hasn't experienced those severe changes in their mental state because of that sensitivity, it's very difficult to empathize. And I guess for anyone who's like listening and maybe they've never heard of PMDD before,

but they're hearing a lot of themselves in this podcast. Where would you signpost them to start in terms of looking for support or maybe finding out a bit more information? So there's lots of support out there. I'm very lucky to have joined as a trustee and ambassador for the PMDD project, which is the first and only UK PMDD charity. So that's UK based and they've got excellent resources on their website. So I would signpost them to charities and organizations that do help support.

So there's numerous ones, the PMDD project being the UK one. There's also the IAPMD, which is the International Association of Premenstrual Disorders. There's also NAPS as well, which is an American organization, lots of support out there to educate people on what the evidence is, what the national news media is surrounding PMDD

as well, because it's getting a lot more media attention, which is good because we do need to start these conversations. And it'll signpost you to tracking apps, tracking questionnaires, symptom monitoring, and then you can utilize those questionnaires that you can download and then take to your GP and explain to them how you're feeling. Because as you've already said, a lot of women can have symptoms that might not be PMS and they might not be PMDD. You know, three to eight percent of women have PMDD. You know, there's over 800,000 women in the UK living with that, which is very significant. And that's only those that

have been diagnosed and it is very much under diagnosed. But I think the biggest issue I have is the fact that 34% of women with PMDD will attempt suicide. So it can be the women I speak to, they feel like there's just no way out and for them to feel that they have to end their life to stop that suffering, we need to as healthcare professionals listen to them and not just dismiss them and try and support them on their journey of how we can manage it because there is no one size fits all with PMDD. I'm not even saying that progesterone is the option for everyone. The pill might be the option for somebody.

An antidepressant might be transformational for another person, but we need to be able to give them options. So I would say if people are struggling, is look on these websites, look on the charity website, have a look at what resources there are, help advocate for yourself. And if you're not happy with when you've seen a healthcare professional, ask for a second opinion. You know, that doesn't need to be private. It can be within that same practice or another GP surgery or ask for a referral

because we do need to advocate for our health because in 10 minutes it's very difficult to really get to know a person and understand how they're suffering. Yeah, yeah, it's just not enough time. No, it's not. I'd love to end with one question. What's one myth about women's health or hormones that you wish didn't exist? The fact that everyone thinks it's a woman, a female women's health problem,

hormones, men and women have the same hormones. And I know you've just asked for one, but I'll give two as well. I suppose there's a lot of conversations around menopause at the moment, but hormones can affect women throughout their lifespan and it can affect them during puberty. It can affect them with infertility, postnatally, with postnatal depression. It can affect them PMS, PMDD, perimenopause, menopause. So it's not just that one transition of the perimenopause, menopause that we need

to start talking about. We need to be talking about PCOS and all of the ranges of different hormonal problems across a woman's lifespan. So that's what I would say, that women's hormones aren't just women's hormones, they're men's hormones as well. And we need to be starting the conversation across someone's lifespan. Yeah, that's so important. Amazing. Thank you so much for your time today. Thank you for having me. Before we leave each other, I would love if you could just take a moment to rate the podcast,

leave a review, or share it with a friend or a loved one that you think would learn a lot from this episode. If today's conversation resonated, my book Not Just a Period is available to pre-order now and it's packed with practical advice to help you understand your hormones, manage tricky periods and work with your cycle for better energy, mood and overall health. You can grab a copy now through the link in the show notes or via the QR code on your screen. I hope you all have a great week and thank you so much for listening.