What happens when your family stages an intervention because they've been avoiding you 10 days every month?

I'm sharing the story of a patient who had a complete breakdown at Christmas dinner. She snapped at her husband, her kids, her mom, her in-laws—everyone. A few hours later, her family told her: "We love you, but for 10 days every month, we actively avoid you."

She came to me asking: Am I bipolar? Am I manic? What's happening to me?

This is PMDD premenstrual dysphoric disorder. And when it collides with perimenopause, it becomes a perfect storm. This is not just PMS. This isn't you being dramatic. It's a real biochemical thing happening in your brain an abnormal response to normal hormonal changes.

I discuss the science of PMDD: how GABA receptors respond to progesterone metabolites, why some brains are change sensitive, and why the hormonal volatility of perimenopause (erratic estrogen, declining progesterone, unpredictable timing) makes everything exponentially worse. I explain treatment options from luteal-phase SSRIs to Yaz to Duavee for refractory cases, and why tracking your symptoms for at least two cycles is critical for diagnosis.

Highlights:

1. Why "I feel like I'm watching myself burn down my life and can't stop it" is the hallmark of PMDD.
2. The DRSP tracking tool: why you need 2 cycles to diagnose PMDD properly.
3. Why Vitex (chasteberry) might help mood swings and breast pain.
4. What Duavee is and why it works for women who can't tolerate progestins.
5. Why Dr. Tammy Rowan calls PMDD a progesterone sensitivity issue.
6. Ulipristal: the emergency contraception drug being studied for PMDD.

If you've ever felt like your brain gets hijacked on a schedule, if you've felt completely out of control, this episode is for you. Track your symptoms. Find a clinician who takes cyclic mood symptoms seriously. You don't have to live like this. Please share this episode with someone you know might be experiencing this or a clinician you think would benefit from it.

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I was spurred by the fact that I'm in the office seeing patients and saw a patient for the first time today in extreme distress over what happened to her just last week during the holidays. This is really life altering for the people living with it. It's premenstrual dysphoric disorder and perimenopause. And what happens when they collide in the perfect shitstorm? It is awful. This is not just PMS and it's not just you being overly dramatic. And it's definitely not a flaw in who you are or a personality defect. It is a real biochemical thing happening to you. And I want to talk about it today.

So welcome to another solo podcast with me. I decided to just impromptu do this discussion about PMDD specifically. I'm just hopping on at the end of a clinic day to do an impromptu solo podcast because I've been so moved by this patient that I saw today. I just can't stop thinking about her and I think it needs its own voice in its own room.

I want to start with the story of a patient I just saw, a new patient. I can't stop thinking about her, especially because this is something that is so fresh and so raw for her. It just happened just last week during Christmas holidays where patient reached out in a state of distress and came in today describing this complete breakdown that happened to her during the holidays.

Now, holidays are so tough for so many reasons. And if you think about the stress of taking care of people visiting, the stress of traveling, the cancellations—I myself had travel issues, cancellation issues. The stress of family dynamics, not everyone agreeing about politics, not everyone agreeing about things happening within the family. The pressure to make sure everything looks fine, keep up with the Kardashians, keep up with the Khans, keep up with the Joneses, whatever you want to say. And if you are on the wrong phase of your cycle and you have significant distress during the luteal phase—the window that happens right after peak ovulation before the period comes—it becomes a perfect disaster for so many people and so many women.

So my patient was at the dinner table and she totally snapped to her husband, to her kids, to her mom, to her sister, to her brothers, to her in-laws. She snapped. She exploded in a tirade. She cried. She said things she told me that she didn't even recognize were coming from her. She felt sort of almost out of body saying some of these things because it was like a total Jekyll and Hyde moment for her. And then she left really humiliated.

And what hit her really the hardest wasn't just what happened at that moment, but what happened a few hours later after she laid it into her whole family for whatever thing was ticking her off. You have to remember, so many women in perimenopause are like almost a ticking time bomb. They've been carrying the weight of the world on their shoulders. They are doing the housework. They are taking care of kids. They are taking care of in-laws. They're taking care of parents. They are taking care of taxes. They are doing a lot. They are doing a lot. And on top of that, sprinkle in a little bit of erratic estradiol levels—high to low, this roller coaster, this time of chaos—and this persistent progesterone deficiency that begins to happen. And what does it look like? It looks like a perfect shitstorm for so many women.

So what happened to her next was her family basically staged an intervention. They see that what's been happening to her over the last year. They said, you've become a different person for at least 10 days out of your cycle. We love you, but for 10 days of the month, we actively avoid you. People don't answer her phone calls. People are avoiding her. People are afraid to look at her the wrong way.

She came to me in a state of distress. Am I bipolar? Am I manic? What's happening to me? What is going on with me? We did a deep dive. And so if you ever felt like your brain was getting hijacked on a schedule every single month, things are happening cyclically for you. And there's no logical reason for it. And then the period comes and you're starting to bleed. And within days, you're like the old person that you used to be. This episode is for you.

And just to say it clearly, if your symptoms ever, ever include thoughts of harming yourself, feeling unsafe or harming others, that is an emergency and you deserve urgent help right away and should seek help right away.

Welcome back to another episode of Gyno Girl Presents Sex, Drugs and Hormones. I'm Dr. Sameena Rahman. I am a board certified gynecologist specializing in sexual medicine and menopause care at my own clinic downtown in Chicago. And I'm here to help you navigate difficult parts of your life, educate you. If you're a clinician, I want to help you do better for your patients as we all should be actively learning all the time.

So I told you about my patient, let's call her Carol, who has this serial episodic 10 days of misery a month. And this has been happening for years, but you know, she's 48. She came off of birth control pills in the last year and it's come up for her. And this is a surprise, but she does remember times in college and other times where she would avoid people. She felt similarly during, and she thought it was stress related or other things, or times in between when she wasn't taking her birth control pill, which was a Yaz equivalent, which is essentially ethinyl estradiol, which is a type of synthetic estrogen plus drospirenone, which is an aldactone derivative, a type of progesterone that we use in birth control pills.

So let's talk about what happened, what it is, and what we should do about it. So what I'm describing to you guys is premenstrual dysphoric disorder. This is different than PMS. It is classified by the DSM-5 criteria as a depressive disorder, and it has a key feature. It significantly interferes with your quality of life, significantly causes distress in relationships, work, parenting, functioning, and it follows a cyclical pattern.

So symptoms show up in that final week, usually before the period, or maybe even for half of your cycle. It improves once the period starts. You might have minimal symptoms the week after, it starts to then trigger again, right when people might be ovulating post-ovulation in that luteal phase, people are starting to have these symptoms. And we're going to talk about the symptoms that people have, but you have to have at least one that has an effect on your core. At least one of the symptoms has to be an affective core symptom, which is mood lability, irritability, anger, depressed mood, anxiety or tension. And critically, this is important: it can clinically cause a significant distress or impairment in your life.

So what's really important is that some clinicians forget you can't reliably diagnose PMDD from memory alone. Retrospective recall really overestimates PMDD. So the standard is to do a prospective—that means starting from the day you are assessed—daily ratings of at least two cycles using a validated tool like the Daily Record of Severity of Problems, the DRSP, Daily Record of Severity of Problems. And so I'm gonna put that link in the bio so you guys know.

So let's talk about this PMDD and how it's different than PMS. PMS is very common. It includes bloating, breast tenderness, fatigue, food cravings, irritability, sleep changes. But most people don't have functional impairment from it. They just kind of feel crummy and maybe they eat a little more chocolate and feel a little more bloated and this kind of thing.

But PMDD is different. The core difference is really severity and the impairment. PMDD symptoms are intense enough to meaningfully disrupt work, relationships, parenting, school, day-to-day function, whatever it is. And the timing is consistent. The symptoms ramp up in the luteal phase, they peak, and then when you start to bleed, there's a clear symptom-free window during the follicular phase.

So if PMS is like, I don't feel like myself, PMDD is like, I don't feel in control of myself. And so that I think is really important to remember.

Remember your follicular phase is a phase in your menstrual cycle. So we talk about the menstrual cycle, the follicular and the luteal phase are the two phases that we talk about when it comes to what's happening in your ovaries. The secretory and the proliferative phases are what's happening in your uterus. So remember, in your cycle in the follicular phase as you are getting a mature follicle as the estrogen levels start to rise, your uterus at the same time is starting to proliferate and build the lining of the uterus until the follicle is mature enough. It's making estrogen, remember. And all of a sudden you realize it's time to ovulate so that egg is released from that follicular cyst, and then you have a luteal surge of the luteinizing hormone. And then progesterone starts to come into the equation as preparing for a pregnancy. And your corpus luteum is really important for that progesterone production, which is the cyst that's made at this time. There's no pregnancy, progesterone levels decrease, and you have that bleeding. And that's the secretory phase. So this is what's happening: follicular phase, luteal phase. The luteal phase is that post-ovulation from mid-cycle to the beginning of your menses. And that's sometimes the time of the most distress for patients with PMDD.

How common is PMDD? People always ask this. It's not rare, but it's also not everybody. Most PMDD estimates are between three and 8%. It's probably underdiagnosed. People sometimes dismiss symptoms. Some women don't feel the need to come in for these symptoms until they become to the point where this poor patient had an intervention. But yeah, it's usually less than 10%, maybe three to 8%.

Part of why it gets missed is, again, people don't seek symptoms, they don't seek relief for years. They normalize it, they blame themselves. Women are stressed out and guess what? Women are really stressed out in perimenopause. We talk about this all the time: pinnacle of their careers or sometimes pinnacle in their home life with kids and maybe they're going through a divorce, maybe they have deaths. I mean, there's so much that can stress you out. There's just looking and paying attention to the world around you. There's ice at your doorstep, whatever. Things are happening to women and it is stressful. But if you normalize it over and over again, you're not actually seeking help. And so that's probably why it's not diagnosed as frequently.

So if you think about people that have these symptoms based on the psychiatric susceptibilities in their genetics, it's closer to 31 to 56% where genetic contribution plays into this beyond just what's happening in your environment, beyond the stress, beyond the lack of sleep, all that stuff. Some studies have shown association with depression severity, higher caffeine intake. Something that I hope we talk about more is really childhood experiences, sometimes adverse childhood experiences. We're talking about all sorts of childhood experiences at ISSWSH this year and how some of these childhood experiences are adverse, some are not, but how it can affect sexual function. If you are listening as a clinician, come check it out.

But smoking and trauma history are real. This shows up consistently in literature. There's some other interesting correlations like Rh negative blood type, obviously is just something that's seen and correlated, but people when they're looking for what's happening with people with PMDD, what are some of the risk factors—that's what we're seeing.

But when someone tells you like, you know what, I've always been like this or mental health runs in my family or my stress tolerance is not there, especially pre-menstrually, this is really a clinical clue for you to kind of dig deeper. And for those of you listening with PMDD, I mean, just because you have a risk factor, we always say that like I have so many cardiovascular risk factors because I am South Asian. I have risk factors across the board for diabetes. So my risk factors and my genetics are not my destiny. I will fight them to the best of my ability so that I can stay healthy. But there are reasons to take a story seriously. We have to start looking at people and screening them differently so that we can be on top of the potential treatment.

And so this makes me think about my patient who was the, we'll call her the holiday dinner patient. When families describe this as like, we avoid you 10 to 12 days out of the month, what the patients experience is, it's almost like I'm watching myself burn down my life and I can't stop it. Again, this lack of control is a big thing that I hear patients talk about. That's why it's important that we continue to label things when they're correct. This is why diagnosis matters. We call it affect labeling.

If we label something, I see this with my PGAD patients all the time. They have been struggling their whole life or for years, and then they realize that there is a term for persistent genital arousal disorder, that it's an actual real thing. And automatically their nervous system calms down and sometimes symptoms diminish. They might go from a 10 out of 10 to a nine or eight out of 10, because now they have something real and concrete that they can label it. This is why tracking matters. This is also why perimenopause can feel like pouring gasoline on something that's already simmering, because all of a sudden you have all this lability in your hormones. And this is what happens to so many women in perimenopause who come off of birth control pill that might've been helping them. And then all of a sudden they realize, am I a Jekyll and Hyde? What the heck is happening?

So which brings me to a question that people always ask, like, why is this happening? Is it abnormal hormone levels? Is it, what is it? And so I think it's a complex issue. It's not just like, oh, your hormone balance is off or whatever the case may be, which is a lot of what people say. Most people with PMDD have regular cyclical normal levels of variations in their hormones and estrogen progesterone. But the core issue really is that PMDD is an abnormal brain response to a normal hormonal change.

And my friend Tammy Rowan, who is brilliant, she's a sex med gynecologist like me at UCSF. And I love some of the ways that she describes PMDD because she's really talking about it as almost like a progesterone sensitivity issue. For some reason, the normal changes that's happening from—some people say it's when the estrogen levels start to decline, others say that it's when the progesterone levels start to go up. And so really it seems to be more of a progesterone sensitivity issue that your brain is abnormally responding to a normal change in the progesterone rise and then the progesterone fall. So I think that's really important.

Until I met Tammy and heard her talk about PMDD—this was years ago at ISSWSH—I never like the lines didn't cross for me. And then of course I did a deep dive after that. And I was like, yeah, this makes total sense now.

But you know, hormones are not just out there floating around. We have to talk about how they work in cells and how they interact with receptors. So think of hormones. We always talk about this lock and key way of thinking of it. The hormone is the key and the receptor is the lock. And so the key turns the lock. It changes behaviors in cells and in tissue. So if you think about as the estrogen interacts with its receptors, as progesterone interacts with its receptors, it turns the key and changes cellular changes.

There are genomic effects and there are non-genomic effects. And these are important to remember because this is really important to understand how hormones shape our lives, how neurotransmitters interact with them, and how receptors are so important. Because why do different people react differently to birth control pills at the vestibule? It comes down to the androgen receptors at the vulvar vestibule. I talk about genitourinary syndrome all the time. And when we talk about provoked vestibulodynia, and I did a podcast on this about talking about hormonally associated provoked vestibulodynia, it comes down to those androgen receptors at the vestibule and how much you have to flood the system in order to keep the tissue where it needs to be, or the tissue starts to change and you get painful sex. It's the same concept.

We have to understand how hormones, which are the key, and the receptor, which is the lock, interacts with each other within cells, within tissues, to have different effects. So we're talking about the brain, for instance. This actually explains a lot. If you think about how premenopausal women experience rapid symptoms—the hot flashes, acute mood changes—and then there's slower progressive changes like bone loss and cardiovascular remodeling, this is the whole concept of genomic versus non-genomic mechanisms.

Hormonal variability, particularly with regard to estradiol fluctuations, really are more important than absolute levels for triggering things. And it's really important to see how those hormones interact with those receptors and influence what's expressed within the cell. So individual differences really come down to how gene expression happens after hormones interact with the receptor, how receptor sensitivity can be different. Some receptors are more sensitive to certain types of molecules.

And so to explain it maybe in a better way: genomic effects are kind of like a slow burn. Hormones enter the cells, they bind to a receptor like in the nucleus, they change gene transcription, the effect can build over hours, over days, over whatever period of time. And so this is where estrogen can influence things like serotonin synthesis, receptor expression, neuroplasticity. Remember, this is the slower sort of progressive change. This is vascular remodeling. This is like bone changes, all the things.

And then the non-genomic effects are kind of when you have receptors near the membrane that triggers a signaling cascade that can happen within seconds to minutes. Think about something like testosterone. Its non-genomic effects are rapid membrane initiated actions compared to the slower gene regulated actions of genomic effects. The non-genomic effects are really interactions with different ion channels, whether that's calcium, potassium, these G protein coupled receptors. If you can think back to biochemistry, and then secondary messenger pathways that lead to immediate outcomes like blood vessel relaxation, muscle enhanced muscle force, neuron signaling.

In fact, if you think about sildenafil, which is Viagra, which was first discovered to inhibit the PDE5 enzyme, the phosphodiesterase type 5 enzyme, inhibits that enzyme by subsequently changing the pathway behind it. That really leads to an increase in something called cyclic GMP, which might ring a bell for some people that we know is in smooth muscle tissue. And that inhibition of that enzyme that leads to an increase in cyclic GMP within the smooth muscle cells causes dilation of the vessels. And that allows for blood to fill up in the penis or when we do it on the vulva and we talk about that kind of stuff. So again, this is an effect through primarily membrane associated signaling.

So I don't know if that helped you or not, but I think it's important to understand how hormones interact with receptors and where they're interacting and how the effects are and if they're within minutes or if it's a longer effect. So that's why the whole point of why I want to talk about that. This is also what we talk about these fast non-genomic effects of receptors and hormones is really why some people feel mood shifts are rapid and not sort of a slow decline, but almost like a switch that's flipping.

So that's really, I think, important too. And you have to remember the neurotransmitters involved. Serotonin helps regulate mood stability, irritability, emotional buffering. Dopamine is a neurotransmitter involved in motivation and reward and drive. Norepinephrine, again, involved in arousal and stress. Your GABA and GABA receptors are really involved—they're really like the brain's primary brake pedal to slow things down. And the glutamate is the gas pedal. So we think about how these neurotransmitters also interact and are modulated by the hormones and the hormone shifts.

So again, PMDD isn't because you have irregular hormones, but more like your brain sensitivity to the hormones. Maybe something within the receptors, maybe how the receptors in the brain interact with those hormones, something is different that impacts the signaling of neurotransmitters like serotonin. So in PMDD, we see that the serotonin signaling is implicated, and that's why using a short course of SSRIs really work well for so many patients. I'm always like, if I give you a sniff of serotonin for about 10 days, it might stabilize everything. It's not something that kind of has to build in your system and all of that stuff.

If you think about one of the metabolites of progesterone, which is allopregnanolone, it really can calm the brain by positively modulating what are known as the GABA-A receptors. So we're calming things down with a metabolite of progesterone. And so that means that the GABA can really put the brakes on stress circuits in so many patients. That's why oral micronized progesterone—I would say about 30 to 40% of patients—helps them sleep, helps them keep relaxed. It's that pregnancy hormone.

But when people have PMDD, the problem isn't that allopregnanolone is all of a sudden bad and the progesterone metabolite isn't necessarily bad, but it's that the brain in the brains that are susceptible, the GABA receptor response... Okay, it's not that progesterone is all bad or the allopregnanolone, which is a metabolite of progesterone is all bad with patients with PMDD. But in those brains that are susceptible, this GABA-A receptors that are really important to put on the brake pedal in your brain, the receptor response to changing levels of allopregnanolone is dysregulated. So all of a sudden you're not responding. In perimenopause, we have less progesterone hanging out. We have erratic amount of estrogen happening. And so we have a dysregulation that is happening due to the receptor response of the GABA-A receptors, more than likely. And so instead of calming, these fluctuations can cause a huge destabilization of mood.

So I don't know if I just confused the hell out of you guys, but I always think it's important to understand what's happening with our receptors and what's happening with hormones and receptors and how they interact with cells and all that stuff.

So that's PMDD. But what happens, like I said, in perimenopause is you have a lot of volatility with estrogen and just a baseline diminishing amount of progesterone. And so we're getting progesterone deficient and we're getting chaotic estrogen. And so the collision point is that you have a lot of hormonal volatility. And in the brains that are susceptible, it leads to these unpredictable swings and moods.

So if you have PMDD and your brain is highly sensitive to hormonal change—the regular hormonal changes, the regular changes that happen with a normal menstrual cycle, the ups and downs, the ebbs and flows—in perimenopause, it can become really prolonged period of changes where you don't know when it's coming and when it's going. And so for some of these women, they experience worsening symptoms as their cycle becomes more irregular and their hormone problems become much harder to predict.

That hormonal volatility with higher highs and lower lows and unpredictable timing, especially in the earlier transition is a problem when your brain is change sensitive. So that's what's important here. Again, your genetic susceptibility, your other things, your receptor susceptibility, everything is making you change sensitive. So the normal ebbs and flows would be difficult. But now the high highs, the low lows, and the unpredictable timing make it really hard.

So like PMDD is my brain hates the luteal phase change. Perimenopause can become my brain is living in chronic change. And it becomes this chronic issue. That's why people might start saying, PMDD is lasting longer. It's not just seven to 10 days anymore. I don't feel like myself more often than not. My cycle is irregular. I can't predict when the crash is coming and what I'm going to feel about.

So this unpredictability is our main reason that a lot of families struggle and why perimenopause is such a bitch, to be honest. But again, if your brain is even more susceptible and you've had PMDD in the past, we have to have really a practical plan to treat it. So again, diagnosing it, we have to track symptoms. You have to have at least, you can use that tool, the DRSP, like I said. The DRSP can track mood lability, tearfulness, irritability, anger, anxiety, tension, depressed mood, hopelessness, feeling overwhelmed, sleep, appetite, energy changes, physical symptoms.

And then we can confirm it by understanding the pattern and the impairment. Because according to our DSM-5, it's all about timing and functional impairment. And those two are key. We always want to make sure that we're screening patients for suicidal ideation, homicidal ideation, all the things. And then we have to rule out other things. We're going to see if the symptoms are persistent all year, all month round, but there's no cyclical change to it, or if there's new onset anxiety, depression symptoms without being cyclical. Because perimenopause can bring all of that. You can have new onset anxiety, new onset depression, you can have sleep deprivation that drives mood, you can have thyroid issues, you can have anemia, you can have fatigue, you can have all the things.

But you can also have PMDD with baseline anxiety and depression. And so the question really becomes: Is there a cyclical exacerbation layered on top of this nuance of anxiety and depression? And that's what takes a little bit of detective work to kind of get under.

In general, we look at all the symptoms and the tracking with all these things during your menstrual cycle and see if you have five or more of the symptoms present the week before your period and stops within a few days of your period. And it must cause significant distress. It must disturb your ability to function in social situations or other situations like I've already mentioned and not related to other health conditions.

So again, the most common symptoms: depression and sadness, hopelessness, feeling worthlessness, this anhedonia, this complete feeling of not feeling joy from anything, increased anxiety, tension, feelings of like being on the edge all the time. We call them sort of ruminating thoughts, brain hiccups, whatever you want to call them. Mood swings, really self-critical thoughts, increased sensitivity to rejection, frequent or sudden tearfulness. The hallmark, a commercial's making you cry. Like everything is making you irritable or angry, which also can happen in perimenopause, by the way, without PMDD. Conflict with families and workers and friends and decreased interest in what normally makes you happy and concentration problems and just fatigue and lack of energy.

And then physical symptoms like binge eating, overeating or craving certain foods. We might have changes in sleep where you're sleeping too much or too little. You might feel overwhelmed or feel out of control and then other physical symptoms like breast swelling or tenderness, headaches, joint or muscle aches, weight gain, bloating, all of these kind of PMS-y symptoms on top of this severe distress related to some of these affective issues.

So while we start monitoring some cycles and see how you're doing, really ACOG, our American College of Ob-Gyn, really emphasizes a multimodalist approach. We're talking, let's look at your lifestyle. We talk about, look at what medications you're on. We're gonna talk about cognitive behavioral therapy. We're gonna talk about exercise and diet and what do these things look like for you?

A lot of people will choose luteal phase medication. Like I said, sometimes I tell a patient, you know what, maybe a sniff of serotonin 10 to 14 days out of the month is all you need. And so fluoxetine is one of the most studied SSRIs in PMDD. And so a 10 milligram dose for some patients 10 to 12 days has been life transforming. It can really work fast compared to medications that we need for antidepressants. So a lot of patients are fine taking it as needed, where they start feeling their mood changing and they can start, or they start it right at the time of ovulation.

And if we look at your brain is sensitive to these hormonal changes, one way to deal with it is to reduce the change, to stop the ups and downs, the ebbs and flows. And so there's a type of hormonal therapy that is known as hormonal contraception. I like to call it just hormonal therapy of some type because some people, the OCPs are getting such a bad rap on social media. And for some people, a combined hormonal contraception with no hormone-free interval—you're skipping that placebo week, we're shortening, we're just taking it what we call continuously—we're avoiding the ups and downs. And so for so many people that can really be life transformative for them.

It's really individualized. Like I said, because we think this is a progesterone sensitivity or progestin sensitivity that some of the classic progestins don't work as well, but the well-known medication, Yaz, which has drospirenone—for people that take progesterone only, that would be Slynd. The drospirenone is an aldactone derivative that binds to the progesterone receptor in a very competitive manner, but it's not a true progestin. So that's what's interesting. And so that's probably why it works so well for patients that have PMDD.

And so the question is like, what about in this perimenopausal period with something like Nextstellis, which is estetrol plus drospirenone, would that be beneficial? And yes, I've seen it anecdotally be beneficial for those patients.

There are patients that have refractory PMDD that none of this works. So what do we do for them? It's hard. We can suppress ovulation, we can eliminate cycling, and we can do that by using medications that are a GnRH agonist or antagonist, which means that they are competing with your gonadotropin releasing hormone acting at the level of the brain to kind of put you into a medical type of menopause. And so we do this and then we get to give back some estrogen and we have to give back some progesterone.

So for some patients with the severe PMDD, and you're shutting them down or putting them into a menopausal state or if they're having their ovaries removed for one reason or another, you can give them back Duavee, D-U-A-V-E-E, which is a combination of both.

There is some promise with the medication that's called Ella or Ella-1, which is ulipristal, which is a prescription used primarily for emergency contraceptive. It's morning after pill to prevent pregnancy after unprotected sex or contraception failure. It's a selective progesterone receptor modulator, an SPRM instead of a SERM. And so it mainly works by preventing or delaying ovulation, the release of an egg. And so it's also been potentially a novel treatment for PMDD. It is ulipristal acetate, remember UPA, which is a selective progesterone receptor modulator. And it modulates progesterone receptors in the brain at a daily dose of five milligrams. In some trials, it has been shown to improve PMDD symptoms over three cycles.

It's still in the early stage of being looked at. It's currently really not approved for PMDD. It's only available as Ella, which is that single 30 milligram dose. I think the one being studied is a five milligram daily. And it is available in Europe at five milligrams daily called Esmya, E-S-M-Y-A, and really used to treat uterine fibroids. Not approved for that in the US, but it is a potentially new option that looks promising for PMDD: ulipristal, selective progesterone receptor modulator.

And then let's not forget non-pharmacological treatments. Cognitive behavioral therapy is really important, can help with symptom coping and relationship repair. Exercise has some evidence. And there are some supplements like the chasteberry or Vitex that I have patients that swear by. Vitex is a popular herbal supplement that is thought to help with mood swings and breast pain, fluid retention by influencing dopamine and lowering prolactin and might help with that menstrual cycle shifts. It's slow acting though, and you have to use it for a few months to see the benefit. It's, like all supplements, difficult because we don't have standardized dosing or standardized regimens to kind of look at this. But there is mixed to modest evidence suggesting its importance.

Also, people are in that perimenopausal transition and they're really vulnerable to the mood swings. We can use transdermal estradiol. I've seen people get a little bit worse sometimes using oral micronized progesterone. So that's why I have worked with them to use Slynd, S-L-Y-N-D, which is drospirenone. But you can actually see some benefit for these patients as well. It's not that hormonal therapy is the answer for everyone, but it does help in that perimenopausal transition for many.

So this is kind of what we're looking at. I wanted to kind of explain how hormonal sensitivity and really your body's ability to respond to hormones has to do with receptor sensitivity and really the lock and key has to be remembered.

But really some key takeaways for you to remember is that PMDD is not a Jekyll and Hyde personality issue. It's a brain sensitivity to hormonal change. And this hormonal change can be very normal hormonal changes of a normal menstrual cycle, or it can be more erratic and crazy changes that are happening in perimenopause. Perimenopause is the season of volatile hormonal change. And so the collision with perimenopause and PMDD can be very brutal and we really should be on top of these patients and helping them navigate this.

And that means even if you're that patient listening and you say, this is me, what should I do about it? Don't dismiss these symptoms. Don't wait till you're on a break and don't wait till you're gonna have a family intervention about it. Track the symptoms for at least two cycles or more. Bring that data to a clinician who takes cyclic mood symptoms seriously. Try to find someone that has time to listen. That might not be your standard PCP that has 40 patients a day, and it might not be the standard OB-GYN that has a waiting room full of pregnant women. It might be someone that's doing GYN only, that's doing more detailed care that can sit with you and understand the nuances of what's happening to your body.

And remember, if symptoms feel unsafe, especially suicidal thoughts, please seek help urgently. If you love somebody with PMDD, it's not that you don't love them during those 10 to 14 days. It's that their nervous system is on fire and we need to treat them. And so again, you're not alone in this. There are real evidence-based options. This is a real condition and you're just more susceptible because of what's happening. But there is help available. So I just want you guys to remember that. And you don't have to feel alone and you don't have to feel like it's time for you to have an intervention that you can work on this before that time.

So I wanted to get this in before the end of the year, but actually this is probably gonna play right at New Year. So happy New Year to those of you listening. Please be safe. I am going to on New Year's Eve or New Year's Day do one of these vision boards so that I can put things into motion. But I'm very excited about my book that will be released hopefully this spring. I have been through the edits. I am working on trying to get a book tour together. So Brown Girl's Disease; A Guide to Sexual Health and Empowerment Through a South Asian Lens is a book for everyone. You don't have to be South Asian. You don't have to be a woman of color. You just have to want to know more about your body and your sexual function.

But for those of you who are women of color and South Asian and brown or black, please know that you finally have someone that is going to listen and guide others in helping you. I'm excited about the new year. I'm excited about the book. I'm excited about being on the upcoming docuseries called Balance. It's a balanced docuseries on perimenopause. So please stay tuned to my social media to find out more about this. I think it's going to be on Netflix. You can catch me and some of my friends and colleagues there.

And I'm excited about the ISSWSH annual meeting in February, the scientific chair. It's been a real journey, probably one of the best things I'm hoping to churn out and one of the hardest things. It's gonna be a great conference. Come to Long Beach February 11th through the, or 12th through the 15th. Spend Valentine's Day with us. What better time to spend Valentine's Day than talking about sex?

And then what else? Yeah, I'm gonna continue to build out my concierge practice. I'm gonna continue to educate everyone and hopefully be more present for my family and friends.

So thank you for joining me for another episode of Gyno Girl Presents Sex, Drugs and Hormones. I'm Dr. Sameena Rahman, Gyno Girl. Remember, I'm here to educate so you can advocate for yourself. Please join me on next week's episode. I have some good ones coming up too, guys. I have my friend Kelly Casperson that's going to be on. We have Avron Blooming. We have many others coming through the pipeline. Camila Phillips. Trying to think who else. I'm interviewing some international people. I'm going to hopefully get Tami Rowan on after ISSWSH to talk about ISSWSH. She's the upcoming or she's going to be one of the next presidents.

So yeah, join us and please like and subscribe to my channel. All right. Take care. Bye.