As women, we experience a fascinating and sometimes frustrating journey of hormonal changes throughout our menstrual cycle.
This natural process consists of distinct phases, each with its own unique characteristics. Whether you're just starting your menstrual journey or have been navigating it for years, gaining a deeper understanding of what's happening within your body can empower you to take care of yourself.
So, let's dive into the details of a typical menstrual cycle!
The Cycle: A Month of Hormonal Changes
The menstrual cycle refers to the complete month of hormonal fluctuations that women experience. Cycles between 24 and 35 days are considered normal.
For ease of discussion we re going to discuss a 28-day cycle.
The follicular phase begins on the first day of your period and lasts until ovulation occurs.
The cycle begins with menstruation, which typically lasts for seven days or less. During this phase, the endometrial lining is shed as progesterone (P) and estrogen (E) levels reach their lowest points. You may experience lower energy levels, less inclination to exercise, and a need to be gentle with yourself and prioritize nourishment.
The follicular phase is characterized by the body's preparation for ovulation. Estrogen levels gradually increase, signaling the brain to release luteinizing hormone (LH). This surge of hormones prompts the release of an egg from the ovaries.
During the follicular phase, estrogen takes the spotlight as the dominant hormone. This can lead to positive mood shifts due to estrogens positive effects on serotonin, healthier and more vibrant skin, improved immunity, higher energy levels, and enhanced creativity and sociability.
Ovulation: A Fertile Window
Ovulation marks a ~24-hour window when the released egg is ready for fertilization. Testosterone levels also peak during this phase, often resulting in an increased sex drive, better pain tolerance, and sustained good energy levels.
Women are fertile for about 6 days each cycle because the sperm can survive in the uterus for up to 5 days.
Luteal Phase: Preparing for Implantation
Following ovulation, the luteal phase begins and lasts until the start of your next period. Progesterone levels rise in relation to estrogen, helping prepare the uterus for potential pregnancy. It's important to note that even with balanced hormones, it's normal to experience some changes during this phase. These can include sleeping more, feeling less social, minor mood changes, and cravings for comfort foods.
Understanding PMS and Its Symptoms
Premenstrual syndrome (PMS) refers to the collection of symptoms that occur in the days leading up to your period. It's common to have one or a few premenstrual symptoms, but clinically significant PMS affects only 3 to 8% of women, while premenstrual dysphoric disorder (PMDD) affects approximately 2%.
Classic symptoms of PMS include:
cravings, increased appetite
bloating (most commonly reported)
feelings of sadness, anxiety, difficulty concentrating
PMS is diagnosed when at least one symptom occurs during the luteal phase and impairs daily functioning.
For women who experience five or more symptoms, with one being an "affective symptom" (such as mood swings, anger, irritability, hopelessness, tension, or anxiety), it may indicate PMDD (premenstrual dysphoric disorder).
Causes of PMS
Hormonal Changes and Abnormal Response:
Contrary to popular belief, studies have shown that cyclic changes in estrogen and progesterone alone are not solely responsible for the symptoms experienced by women with PMS or premenstrual dysphoric disorder (PMDD). Research indicates that women with PMS have normal concentrations of serum estrogen and progesterone but some women may be more susceptible to the changes and have an abnormal response to normal changes in the hormones (1).
When progesterone starts to fall around day 21 of the cycle is typically when many women experience PMS symptoms, this is why replacing progesterone during this time with a prescription oral progesterone or cream can help to alleviate symptoms in women who are more sensitive to this change.
Another important factor contributing to PMS is the interplay between hormones and neurotransmitters. Serotonin, a crucial neurotransmitter involved in mood regulation, has been implicated in the pathogenesis of PMS. Women with PMS often exhibit lower serotonin levels during the luteal phase compared to those without the condition. This finding is supported by studies showing that PMS symptoms improve with the use of serotonin agonists like fenfluramine and worsen when there is an acute depletion of the serotonin precursor tryptophan (1).
Serotonin reuptake inhibitors (SSRI), such as Prozac, are one of the most effective treatment options for PMS.
Approaching and Treating PMS
Stress management techniques and regular exercise have shown positive effects on reducing symptoms of PMS.
Specific natural remedies like magnesium, curcumin, ginger, and fish oil may also be helpful for alleviating cramps and supporting hormonal changes.
Vitex agnus castus (chaste berry) is an herbal remedy that appears to be an effective treatment option for women with mild premenstrual symptoms. Overall, vitex appears to be more effective than a placebo for PMS symptoms (2).
Taking progesterone orally in small doses in the last part of the luteal phase until the start of the period is also very helpful for a lot of our patients. This requires a doctor's prescription.
For PMDD, treatment options may include selective serotonin reuptake inhibitors (SSRIs), progesterone supplementation, and cognitive-behavioral therapy (CBT).
Testing and Monitoring Hormone Levels
To better understand your hormone levels, testing can be helpful. Blood work done between days 19 and 21, around 5-7 days after ovulation, can provide insights into estradiol (E) and progesterone (P) levels.
The DUTCH test, a preferred testing method for sex hormones, examines hormone metabolites and provides insights into detoxification and methylation pathways. Additionally, a four-point cortisol test can help evaluate stress levels.
By understanding the complexities of your menstrual cycle and identifying potential hormone imbalances, you can take proactive steps toward improving your well-being.
Remember, every woman's experience is unique, and seeking guidance from healthcare professionals who specialize in hormonal health is crucial.
Kimberly A Yonkers, MD Robert F Casper, MD. Epidemiology and pathogenesis of premenstrual syndrome and premenstrual dysphoric disorder. In: UpToDate, Basow, DS (Ed.), UpToDate, Waltham, MA. (Accessed June 30, 2023).
The American College of Obstetricians and Gynecologists (ACOG)
Diagnostic and Statistical Manual of Mental Disorders (DSM-5)