Mental Health Awareness Month
Diving Deeper into Premenstrual Dysphoric Disorder: The Benefits of Charting
By: Shannon Coyne, DO
Director’s Note: Many women suffering from premenstrual dysphoric disorder (PMDD) are met with antidepressants and oral contraceptive pills (OCPs) as the first-line or only treatment. However, this Mental Health Awareness Month we are diving into the role of charting with fertility awareness-based methods (FABMs) as a valuable tool to identify the cyclical nature of symptoms in the luteal phase. Charting can guide the timing of targeted hormone profiles to facilitate the diagnosis and treatment of PMS or PMDD with progesterone or other supplements, such as low-dose naltrexone (LDN). Through this interview with an FABM user, former FACTS elective student Dr. Shannon Coyne lends insight into the role that cycle tracking and restorative reproductive medicine play in addressing underlying hormonal imbalances.
While fertility awareness-based methods (FABMs) — which involve tracking biomarkers of the female cycle — may be best known for their use in family planning, they also have additional applications for both physical and mental health. As a college student, Caitlyn* began casually tracking her cycle using various apps. However, it wasn’t until she took a course in the Sympto-Thermal Method (STM) and started consistently charting that she was able to see several health benefits. Caitlyn had prior knowledge of some methods, like Billings and Creighton, that use cervical mucus exclusively to track patterns of fertility. However, the Sympto-Thermal Method was ideal for Caitlyn since she had chronic cervical mucus throughout her cycle and wanted a “double-check” to confirm when she was infertile. With the Sympto-Thermal Method, women learn to chart both cervical fluid observations and basal body temperature (BBT), which is measured at the same time each day. Influenced by the rise in progesterone, a woman’s BBT noticeably increases after ovulation and stays elevated throughout her post-ovulatory, or luteal phase. It then drops during menstruation. Caitlyn and her husband planned to use the method to avoid pregnancy for the first few years of their marriage, since she would be getting a Master’s degree during that time.
“The Sympto-Thermal Method was ideal for Caitlyn since she had chronic cervical mucus throughout her cycle and wanted a ‘double-check’ to confirm when she was infertile.”
For the past two years Caitlyn used this method, identifying consistent patterns in her mood that coincided with her luteal phase. Every month, for about 10 days she would experience mood swings, depression, irritability, insomnia, and fatigue. She has a family history of depression and had seen a therapist for several years without any relief of her symptoms. Recognizing this pattern in her cycle charts prompted her to bring up her symptoms to her primary care clinician who used her chart to diagnose her with premenstrual dysphoric disorder, or PMDD. PMDD is a severe form of premenstrual syndrome (PMS), in which various mental and physical symptoms regularly present in the week leading up to menses and improve within a few days of onset of menses. Symptoms commonly include mood swings, anger, irritability, anxiety, sense of hopelessness, difficulty concentrating, changes in appetite, fatigue, bloating, insomnia, hypersomnia, and feeling overwhelmed. A woman does not need all of these symptoms to be diagnosed with PMDD, but the symptoms do have to interfere with one’s daily life.
For many women, including Caitlyn, these symptoms can become debilitating.
Caitlyn’s doctor recommended treatment with a selective serotonin reuptake inhibitor (SSRI), a type of antidepressant. SSRIs are often considered the first-line treatment for PMDD and have good evidence for efficacy. Combined estrogen-progesterone contraceptives (COCs) are often recommended as a second-line treatment. For patients who prefer a hormonal form of contraception, COCs may be offered in addition to or in the place of SSRIs. Alternatively, for patients looking to avoid pharmacological intervention or hormonal contraception, medical protocols affiliated with various FABMs may provide another option to monitor and manage PMDD symptoms.
Caitlyn described herself as someone who prefers a natural approach to her health, so she was initially hesitant about starting an antidepressant. However, her symptoms had become debilitating and were negatively impacting her life. As Caitlyn approached ovulation each cycle, she began to dread the onset of her luteal phase because of her symptoms. She felt helpless to prevent them, and she voiced her frustration about feeling as though she had no control over her own body. Once she started taking the SSRI, however, it became “very apparent that my symptoms became way more manageable, and it showed in my daily living.” After several weeks of taking the medication, she noticed a significant difference — she no longer dreaded the start of her luteal phase.
“As Caitlyn approached ovulation each cycle, she began to dread the onset of her luteal phase because of her symptoms. She felt helpless to prevent them.”
Caitlyn has now been taking an SSRI every day for six months. While this continuous regimen has worked well for her, alternative protocols may be warranted depending on a patient’s pattern of symptoms. For a woman with predictable symptoms and cycles, luteal phase-only therapy may be implemented.For example, a patient might only need to take the SSRI on the day of ovulation and continue until menses begins. For women with an easily-identifiable onset of symptoms lasting less than a week, there is also the symptom onset method, in which patients start taking the SSRI at the onset of symptoms and continue until the first few days of menses. The continuous SSRI regimen has been shown to be most beneficial for those with irregular cycle lengths, mild symptoms during the follicular phase, and those with physical symptoms such as fatigue, bloating, and appetite changes.
As Caitlyn experienced, SSRIs and oral hormonal contraceptives are often recommended as standard treatment for PMDD. However, because Caitlyn was charting her cycle, she began to recognize the cyclical nature of her symptoms. Utilizing charting to identify peak day and ovulation, an FABM-trained physician can time lab work to examine hormone levels throughout the subsequent luteal phase. As discussed in the FACTS elective, women with PMS and PMDD commonly experience falling levels of progesterone and estrogen during the luteal phase. These abnormal hormone levels are also often apparent in a woman’s chart, manifesting as premenstrual spotting or a short luteal phase.
For women like Caitlyn, suffering from PMDD and looking to avoid OCPs and SSRIs, progesterone and other supplements offer an alternative intervention. Cycle charting and targeted lab work can be used to time treatment with progesterone supplementation, as bioidentical hormone therapy can counter the steep drop in progesterone and normalize hormone levels. Another option discussed in the elective is low-dose naltrexone for PMDD.
“Caitlyn has ‘reaped the benefits’ of using FABMs and urges others to be open minded about them. She also stresses … the importance of teaching younger people about cycle tracking.”
Caitlyn has “reaped the benefits” of using FABMs and urges others to be open minded about them. She also stresses the need for more research in fertility awareness, as well as the importance of teaching younger people about cycle tracking. An earlier education in FABMs will enable young women to learn about the biomarkers that signal not only patterns in their fertility, but also what is normal or abnormal. With earlier education and identification of treatable conditions, women can be empowered to make the best decisions for their physical bodies and mental health.
*Names have been changed to respect the privacy of the interviewee. All information is shared with permission.
ABOUT THE AUTHOR
Shannon Coyne, DO
Shannon Coyne, DO is a first year Family Medicine Resident at Geisinger Northeast, in Wilkes Barre, Pennsylvania . After recognizing the lack of education on Fertility Awareness Based Methods (FABMs) in her medical school curriculum, she elected to take the FACTS elective to learn about these methods so that she could confidently care for patients using FABMs, desiring to use FABMs, or who may not know about FABMs. She strives to be an educational resource and advocate for all her future patients, and hopes to empower patients to take control over their bodies and health.
