PMS Anxiety: Causes and Treatments

When you hear the words premenstrual syndrome (PMS), the first things you probably think about are mood swings, bloating and cravings. What may not spring immediately to mind is anxiety. Yet premenstrual anxiety is one of the possible symptoms many women experience during the week or two before their period. It just hasn’t been talked about as much as those other, arguably more well-known, symptoms.

However the conversation about premenstrual anxiety is growing these days – perhaps it’s a sign of the times we’re living in. But while it’s one thing to feel a bit tense or to worry a bit more than usual in the run-up to your period, experiencing stomach wrenching, panic-inducing anxiety is quite something else. In other words, some anxiety is considered normal, but severe anxiety definitely is not.

Is it normal to get anxiety before your period?

According to the NHS, most women who have periods experience one or more of the symptoms of PMS at some point or other (i). What we don’t know is how many women are affected by premenstrual anxiety, which is just one of around 150 physical, psychological and behavioural symptoms associated with PMS – you can read more about these in our guide to premenstrual syndrome.

Anxiety is an emotional symptoms of PMS, with others including:

• Irritability

• Hostility

• Concentration and memory problems

• Depression and low mood

So how do you know if you’re suffering with anxiety in the first place? According to the NHS anxiety is a feeling of unease, such as worry or fear, that can be mild or severe (ii). It’s one of those things that affects just about everyone at some point or other. Indeed many things in modern life can make us anxious, such as sitting exams, going for a job interview, taking your driving test or speaking in public. And that’s quite normal.

But if you find it hard to control your worries, if you worry most of the time rather than just occasionally, or if your worries are so severe that they affect your daily life, you may have an anxiety disorder such as generalised anxiety disorder (GAD), panic disorder, social anxiety disorder or post-traumatic stress disorder (PTSD).

Anxiety can make you feel uneasy, but there are other ways it can affect you too, including making you feel restless, irritable, constantly on edge and unable to concentrate. Physically you may also feel dizzy or lightheaded, and you may feel nauseated or have a stomach ache. Some people also experience problems with their heartbeat (it may be faster than it should be or irregular), and feel shaky or sweaty, or even short of breath. Specific things can trigger these symptoms – especially if you have a phobia. But it’s also common to feel anxious for no obvious reason.

Find out more about anxiety and what you can do about it in our guide to anxiety symptoms.

What causes premenstrual anxiety?

According to the Mental Health Foundation, more than eight million people in the UK experience anxiety, with women almost twice as likely to be diagnosed with anxiety disorders as men (iii). Women, says the Anxiety & Depression Association of America, are also more likely to have multiple psychiatric disorders during their lifetime than men (iv). Differences in brain chemistry are likely to play some part in this, but it’s also thought that the female menstrual cycle and all the hormone fluctuations that go with it could also be to blame.

The same may apply to other PMS symptoms too. According to the US-based Office on Women’s Health, while scientists still don’t know exactly what causes PMS, many have suggested these hormone changes – particularly the ups and downs in the levels of the hormones oestrogen and progesterone – could be at least partly responsible (v).

Here’s how it works:

During the first half of your cycle, levels of certain hormones – follicle-stimulating hormone and oestrogen – start to rise. Then roughly halfway through your cycle (this is around day 14 of a typical 28-day cycle) your oestrogen levels are high and you start producing another hormone called lutenising hormone to trigger the release of an egg (in other words, ovulation).

After you’ve ovulated your body starts pumping out progesterone as well as higher amounts of oestrogen. But if the egg isn’t fertilised – that is, if you don’t become pregnant – your oestrogen and progesterone levels drop dramatically during the last phase of your cycle, called the luteal phase. While your body is experiencing the rising and falling of these hormones you’re also most likely to be affected by PMS symptoms, including anxiety. Thankfully your hormone levels settle down again and you feel much more like yourself again when your next cycle starts, which is when you get your period.

But why do some women experience anxiety and other PMS symptoms while others seem to sail through their cycle without breaking a sweat? The truth is we don’t really know, but increased sensitivity to these shifts in hormonal activity may be to blame (the more sensitive you are, the worse your anxiety and PMS symptoms may be). It’s also thought that women who have ongoing mental wellbeing problems – that is, women who experience symptoms all or most of the time, not just before their period – are more likely to feel worse during the premenstrual stage of their cycle.

Changes in brain chemicals

We still don’t know exactly why fluctuating levels of oestrogen and progesterone can cause so many PMS symptoms during the premenstrual phase of the menstrual cycle. But one theory that relates to the emotional symptoms of PMS is that both these hormones can alter the production of certain brain chemicals – or neurotransmitters – linked with mood regulation, including:

Serotonin Often called the ‘feel-good’ hormone, serotonin is important for your mood as well as other things such as your sleep-wake cycle and cognitive function. According to the Anxiety & Depression Association of America there’s also some evidence to suggest the female brain doesn’t process serotonin as quickly as the male brain (iv).

Dopamine Often described as controlling feelings of pleasure and reward, dopamine is also involved in motivation and learning.

Glutamate This is also important for cognitive functions such as memory and learning.

GABA Gamma aminobutyric acid has a calming effect, so it’s important for managing feelings of anxiety and stress.

Changing levels of the hormone cortisol may also have something to do with premenstrual anxiety. That’s because cortisol is known to trigger anxiety and rises rapidly in the few days before your period starts, which is when your premenstrual anxiety may be at its worst.

There’s also a theory that, in many cases, premenstrual anxiety may simply be triggered by a dread of PMS itself, especially in women who experience particularly troublesome PMS symptoms.

PMS or PMDD?

Anxiety before a period can be a symptom of PMS, but if your premenstrual anxiety – or any other PMS symptom – is so severe that it’s having a negative effect on your quality of life, it may be a sign that you’re experiencing a severe form of PMS called premenstrual dysphoric disorder (PMDD).

PMS and PMDD both have physical emotional symptoms. However with PMDD the emotional symptoms can be extreme, including:

• Severe anxiety and panic

• Feeling completely overwhelmed

• More severe depression

• Severe mood swings

• Severe irritability and anger

• Social withdrawal

• Tearfulness, sudden sadness or a feeling of hopelessness

There is also some evidence linking anxiety with PMDD that suggests women with generalised anxiety disorder are more likely to experience PMDD symptoms (vi).

According to experts at the mental health charity Mind, the causes of PMDD are likely to be the same as those of PMS – that is, it’s caused by sensitivity to changes in hormone levels during the menstrual cycle. However they also claim there’s evidence some cases of PMDD may be linked to stressful and traumatic past events such as emotional or physical abuse (vii).

If you think you may have PMDD it’s a good idea to speak to your GP, gynaecologist or another healthcare professional, as there are treatments available that might be helpful. Treatments include antidepressant and anti-anxiety medications as well as hormone therapy and cognitive behavioural therapy.

You can find out more about PMDD and how it’s treated, as well as things you can do to help yourself by reading our guide to premenstrual dysphoric disorder.

What is PME?

Anxiety can also be a sign of a condition often called premenstrual exacerbation (PME). PME affects women with existing mental health conditions whose symptoms become worse during the premenstrual stage of their cycle, before their period starts. Besides anxiety disorders, some of the mental health conditions that may worsen during the premenstrual phase of the menstrual cycle can include:

• Depression

• Eating disorders

• Schizophrenia

• Substance use disorder

What helps PMS anxiety?

If you experience anxiety in the run-up to your period, the good news is there are things you can do that may help make you feel better.

Keep exercising

The more active you are, the better you may cope with PMS symptoms including anxiety. One small-scale study involved young women aged 18 - 25 who were diagnosed with PMS. They took regular aerobic exercise, and after just eight weeks of training their PMS symptoms – including anxiety – had improved significantly (viii). Exercise is also considered beneficial for mood disorders in general, since it helps boost your brain’s level of feel-good chemicals called endorphins. Plus it can be useful for relieving physical PMS symptoms such as bloating, digestive problems and headache.

To get the benefits yourself, aim for at least 150 minutes of moderate exercise each week (try something you enjoy that leaves you slightly out of breath for about half an hour, five times a week).

Get a good night’s sleep

If you’re not sleeping well, you’ll probably find it more difficult to cope with anxiety and other PMS symptoms. That’s because a lack of sleep can make you more anxious as well as more vulnerable to the negative effects of stress. During the run-up to your period, try to make getting a good night’s sleep a priority – discover ways to improve your sleep by reading our guide to sleep and insomnia

Find ways to relax

Relaxing and reducing your stress levels can drive down anxiety, so do whatever helps make you feel calmer. Lose yourself in a relaxing activity or hobby, or try some yoga or meditation. Breathing exercises are quick ways to make you feel more relaxed quickly – indeed one study has found practising pranayamic breathing (exercises used in yoga) and other types of breathing that focus on controlling the movement of your breath may improve anxiety by having a positive effect on your heart rate (ix).

But you don’t have to become a yoga expert to benefit from breathing exercises. Just put one hand under your ribs and relax your stomach, breathe in slowly and deeply through your nose, making your hand rise, then breathe out slowly through your mouth, making your hand fall. Keep going until you feel the anxiety melting away.

Avoid smoking

You don’t need us to tell you that smoking is bad for your health. But here’s another reason to quit. Smoking, say researchers, makes you more likely to develop not just PMS but also PMDD (x). If the mere thought of giving up smoking makes you feel even more anxious, bear in mind that there are lots of stop smoking aids to make your smoke-free journey easier, including patches, lozenges and gum that can help with nicotine cravings.

Drink alcohol in moderation

The NHS also claims alcohol has been shown to make anxiety worse (xi). Only drinking moderate amounts may help reduce your anxiety – this means not regularly drinking more than 14 units of alcohol each week and spreading your drinking over three days or more if you do drink that much.

Track your cycle

If you know in advance when you might start feeling more anxious than usual, it can help you take steps to relax more and even reschedule events or activities that could make your anxiety worse. One way to keep an eye on your cycle as well as any PMS symptoms you experience is to use a cycle tracking app on your smartphone, such as FitrWoman or MyFlo (both are available from the App Store and Google Play). Alternatively, keep a record of when your cycle starts and when any symptoms appear in a diary or written log – you’ll soon notice a pattern emerging, which could help you be more prepared.

Eat healthily

A balanced, healthy diet that includes at least five daily portions of fruit and vegetables is a must for all aspects of your health, including your emotional wellbeing. Put foods rich in complex carbohydrates on your plate too – whole grains, for instance – as they may help you feel calmer. But avoid indulging in too many sweet foods, as well as foods that contain a lot of salt or caffeine (according to the NHS drinking too much caffeine can make you more anxious than normal (xi)).

What’s the best supplement for PMS?

As well as eating healthily, you may also want to consider taking one or more nutritional supplements that could help with anxiety and PMS symptoms in general.

St John’s wort

This herbal remedy is used for the relief of slightly low mood and mild anxiety, based on traditional use only. There’s also some evidence it may be helpful for PMS-related mood changes (xii). St John’s wort may be useful if you experience some depression alongside anxiety, with research suggesting it’s as effective as conventional antidepressant (xiii). However, if you take any other medicines, always check with your GP or pharmacist that it’s safe to take St John’s wort alongside them, as it interacts with certain medications (the oral contraceptive pill, some antidepressants, statin and warfarin, for instance).

5-hydroxytryptophan (5-HTP)

This amino acid is converted in the brain to serotonin. It’s been studied for its potential effect on anxiety symptoms, with studies claiming it may well be effective – though not quite as effective as a medicine called clomipramine (xiv). Studies also show 5-HTP may work as well for depression and low mood as conventional antidepressants (xv), plus it could help if you’re finding it hard to get a good night’s sleep (xvi).

Valerian

Valerian is a herb used for the relief of mild anxiety as well as sleep disturbances, based on traditional use only. There’s some evidence that it may help keep you calm in stressful situations (xvii), though most of the research into valerian tends to focus on its ability to improve sleep (according to the National Institutes of Health in the US, valerian has sedative properties (xviii)).

Rhodiola rosea

With a long history of traditional use throughout Europe, rhodiola is a popular herbal remedy for stress. There is some research to suggest it works significantly better than a placebo (dummy pill) for reducing anxiety and boosting overall mood (xix), with another study also concluding that rhodiola has possible beneficial effects on mood (xx).

Vitamin B6

You need vitamin B6 to help your brain produce chemicals (or neurotransmitters) such as serotonin and norepinephrine, both of which are important for regulating your mood. There’s also some evidence to suggest B6 supplements might help reduce the symptoms of PMS in general, with a review of nine published studies finding it’s more effective at reducing PMS symptoms than a placebo (xxi). Meanwhile a small-scale randomised controlled trial has found taking B6 for three months may help reduce a range of PMS symptoms, particularly anxiety (xxii).

Vitamin B6 is available as a single nutritional supplement, but you can also get it in multivitamin and mineral supplements formulated for women.

Magnesium

Like B6, magnesium can be taken as a single supplement or as part of a good-quality multivitamin and mineral. This mineral may be important for people who experience anxiety as it’s thought to help balance levels of GABA in the brain (xxiii). Experts also believe your magnesium levels may be low if you’re feeling stressed (xxiv), while researchers elsewhere have found a multivitamin containing magnesium along with other minerals may help reduce anxiety and stress symptoms (xxv)).

Evening primrose

If you tend to get anxious because you dread having PMS every month, evening primrose oil could be useful as it may help with a range of premenstrual symptoms. Evening primrose oil contains gamma-linoleic acid (GLA), which researchers believe might improve the duration and severity of PMS symptoms (xxvi).

Ashwagandha

A traditional Ayurvedic herb, ashwagandha is best known as being helpful for tiredness, fatigue and stress. One small-scale study suggests it may reduce levels of the stress hormone cortisol (xxvii), which could play a part in triggering premenstrual anxiety. Other researchers found 88 per cent of trial volunteers felt less anxious after taking ashwagandha, and that it was well tolerated and as safe as a placebo (xxviii).

Fish oils

The omega-3 fatty acids EPA and DHA, found in oily fish and fish oil supplements, are widely thought to support brain health, with a review of 19 clinical trials concluding that they may have a positive effect on anxiety (xxix). You can get these fatty acids by eating oily fish such as salmon, trout, pilchards and mackerel or by taking a good-quality fish oil supplement. Vegetarians and vegans can benefit from these nutrients too, since non-fish omega-3 supplements that contain the natural triglyceride form of omega-3 sourced from marine algae are now available.

Vitamin D

You may mainly associate vitamin D with keeping your bones, teeth and muscles healthy, but there’s lots more to this nutrient, including mood regulation benefits. There’s even some research that links a vitamin D deficiency with anxiety (xxx), with one study finding taking vitamin D supplements may improve anxiety as well as depression in women with type 2 diabetes (xxxi).

Official UK guidelines recommend that everyone should consider taking a daily vitamin D supplement during the autumn and winter, and that some people who have very little or no sun exposure, as well as people with dark skin, may want to take them all year round (xxxii).

The recommended supplement form of vitamin D is D3 (cholecalciferol), as this is the natural form of vitamin D our bodies make when we’re exposed to sunlight. You can get it in tablets as well as veggie-friendly drops. Most vitamin D3 supplements aren’t suitable for vegans, however, since they’re made from the fat of lamb’s wool. But the good news is you can now get vegan vitamin D3 supplements that are sourced from lichen.

Myo-inositol

A vitamin-like substance (also sometimes called a pseudovitamin) found in many natural sources, myo-inositol – often called simply inositol – is a carbohydrate with a molecular structure similar to that of glucose. It’s found in high concentrations in the brain and is often used to relieve the symptoms of anxiety. In fact there is evidence to suggest myo-inositol works in a similar way as anxiety and low mood medications, as it increases the function of the brain receptor GABA-A and enhances the sensitivity of serotonin receptors (xxxiii).

A trials review has also found inositol may be beneficial for women who are experiencing depression associated with premenstrual dysphoric disorder (PMDD) (xxxiv).

Lavender oil

Lavender essential oil has a long-established tradition of helping you feel more relaxed. Indeed one study suggests it may be an effective natural way of treating the signs of anxiety (xxxv). Meanwhile researchers elsewhere have discovered lavender oil may be more effective for generalised anxiety disorder than a placebo (xxxvi). Try having a warm bath with a drop or two of lavender oil or simply add some to an aromatherapy diffuser whenever you feel to feel calmer.

Premenstrual anxiety can be unpleasant and make life difficult every month. But there are ways of coping with it better and reducing the effect it has on your quality of life. If, however, your anxiety is severe, don’t put off seeing your GP about it, as there are treatments that could help you. In the meantime having a healthy lifestyle can go a long way to making you feel more like yourself.

To find out about lots of other health issues – including those that affect your emotional wellbeing – take a tour around our health library.

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