Part 2 of PMS in Perimenopause read Part 1 HERE 

With the right support, women with PMS can move from feeling chaotic, overwhelmed and “not themselves” to feeling steadier, clearer, calmer and more in control of their lives and cycles.

If your PMS has become louder, sharper, or harder to manage as you enter your 40s (or even late 30's), you’re not imagining it. Perimenopause brings a perfect storm of:

• Bigger, more erratic oestrogen swings

• Irregular, often weaker progesterone production

• A brain that has become increasingly sensitive to hormonal fluctuations over time

• Higher stress load, poorer sleep, and multiple demands on your energy

PMS is not a character flaw. It is a neuro-hormonal condition driven by how your brain responds to changing hormones. And in perimenopause, those hormone changes become more dramatic — and less predictable.

Although there are no clinical trials performed specifically on PMS during perimenopause, we have excellent evidence from PMS and PMDD in reproductive-age women, and the underlying biological mechanisms are the same. That means we can still build a strong treatment plan to support PMS in perimenopause.

The Power of Tracking, Planning and Self-Compassion

Before we talk about medication or supplements, one of the most powerful tools you can use is simply awareness:

• Tracking your cycle (with an app, spreadsheet or paper diary)

• Noting when symptoms start and peak

• Noticing patterns in sleep, stress, food, alcohol, workload and relationships

Over 2–3 months you’ll usually see a clear pattern: perhaps days 21-24 are your “red-flag days”, or maybe symptoms are most intense right after ovulation.

Once you know your pattern, you can start to:

• Pre-plan lighter days around your worst phase (fewer late nights, fewer big meetings, less people-pleasing)

• Book in support: therapy sessions, a walk with a friend, extra childcare where possible

• Schedule micro-treats: massage, yoga, a solo coffee, early nights, comfort foods that still feel nourishing

• Brief your support network (if you feel comfortable):

  • Let your partner, kids or close friends know: “This is the week I’m more sensitive; this is how you can support me.”

This isn’t “giving in”; it’s working with your brain and hormones, not against them. In fact, some of the most effective PMS programs in research are built around self-monitoring + planned self-regulation, not just medication. That compassionate planning is part of treatment, not an optional extra.

1. Why Treatment in Perimenopause Needs a Layered Approach

Perimenopause adds hormonal turbulence on top of PMS sensitivity. The most effective approach usually combines:

1. Brain support
   Stabilising serotonin, dopamine and GABA (the brain’s calming neurotransmitter).

2. Hormonal modulation
   Smoothing fluctuations or reducing sensitivity to them.

3. Nervous system care
   Sleep, stress, nervous system regulation and CBT-based strategies.

4. Body support
   Nutrition, movement, micronutrients, herbal therapies.

You do not need to use every layer — but understanding them helps you choose the right combination for your symptoms and health profile.

2. Medical Treatments With the Strongest Evidence

2.1 SSRIs — The Most Reliable First-Line Treatment

Selective serotonin reuptake inhibitors -SSRIs (fluoxetine, citalopram, sertraline, paroxetine, fluvoxamine, clomipramine) consistently show:

• Meaningful improvement in overall PMS/PMDD severity

• Reductions in irritability, anxiety, low mood, cravings, breast tenderness, bloating and sleep problems

• Benefits appearing within 1–2 cycles

• Clear effectiveness even in women without major depressive disorder

Across multiple meta-analyses, women taking SSRIs are roughly 2–2.5 times more likely to achieve ≥50% symptom reduction compared with placebo. Benefits occur across mood, physical and behavioural domains.

Two dosing strategies are effective:

• Continuous dosing: every day throughout the cycle

• Luteal-phase dosing: from ovulation to the start of bleeding

Continuous dosing gives slightly stronger results overall, but luteal dosing is a good option if you prefer not to be on daily medication all month or if side-effects are an issue.

Side-effects (nausea, headache, reduced libido, sleep changes) are generally dose-related. Starting low and titrating up improves tolerability for many women.

In perimenopause, SSRIs remain the best-supported first-line pharmacological treatment for moderate–severe PMS/PMDD, and they can also help co-existing anxiety or depression, which are more common in this life stage.

2.2 Combined Oral Contraceptives (COCs)

Moderate effectiveness, important nuances in the 40s

How they help

Combined oral contraceptives suppress ovulation and flatten hormonal fluctuations. Pills containing drospirenone are best studied and show modest–moderate improvements in PMS/PMDD:

• Better cycle predictability

• Reduced irritability, physical symptoms, headaches and bloating

• Combined benefits for acne and contraception

They’re most useful when you want PMS support and reliable contraception in one.

The “plummet” when you stop the pill in your 40s

COCs override your natural cycle and can mask underlying ovarian decline. When you stop them in perimenopause, you suddenly see your real hormonal state:

• Periods may become irregular, heavy or closer together

• Hot flushes, night sweats, anxiety, brain fog, and insomnia can appear very quickly

• PMS symptoms may feel more intense and chaotic

This can feel like “the pill broke my hormones,” but what’s actually happening is that the pill was hiding the transition, and stopping it reveals perimenopause in full colour.

Knowing this ahead of time helps you:

• Plan a supported pill exit (rather than stopping suddenly in a chaotic life phase)

• Have a next step ready (e.g. SSRI, estradiol-based HRT, IUD, lifestyle emphasis)

• Anticipate that some turbulence is expected — not a personal failure and not permanent

Bone and cardiovascular health with COCs in your 40s

Bone health

• COCs maintain a steady level of synthetic hormones and are generally neutral to mildly protective for bone while you’re on them (if used later in reproductive years)

• However, they are not as bone-protective as well-dosed transdermal estradiol, especially later in the transition

• In your 40s, thinking ahead about long-term bone health (DEXA timing, calcium, vitamin D, strength training, and future HRT) is important

Cardiovascular health

• COCs increase the risk of venous thromboembolism (blood clots) and stroke compared with non-use

• That risk rises with age, smoking, migraine with aura, hypertension, obesity and metabolic syndrome

• For women over 40, especially over 45, many clinicians prefer transdermal estradiol-based HRT plus a progestogen or IUD if the goal is symptom control and long-term health, rather than contraception alone

COCs can still be appropriate in perimenopause, but require a careful, individualised risk–benefit discussion.

2.3 GnRH Agonists — A Specialist Option for Severe PMDD

GnRH agonists temporarily switch off ovarian hormone production, creating a reversible menopause:

• They are highly effective for severe, treatment-resistant PMDD, because they eliminate the cyclical hormonal trigger

• But they also cause menopausal side-effects: hot flushes, bone loss, vaginal dryness, sleep disturbance

• Long-term use usually requires add-back HRT and specialist supervision

They’re sometimes used as a diagnostic tool: if symptoms vanish with ovarian suppression, that strongly confirms a hormone-triggered condition.

3. Hormone Therapy (HRT): Where It Helps, Where It Doesn’t

3.1 Estradiol-Based Regimens for PMDD

PMDD research suggests that the problem is not “low hormones” but brain sensitivity to rapid falls in estradiol and progesterone. One strategy is to prevent the withdrawal:

• Continuous transdermal estradiol (e.g. 100–200 µg patches) given across the cycle has been shown to:

  • Reduce PMDD symptoms

  • Improve mood and function by smoothing hormonal swings

Progesterone choice is key:

• Many women benefit from the calming, anxiolytic effects of micronised progesterone, mediated via its metabolite allopregnanolone (ALLO) acting on GABA receptors

• A smaller group are ALLO-sensitive and feel more tearful, flat or anxious with natural progesterone

• These women sometimes do better with:

  • Norethisterone, or

  • Levonorgestrel IUD (Mirena®) as the progestogen component

These regimens do not provide contraception unless combined with an IUD.

3.2 Standard HRT for PMS in Perimenopause

Large reviews and guidelines on HRT focus on:

• Hot flushes and night sweats

• Sleep disturbance

• Urogenital symptoms

• Bone and cardiovascular outcomes

The evidence that standard HRT helps PMS specifically is limited and mixed. Some women do report better mood and fewer premenstrual symptoms when vasomotor and sleep symptoms are controlled, but:

• Progesterone and progestins do not have much evidence of effectiveness for PMS treatments on their own

• In susceptible women, they can temporarily worsen mood

So:

• HRT is appropriate and often transformative for classic perimenopausal symptoms and long-term health

• It should not be seen as the primary or only treatment for PMS, but as one tool that might indirectly help in combination with other supports

4. Psychological Therapies – Treating the Brain’s Sensitivity

4.1 Cognitive Behavioural Therapy (CBT)

CBT is one of the best-studied non-drug treatments for PMS/PMDD:

• Reduces overall symptom burden by ~60% in some trials

• Strong impact on anxiety, irritability, overwhelm, self-criticism

• Helps women understand their patterns, challenge unhelpful thoughts, and build better coping strategies

• Benefits often outlast medication at 12-month follow-up

A trial comparing fluoxetine, CBT and their combination found:

• All treatments improved symptoms

• Fluoxetine worked faster initially

• CBT had better long-term maintenance

• Combining them didn’t add much beyond either alone

Digital CBT and mindfulness-based interventions (e.g. smartphone apps, internet CBT) also show significant improvement in PMS severity and quality of life.

4.2 Trauma-Informed and Relationship-Focused Support

Women with a history of trauma, chronic stress or relationship strain often benefit from:

• Trauma-informed therapy

• Emotionally focused or couples therapy

• Somatic approaches (body-based therapies, yoga, breathwork)

These don’t “cure” PMS, but they reduce vulnerability and help you buffer hormonal shifts with a more resilient nervous system and more supportive relationships.

5. Lifestyle Interventions With Strong Scientific Support

5.1 Exercise

Exercise is one of the most consistently helpful lifestyle interventions:

• Meta-analyses show large effect sizes for exercise in reducing global PMS symptoms, psychological distress, physical discomfort and behavioural symptoms

• Aerobic exercise (e.g. brisk walking, cycling, swimming) 3–5 times/week improves mood, energy, sleep and pain

• Yoga and Pilates, which combine movement with breath and relaxation, often perform particularly well for emotional symptoms

In perimenopause, exercise also supports:

• Bone density

• Insulin sensitivity and weight management

• Cardiovascular health

• Cognitive function

• Overall quality of life

A practical target:
At least 30 minutes of moderate movement most days, plus strength training and yoga/Pilates where possible.

5.2 Nutrition

Dietary patterns matter more than single foods.

Patterns associated with fewer PMS symptoms:

• A “healthy” or Mediterranean-style diet:

  • High in vegetables, fruit, whole grains, legumes, nuts, seeds and olive oil

  • Moderate fish and minimally processed proteins

Patterns associated with worse PMS:

• “Western” patterns:

  • High in fast food, sugary drinks, sweets, processed meats and refined grains

Studies show:

• Whole-grain enriched diets significantly reduce global PMS scores, including mood, physical and behavioural domains

• Higher intake of nuts, seeds and legumes is linked to lower PMS risk and severity

• High sugar and refined carbohydrate intake are linked to higher PMS risk

Mechanisms likely include:

• Blood sugar instability

• Inflammation

• Micronutrient shortfalls (calcium, magnesium, B-vitamins, zinc)

• Changes in the gut microbiome and oestrogen metabolism

5.3 Sleep and Stress

Structured lifestyle programs that include:

• Sleep hygiene

• Stress management skills

• Self-monitoring and self-regulation

• Vitamin D and nutrition education

• Group or online support

have demonstrated large reductions in PMS severity, sometimes up to 75%, with benefits maintained at 18 months.

For perimenopausal PMS, building predictable, calming routines in your vulnerable phase (based on your cycle tracking) is particularly powerful:

• Earlier bedtimes and screen curfews

• Lower caffeine and alcohol intake in the luteal phase

• Regular nervous-system “micro breaks” (breathing, stretching, brief walks)

• Saying “no” more often during your worst days

6. Supplements and Herbal Treatments With Evidence

6.1 Calcium + Vitamin D

Among nutritional interventions, calcium has some of the strongest evidence:

• 1000–1200 mg/day calcium carbonate for 2–3 cycles produces:

  • Around 48% reduction in overall symptoms vs 30% with placebo

  • Significant improvements in mood, water retention, cravings and pain

• Calcium + vitamin D (e.g. 600 mg calcium + 400 IU vitamin D twice daily) produces high response rates, with ~76.9% of women achieving ≥50% symptom reduction and large improvements in physical symptoms.

This is particularly attractive in perimenopause, where bone health is also a major concern.

A note on safety: calcium and cardiovascular risk

There has been ongoing discussion about whether calcium supplements increase cardiovascular risk. Here’s the balanced, evidence-based view:

• The concern mainly comes from older adults taking large doses of calcium, particularly ≥1500 mg/day, often without vitamin D or magnesium.

• The theory is that large, infrequent bolus doses may cause transient spikes in blood calcium, which could (in theory) contribute to arterial calcification — but evidence is mixed, and many studies show no significant increase in heart attack or stroke risk.

• In younger, healthy women (including those in perimenopause), taking calcium in recommended, divided doses — especially alongside vitamin D and a varied diet — is generally considered safe and well tolerated.

• Getting as much calcium as possible from food first (e.g., leafy greens, tofu, fortified plant milks, nuts, seeds, legumes) is ideal, but supplements are appropriate when dietary intake is low or when PMS symptoms are stronger.

In short:
For women in their 40s, using standard doses (1000–1200 mg/day split across the day), ideally with vitamin D, is considered low risk and highly effective for PMS.
If you have kidney stones, vascular disease, or other risk factors, this is something to discuss individually with your health professional.

6.2 Vitamin B6 and Broad Micronutrients

Vitamin B6 (pyridoxine):

• Supports synthesis of serotonin, dopamine and GABA

• At doses of 50–100 mg/day, multiple trials show improvement in mood and global PMS symptoms

One trial found that a broad-spectrum micronutrient formula (containing B6 plus other vitamins and minerals) outperformed B6 alone, particularly in women with PMDD-level symptoms.

Because very high doses of B6 over long periods can, rarely, affect nerves, many clinicians keep daily intake ≤100 mg.

6.3 Zinc

At 30 mg/day, zinc supplementation has been shown to:

• Reduce both physical and psychological PMS symptoms

• Increase BDNF (a brain health marker) and antioxidant capacity

• Lower markers of oxidative stress

This makes zinc especially relevant where mood, fatigue and immune resilience are issues.

6.4 Magnesium

Magnesium is involved in:

• Nerve and muscle function

• GABA and glutamate regulation

• Stress resilience and sleep

Evidence is mixed because formulation matters:

• Magnesium pyrrolidone carboxylic acid in luteal-phase dosing has shown improvements in mood and overall PMS scores

• Magnesium oxide, a poorly absorbed form, has not shown benefit

In real-world practice, magnesium glycinate, citrate or similar forms are often used to help with:

• Luteal-phase anxiety

• Headaches and migraines

• Muscle tension and cramps

• Sleep disturbance

with a good safety and tolerability profile.

6.5 Saffron

Saffron (Crocus sativus L.) has moderate–strong evidence for PMS:

• 30 mg/day significantly reduces depression, anxiety, mood swings and some physical symptoms

• Several trials show saffron is as effective as fluoxetine for PMS/PMDD mood symptoms, with:

  • Fewer side-effects

  • Better improvement in some physical symptoms (e.g. breast and abdominal pain)

• Clinical trials report good safety and tolerability

It’s an excellent option for women wanting a plant-based, evidence-backed mood treatment.

6.6 Vitex agnus-castus (Chaste Tree)

Vitex is well-studied and useful particularly for physical and mixed PMS symptoms:

• Standardised extracts taken once daily for 3 cycles produce:

  • Response rates around 52% vs 24% with placebo

  • Significant improvements in irritability, mood alteration, anger, headache and breast fullness

In head-to-head comparisons:

• Vitex was better than fluoxetine for physical symptoms (breast tenderness, fluid retention, headaches)

• Fluoxetine was better for mood symptoms

Vitex acts through:

• Reducing prolactin (via dopamine D₂ receptor effects)

• Modulating opioid and oestrogen receptors

It’s a good choice when breast pain, bloating and irritability are dominant features.

7. A Realistic, Evidence-Informed Plan for Your 40s

For a woman in her 40s with worsening PMS in perimenopause, an evidence-informed plan might look like this:

1. Track and plan

   • Map your symptoms over at least 2–3 cycles

   • Identify your “high-risk days”

   • Intentionally lighten your load and build in extra support for that window

2. Lay strong foundations

   • Mediterranean-style eating pattern

   • Regular movement (aerobic, strength, yoga/Pilates)

   • Sleep hygiene and stress regulation practices

3. Layer in targeted nutrition and supplements

   • Calcium + vitamin D

   • B6 and zinc for mood

   • Magnesium for sleep, tension and headaches

   • Consider saffron and/or Vitex depending on symptom profile

4. Add psychological support

   • CBT (online or in person)

   • Trauma-informed or relationship-focused therapy if relevant

   • Mindfulness or nervous-system regulation work, especially in your vulnerable days

5. Use medications when appropriate

   • SSRIs as first-line pharmacological therapy

   • COCs when contraception is needed and risks are acceptable (with a plan for coming off)

   • Estradiol-based regimens in PMDD patterns or where severe cyclical mood destabilisation persists

   • GnRH agonists only for severe, refractory PMDD under specialist care

6. Consider HRT for classic perimenopause symptoms and long-term health

   • Use primarily to manage vasomotor, sleep, urogenital and bone/cardiovascular concerns

   • Allow any PMS benefit to be a bonus, not the sole reason for HRT

8. A Final Word of Encouragement

If PMS in your 40s (or late 30's) feels like it’s taking over your life, it does not mean you’re weak, broken, or doomed to feel this way until menopause. It means your brain and body are reacting strongly to a major hormonal transition — and that is something we can work with.

There are many evidence-based options:

• Medical

• Psychological

• Nutritional

• Lifestyle

• Hormonal

• Herbal

They can be combined and tailored to you. With the right support, women routinely move from feeling chaotic, overwhelmed and “not themselves” to feeling steadier, clearer, calmer and more in control of their lives and cycles.

You are allowed to ask for help. You are allowed to adjust your workload. You are allowed to rest, to be supported, and to take your symptoms seriously.
And you absolutely can feel better than this.

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