Why PMDD Treatment Fails: SSRIs for PMDD, Birth Control, and What Your Doctor May Be Missing

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0:42Gemini and Chrome is here for it. Ready to make anything online make sense? There's no place like Chrome. Check responses set up required. Compatibility and availability varies 18+. If you have PMDD and you are wondering why can't anyone effectively treat this, I've been suffering for months to years. No one has helped me. I've tried everything. Nothing works. Or if you're wondering, is it PMDD, perimenopause, or my ADHD, I want you to stay with me. This episode of the Dr. Brighton Show, we are going to go into what actually works for PMDD, what we know about PMDD, and why so many treatments fail.

1:19I'm your host, Dr. Jolene Brighton, and I'm so glad to have you joining me today. Now, at the end of this episode, we're gonna play, is it PMDD, perimenopause, or late diagnosed ADHD? Because that was a question that I was sent in. Now, if you want help figuring out your PMDD pattern, especially if ADHD, perimenopause, histamine, inflammation, estrogen, progesterone are part of the picture, as they are for most PMDD women, I want you to join me live for a PMDD workshop that's happening on June 10th. Now, for a limited time, as a pre-order bonus, when you grab ADHD and women, you're going to get access to this live workshop with me where you're going to be able to ask me questions.

2:00Now, go to drbrighton.com, d-r-b-r-i-g-h-t-e-n.com slash p-m-d-d. You can pre-order the book, claim your spot. Doesn't matter where you pre-order it, pre-order it anywhere. Just give me your receipt and I'll get you in and you will join me on June 10th. Okay, with that said, let's not hold this up any longer. If you feel like you've tried everything and nothing works for your PMDD, that's because honestly, you've been set up to fail in some ways. So I need you to understand that there is not just one treatment for PMDD that works for everyone. And we're going to be getting into the different treatment options that you may be offered by your doctor.

2:43Now, you told me knowing your gut is why your symptoms are so bad, but doing a million gut protocols didn't help. You've tried everything. The problem with PMDD is that as we get more research, for which we have very little, it's starting to appear that PMDD is not just one condition. It's like a network of problems that is involving neurosteroid metabolites, neurotransmitters, immune signaling, inflammation. So neurosteroid metabolites, that has to do with how your progesterone is broken down. That is why PMDD seems to hit most in the luteal phase. But there's also the histamine component that we talked about in part one of this PMDD series.

3:24The problem is, is that you're usually just given one thing and it only affects one aspect of this PMDD system. So you do a gut protocol and that absolutely should be helping your histamine. But if your issue is dopamine sensitivity, allopregnenolone, GABA system, not feeling right, luteal phase neural inflammation, then the gut component may not have been enough on its own. Does it help? Absolutely. Was it for nothing? Like it is always going to help to make sure your gut is functioning optimally. But there are people out there that promise all you have to do is fix your gut and your PMDD. hey, it'll go away.

4:03Unfortunately, that's just not the reality. And this complexity of PMDD is why what works for someone else may not work for you. So some women are like, I took the antihistamine Pepsid protocol. I felt amazing. And the next woman's like, I didn't do nothing. Didn't do nothing for me. That's because PMDD is much more complex than, you know, the internet's making it out to be. But I always appreciate a woman who tries something, it helps them, and she's willing to share. The thing we know about PMDD is it's not caused by too much estrogen or low progesterone alone. It's not just about the hormone levels.

4:40It's how sensitive your brain is to the hormone levels and what the hormone levels are doing to the rest of your body, like your immune system. So what the data we currently have shows is that women with PMDD typically have normal hormone levels, but the issue is an abnormal sensitivity to the hormone changes. specifically progesterone rising and its metabolite allopregnenolone acting on the GABA receptor. And rather than making you feel chilled out and calm, it makes you feel moody and anxious and like you're having a major stress response. And that may be related to inflammation in the brain occurring at the same time.

5:21But if you add to that increased inflammatory signaling via histamine or cytokines, immune system chemical messengers, if you have an altered serotonin response, if your serotonin is going down the wrong pathway, for example, or you're having the histamine problems we talk about in episode one that are affecting your brain as a neurotransmitter, all of that is going to compound what you're experiencing in the luteal phase. If you are that someone that an antihistamine helped, even though it was just a little, that's a clue it's not the full answer it's just a clue that like yes immune system dysregulation primarily what is dumping histamine into your system and as we talked about previously could be related to like endometriosis or other conditions that are related to having histamine issues like adhd even ehlers-danlos syndrome and as we talked about in the last episode pms is often due to not having enough progesterone, PMDD is usually a neurohormonal sensitivity disorder, not a hormone deficiency.

6:26So giving more progesterone doesn't always help in PMDD. In fact, it can make things a lot worse. I have an entire episode that I will link in the show notes at drbrighton.com that is about progesterone intolerance. And we see that a lot with neurodivergent women, ADHD, autism, OCD women also reported. We don't have as much research outside of ADHD and autism in some of these conditions, but like certainly we know that women who have neurodevelopmental conditions, they tend to be more hormonally sensitive. So if you are someone who for any reason, maybe PCOS, perimenopause, postpartum, you took progesterone therapy and it made you feel worse, I want you to check out the episode on progesterone intolerance to give you some strategies of what you can do instead.

7:12As we talked about in our first episode, PMDD stands for premenstrual dysphoric disorder. It is severe, severe form of PMS. It lasts longer, it's much more severe, and there's a high propensity to want to self-harm. Great question that came through was, does endosurgery, so endometriosis surgery, fix PMDD? Now, if endometriosis-related inflammation, histamine issues were driving your symptoms, then yes, surgery may help. But what I need to caution people about is that even after lesions are removed, so endometriosis lesions removed via excision surgery, there can still be this like immune memory that persists and continues to drive neuroinflammation.

7:52And that is part of the picture of why we see central sensitization. That is the memory of pain that persists even when you remove the thing that was driving pain. That neuroinflammation can be part of why that sticks around and that women chronically have pain even after excision surgery. Though the same can be true of PMDD. And when you remove the endo lesions, sometimes women are like, yes, things got so much better. Other women are like, it got slightly better. It was one step in removing the root cause of what was going on. But you may have had, like many women with endometriosis, gut dysfunction, intestinal permeability, dysbiosis, small intestinal bacterial overgrowth.

8:34You may have other things that are still going on. And so you have to peel back the layers and work on all of that to get that PMDD relief. Now we're still going to play the PMDD late diagnosed ADHD perimenopause game at the end. So stick around for that. But I want to give you some quick answers to the questions you sent in. So we're going to go like a little lightning round here. So can PMDD start in your 30s? Yes. PMDD can come on at any age. As I talk about in my book, ADHD and women, there's the five Ps of when we particularly see hormonally sensitive women getting triggered for having worsening ADHD, worsening PMDD, just worsening everything is what it feels like, honestly.

9:15So PMDD can emerge at any age, but puberty, starting or stopping the pill, postpartum, perimenopause, and then pre-period, luteal phase. That's when we see hormonally sensitive women are activated by their hormones. And so we can develop PMDD at any phase of your life. Just because you're 30 and you didn't have it before doesn't mean it's not starting now. But what I would say is that we should always rule out other things. Do we have a nutrient deficiency? Do we have an underlying autoimmune condition possibly going on? Are you developing depression? Like, is it something else? We always want to ask.

9:52We want to rule other things out. Quick answer to this question, birth control, help or hurt? For some women, it can help, but for others, it can absolutely hurt. It depends on the formulation. And stick around because we're going to go deeper into birth control and SSRIs in this episode. Is PMDD a histamine issue? If you did not catch episode one, I want you to go back and listen to that. But sometimes, not always, but antihistamines, they may help some women, but they are not long-term treatments. We want to figure out why you have the histamine problem to begin with. Can you have good cycles and then suddenly crash?

10:28Absolutely. You are a complex biological system navigating a very complex environment. Stress, inflammation, hormone variability, you know, hitting those five Ps somewhere in your life cycle, developing an illness, flipping the switch on an autoimmune disease. All of these things that upregulate neuroinflammation could tip the scales so that you go into PMDD symptoms and having a flare. The truth about PMDD, there's not a one-size-fits-all answer. That is why so many people feel stuck is because medicine has been trying to push us into just one answer, but that's just not the reality. And when medicine does that, it's usually us who feels broken and we get gaslit about like, why is this not working for you?

11:13So with that said, let's talk about the standard of care, which is SSRIs. They're considered the first-line treatment for PMDD. And before anyone gets mad at me, let me be really clear. They absolutely can help, but can help is not the same thing as works for everyone. I know there are people who love their SSRIs and there are people who hate SSRIs. And guess where I'm at? I'm in the middle because I'm a doctor and I'm like, what works for you? I want to save your life. I want to keep you healthy. I want to keep you on this planet. I know the high rate of suicide that comes with PMDD. we can't be messing around with that.

11:47So whether you think SSRIs are a villain or you think they're the hero, I'm going to break down the truth for you in the science. This is not my opinion. This is what science says. So we have a recent Cochrane review. It looked at 34 randomized control trials, almost 5 ,000 women diagnosed with PMS or PMDD. They're different, but they always throw them together in the research. And what they found is that SSRIs, they can probably help. It's like, more effective when taken continuously compared to luteal phase dosing. But here's the part we have got to stop skipping in this conversation. SSRIs also increased adverse effects.

12:28So women had nausea, lack of energy, sleepiness among the most common symptoms. But this review also noted that they suspected there was publication bias in response rate analysis and that 68 % of the included studies were funded by pharmaceutical companies. We're going to talk about the history of PMDD. I went all through it in my book. Now, if SSRIs helped you, beautiful, love it, love the tool that worked for you. But if you tried it and it didn't help or you couldn't tolerate the side effects, which by the way, can also be low libido or inability to orgasm, that doesn't mean you're broken or that you failed.

13:10It means that we have to understand your pattern of PMDD better, and we have to actually address what is happening for you. And you can take comfort in the fact of knowing that the standard of care only addresses roughly 50 % of PMDD cases successfully. And that doesn't mean they're without side effects. And this is what I hate about women's medicine, is we are constantly trading just quality of life in one area for diminished quality of life in another area. We're talking about PMDD in this episode, but name a women's health condition and I can name a treatment that you're given and that you're treated like you're just that compartment.

13:49Take endometriosis, for example, and they might give you a GnRH agonist and they might shut down your hormones to try to treat your endo. Spoiler, doesn't really work. We have episodes on that. But they don't care that they're compromising your future bone health, brain health, heart health, and that you're depressed and that you might self-harm. Like that bothers me immensely because the same with an SSRI. You shouldn't have to put up with side effects like just to get a little relief in other areas. And that is where I want to challenge medicine to do better. It's not to say that like if an SSRI worked for you that like it's bad, throw it out or anything like that.

14:31Or that if SSRI is keeping you from self-harming but you have no libido, like that means just throw out the SSRI. Which by the way, we talked about in the last episode about saffron helping with libido. There is some research that shows that saffron can help mitigate some of those SSRI side effects like low libido, anorgasmia, inability to orgasm. So I always think like, you know, we have to address the individual. Now, who's ready for some tea on pharma and PMDD? As I mentioned in the last episode, this is why your doctor may not believe that PMDD is real. And what I'm about to share with you sounds a hell lot like a conspiracy and I'm bringing receipts, okay?

15:10I wrote about this in ADHD and Women because I don't think that we can talk about PMDD without talking about this history and understanding why there's such resistance in medicine, but also why we don't have such great treatment. So back in the day when I was a teen experiencing PMDD, there was no diagnosis for it. It wasn't even named. Pharma steps in is like, we see something profitable here because that's what pharma does. It's a business. It makes money. And anyone out there like trying to act like pharma is just like out here out of the goodness of their heart doing all these things, they're like delusional.

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17:50Before starting EBCLIS, Tell your doctor if you have a parasitic infection. Ask your doctor about EpGliss and visit epgliss.lily.com or call 1-800-LILY-RX or 1-800-545-5979. Now, as I move into this, I am not anti-pharma. And I know someone's going to come for me and be like, she's just one of those wellness people who's anti-pharma. Yeah, your girl takes the thyroid meds every single day. Love that. Love that for me. So no, I'm not anti-pharma. Leverage pharma when it's necessary. But you have to understand this to understand why your doctor may believe PMDD is not real. So pharma comes in. They see all these symptoms.

18:25They're just like, hey, hey, let's put together the committee. Let's push this forward. Let's get the FDA approval. Then we're going to take Prozac and we're going to rebrand it as Seraphin. And we're going to make it like pretty because girls like purple and pink. So we'll just like rebrand it pretty. And then we'll like up the price on them. And it'll be fantastic for us. And it was fantastic for them. except wah-wah, SSRIs don't totally work for PMDD. They work for like half of women. So seraphin ends up going off the market. But that's not before the FDA did push this through and did approve that the Eli Lilly got to be the only company with a drug to treat this brand new condition called PMDD.

19:03And so that's the history of PMDD. PMDD is real, but it is a pharma-backed diagnosis that was pushed through for profit. And that is what makes some doctors say, PMDD must not be real because it is a pharmaceutical conspiracy to make more money. And it was. But then PMDD is still real because you're on this episode with me and you're living it and I've lived it. And I reject anyone saying that like, oh yeah, your symptoms are just made up because you got basically influenced by the pharmaceutical company. No joke. People have said that to me. Like you think you have PMDD. it's because pharma has influenced you subliminally and you're thinking all of this and like you've fallen into the trap of pharma and I'm like so I wrote this book called beyond the pill which is like a total slap in the face to pharma and the way the doctors use the pill for like everything and that's literally the premise of the book stop giving the pill for every damn thing and work her up because she deserves to know what's happening in her body and actually address what's going on and the pill should be an option not a this is all we got for you so take it or leave it.

20:08What are you going to do? It should be a, the pill is always available. That's your choice. You want to take it? Like, great. We support you in that. We'll monitor you. We'll make sure that you stay safe on it. We'll look for any of those side effects. But you can't make that informed consent if you do not know what's actually going on. And that's what happens with PMDD as well. So why might the SSRI not work for you? Okay, so if the biggest driver is actually histamine and neuroinflammation, then the SSRI may not be able to overcome that enough. Now, we know that serotonin, it is involved in ADHD.

20:42It is involved in perimenopause symptoms. It is involved in neuroplasticity, making sure that we remember good things, but serotonin may not be enough on its own. Now, the takeaway here is not that pharma is the devil, so SSRIs are the devil. It is that SSRIs can be a valid tool. They're not the whole toolbox. Side effects are real. Believe women about their side effects and also understand that the research per the Cochran review, okay? Those are the bros who like throw down their like highest level of evidence saying this PMDD research is heavily influenced by pharma. So I say this to you so that if the SSRI didn't work for you, you know it's not a you problem.

21:25There's something more going on. But if there's not money to be made, then why the hell would we want to study it, right? At least that's what it feels like in women's medicine. So because of the SSRI side effect profile, that's why a lot of women opt to only take it during the luteal phase. And there are women who report that it works really well. The research is showing us that it may work better to take it consistently throughout the month, but we always need to tailor treatments, make them individualized, make them work for your life. I promised we'd circle back to that birth control, can it help or can it hurt question.

21:57And it depends. I want to talk about the birth control data and then stick with me because I want to talk about ADHD and birth control because we just got our first study like two years ago. Like, thanks, guys. Anyhow. Okay, so birth control. So if you've ever been to a gynecologist, you've probably been offered the pill for whatever concern you come in with at some point. Most of us have been. And with PMDD, you're offered the pill and you're told this will fix it. And sometimes it helps. Yay, that was easy, but the evidence is not nearly as magical as your doctor is making it sound. So there was a 2023 Cochrane review that looked at five randomized control trials.

22:35It was under 1 ,000 women, most diagnosed with PMDD, and the studies looked at combined oral contraceptive pills containing drosperinone and ethanol estradiol. and they compared it to placebo. Now, drosperinone, first formulation of progestin that was approved for PMDD. So drosperinone-containing birth control may improve PMDD symptoms and functioning, but here's the part I need you to hear. In one trial, 48 % of women on drosperinone-containing birth control responded compared to 36 % on placebo. That means the medication, this birth control pill. It helped some women, but it also means it is not a universal fix.

23:20And the review authors concluded the difference between placebo and the pill may not be clinically significant. And the evidence quality was low. And we don't know if it works beyond three cycles, but it's not a given. And this was also FDA approved as the treatment of PMDD. And then spoiler, It doesn't work for a lot of women. And then side effects matter because the women on this formulation of birth control were more likely to withdraw from the trial because of adverse effects. And the adverse effects were higher in the birth control group than placebo, which, you know, makes sense. Now, if birth control helps you, I'm a fan.

23:59That's amazing. But if it made you feel worse, you didn't do anything wrong. You're not the problem. The treatment may not have matched your biology. Having had PMDD and being put on this same formulation of birth control, I can tell you it was like gasoline. And my brain was on fire. And it was horrible. And I remember sitting in the shower and not being able to get out. And the hot water would run out. And I'd just be sitting on the floor of the shower crying. I was in such a bad state. And my doctor said, it's not the pill. It couldn't be the pill. There's no research to say that, you know, the pill does this.

24:32But let's change your formulation. and then lo and behold, things did get better. Now, it wasn't until just a couple of years ago that a study came out on ADHD and birth control pill. So here's the deal I need you to understand. We don't have anything for autistic women. I know a lot of my listeners are concomitantly ADHD and autism. It's not uncommon to see. But for ADHD, five times increased risk of adverse mood symptoms. So if you're ADHD with PMDD and the pill worked for you, don't take this episode as like, oh, like let's undermine this thing that's working for you. What I want you to understand is if you're ADHD and you took the pill for your PMDD and you got worse, research is backing you up.

25:19And we need more studies. We certainly need more studies to validate the findings of this one and understand further what is going on. but it is what we've been talking about these last two episodes, hormone sensitivity on the brain at play. And we do know, if you read Beyond the Pill, I go into what we do know about the inflammation that the pill can cause, the increase in neurotoxins, the disruption of the serotonin pathway, and that people who are vulnerable when those things happen may have adverse mood symptoms. So having PMDD, that doesn't mean that you can't use birth control, but if it's due to neuroinflammation, if you are having disruption in your serotonin pathway already, the birth control pill may not be the right solution for you.

26:08Does that mean don't try it? Not necessarily. You can still try it. But if you take it and you're like, this isn't right, that's not because your problem and you failed a treatment. It's because that treatment is not really the best that medicine has. We don't really have anything great for PMDD if we're being honest in this conversation. It's a lot of trial and error. All right, let's play our game that I said we were going to play. So is it PMDD? Is it perimenopause? Or is it my late diagnosed ADHD? So let's walk through it. If your symptoms, they're predictable, you know them like clockwork.

26:45They're cyclical. They're showing up in the luteal phase. And if you are further along in perimenopause and your cycles have become really inconsistent, but you're tracking it and you're like, yep, there's this period of time. It's coming back. That's PMDD. If your symptoms are more random, like you get them during your period. You get them around ovulation. If they're getting worse over time and your cycle is changing, or maybe your cycle's gone away and every day you're feeling this rage, this irritability, this wanting to cry, you can't sleep. that is more of a perimenopause picture. If your symptoms are lifelong overwhelm, doing everything on the outside and silently screaming on the inside, people-pleasing, perfectionism, difficulty focusing, concentrating on things you're supposed to but they're not interesting, you have had emotional regulation challenges, you are struggling with your executive functions, that's ADHD.