Progesterone Sensitivity: What is it and why does it matter?

For some of us, the natural rise and fall of our hormones during our fertile years can cause significant swings in our mood. Although most of us have one or two mild symptoms as we approach our periods, women suffering with one of the premenstrual syndromes will undergo a much more debilitating onslaught of symptoms at this time.

Pre-menstrual syndrome (PMS) and pre-menstrual dysphoric disorder (PMDD – a more severe form of PMS) are common, and underdiagnosed – meaning many women live a lifetime struggling with their mood with all the associated impacts on their lives, work and relationships. For women who are sensitive to progesterone, other patterns can be common too: mood change with contraceptives, mood change related to pregnancy and the post-partum period, and significant mood change through perimenopause and menopause.

It is estimated that about 30% of women have enough of the 150 possible symptoms to get a diagnosis of PMS. Of these, 5-8% will suffer symptoms severe enough to be called PMDD. We now further understand that other mental health issues can become more severe in the run up to our periods (such as eating disorders, self-harm or alcoholism) – this is referred to as Premenstrual Exacerbation: so far, we don’t fully understand how many women experience this form of reaction to hormonal changes, but it likely to be a significant number.

What happens in our menstrual cycles?

It is important to understand that PMS, PME and PMDD are not a result of hormonal imbalance, but instead a response to normal fluctuations of our sex hormones during our fertile years.

The diagram shows the ebb and flow of the female hormones in the typical menstrual cycle. For women with PMS and PMDD, the symptoms correspond with the rise and fall of progesterone, usually in the last two weeks of the month.

In most women, progesterone’s effect on the brain is to increase the sense of calm. However, women who are progesterone sensitive react quite differently to this hormone: research shows that rather than being quiet and calm during this phase, instead their brains show increased activity in the emotional centres, leading to negative mood changes. Research looking at genetic differences between those women who suffer PMS/PMDD and those that don’t has confirmed there are genetic differences in the parts of the DNA that code for how we process sex hormones. In other words – this is real, and it not your fault.

What symptoms are typical in PMS/PMDD?

Women experiencing PMDD may experience any of the following:

• Mood/emotional changes (e.g. mood swings, feeling suddenly sad or tearful, or increased sensitivity to rejection)
• Irritability, anger, or increased interpersonal conflict
• Depressed mood, feelings of hopelessness, feeling worthless or guilty
• Anxiety, tension, or feelings of being keyed up or on edge
• Decreased interest in usual activities (e.g., work, school, friends, hobbies)
• Difficulty concentrating, focusing, or thinking; brain fog
• Tiredness or low-energy
• Changes in appetite, food cravings, overeating, or binge eating
• Hypersomnia (excessive sleepiness) or insomnia (trouble falling or staying asleep)
• Feeling overwhelmed or out of control
• Physical symptoms such as breast tenderness or swelling, joint or muscle pain, bloating or weight gain

The symptoms marked in bold are the “core” diagnostic criteria needed for PMDD; diagnosis is based on five of the symptoms above, with at least one being one of the core features.

What can be done about progesterone sensitivity?

Women with this problem will experience issues throughout their lives, but will often find they peak where hormone fluctuations are most marked: at the onset of their periods (menarche), as they go through pregnancies and postnatal periods, and in perimenopause. In addition, because the condition is inherited, there is a good chance their daughters will also show this trait: meaning life can feel very explosive at times if you have a daughter starting out on her periods whilst you are going through your perimenopause!

What we can do about it varies with the stage of your life, and with the impact and severity of your
symptoms.

• Care is needed with prescribed progestogens: many women will have experienced negative change with progestogen containing contraceptives or hormone replacement therapies. At menopause, it can help to pick the lowest dose of progestogen (for example, using a mirena coil or by using a half-dose of utrogestan vaginally). Choosing utrogestan, the body-identical progesterone, is better as evidence shows this form can be better tolerated by most women.
• A good option for women in perimenopause can be the combination of a transdermal oestrogen (a patch, spray or gel) and a progesterone-containing coil. For many, this will stop ovulation and keep progesterone levels low and stable in the body.
• Care needs to be taken with HRT options such as Tibolone and those containing synthetic progestogens. Women may need to keep a diary of mood to help them assess what is happening.
• More severe symptoms may require hormone blocking medications such as zoladex or prostap to take hormone levels in the body to a very low level. Usually, low dose HRT is then added back to protect bones/brain/heart – though some women will struggle even with that. The most severely affected women sometimes have surgery to remove their ovaries because quality of life has been so affected.

At Spiced Pear Health, we are very aware of the issues with progestogen sensitivity and have lived experience of its effects. We think it is vital that women are more aware of this issue and that health professionals understand the impacts on life, relationships and work from this condition. Too many women struggle their whole lifetime, unaware of what the underlying cause of their experience is – for a condition that possibly affects up to 800,000 women in the UK alone.