In this podcast, we talk about the difference between PMS (premenstrual syndrome) and perimenopause.  We get this question all the time, Doc, I think I am going into menopause.’ When really, they are nowhere near menopause, let alone perimenopause. What makes it so confusing is that there are so many similarities between PMS and perimenopause.

But some distinctions are important to point out, especially when it comes to testing and treatment. PMS (premenstrual syndrome) is pretty much as it sounds.  Symptoms appear prior (pre) to the period (menses). But usually, the symptoms appear in a cyclical pattern.

The symptoms will appear anywhere from 14 days to just a couple of days before the period. The distinction between PMS and perimenopause, is the symptoms are present all month in perimenopause.

Perimenopause is NOT menopause.  It is the time before a woman enters menopause.  It can be anywhere from age late 30’s to late 40s.  In perimenopause, you are still getting your period (it might be irregular, but you are STILL getting your period).        

But the symptoms between PMS and perimenopause are similar.

So just to reiterate:

• Symptoms in PMS occur between 14 days to 2 days before your period.
• Symptoms in perimenopause occur all month long.

Symptoms that are similar in PMS and perimenopause:

• Irritability: patience is short.  Becomes easily irritated, even at situations that it is not warranted.  Of course, you feel guilty after having a hormonal tantrum and cry and feel badly about the encounter.  You are not crazy, it is your hormones.
• Acne
• Carb cravings
• Sleep issues –waking in the middle of the night and cannot go back to sleep
• Fatigue: low energy–both physically and mentally tired
• Anxiousness not always warranted for the situation
• Bloated: even though your bowels are moving fine
• Cramping before period even starts

Symptoms that are different between PMS and Perimenopause

• All of a sudden your periods get weird.  Periods come early or late. Your spot for days.  One month your period is super heavy, and the next kinda light.  Every month can be different in perimenopause.
• Crampy painful periods
• Symptoms all month long in perimenopause–it is like #pmsallmonthlong
• Symptoms 14 days to 2 days before your period
• Hair loss
• Weight gain = belly fat, muffin top: even though you are exercising and eating well
• Loss of short term memory: forgetful, repeating questions, keeping lists that you lose.
• Skin texture and integrity has changed.  Skin seems more lax, and there are more fine lines,  Yes, I get it, we get wrinkles with age. But in perimenopause, it is like the wrinkles appeared overnight.
• Night sweats: night sweats will usually appear about a week before the period shows up (whenever that is).

Okay, we don’t want to bore you here.  But we want to describe what happens in a female menstrual cycle.  Just to give you an understanding of what might be happening hormonally in PMS and perimenopause.  

In both PMS and perimenopause, unless you have had your uterus removed (hysterectomy), you will still be having a period.  This part is written in a perfect 28-day cycle,” which we know that not everyone has a 28-day cycle. It is common and perfectly healthy to have anywhere from 25 to 35-day cycles.  

For physiology sake, I am going to describe a 28-day cycle.

• Day 1-5 = period: Estrogen and progesterone are basically non-existent.  This low hormone level is what causes a period. Which is why if you test your hormones on a blood test (day 1-5), the levels are low.    Day 6-11: Estrogen levels are increasing. But there is very low to no progesterone levels.
• Day 12: Estrogen levels rise quickly.  This huge spike in estrogen is what helps to stimulate ovulation.
• Day 14: The egg leaves the ovary. Traveling down the fallopian tube.  
• Day 14: Ovulation.  When the egg leaves the ovary, it leaves a spot on the ovary called the corpus luteum.  The corpus luteum makes progesterone. So progesterone is not in the body until around day 14.  That is why if you test your blood for progesterone before day 14, it is low. Which is normal.
• From day 14 to day 20: Progesterone is climbing.  Estrogen levels will stop rising and will start to drop.  
• Day 21: The progesterone is the highest it will be in your cycle.
• Day 21-28: Both progesterone and estrogen are declining.  If there is no pregnancy, then the estrogen and progesterone drop very low. This stimulates the lining of the uterus to slough off.  Hence, a period.

Issues that can go wrong with your cycle:

This is the interesting part.  There are areas and places in the 28day cycle that things can go wrong.

Progesterone: In both perimenopause and PMS, the progesterone will drop in both PMS and perimenopause.  This drop in progesterone can create a lot of the issues that women experience in PMS and perimenopause.

Estrogen: In perimenopause, the estrogen drops slightly.  But in PMS the estrogen does not drop. In fact, estrogen can be high (estrogen dominance) in PMS.  But in perimenopause, the estrogen declines a slight amount.

Insulin and Cortisol: When there is estrogen-dominance or progesterone-insufficiency, insulin and cortisol have no buffer. Again, I don’t want to bore you with physiology.  But when there is stress, it raises the cortisol. A rise in cortisol will cause an immediate surge in glucose. An increase in glucose will cause the pancreas to secrete insulin. Insulin is important for glucose to be facilitated into the cell.

But insulin is the only fat storing hormone.  Example: you are sitting at your desk. You get some stressful news.  This stressful news will cause your cortisol to rise. This sends a signal to cause a rise in glucose (even though you didn’t eat anything).  The increase of glucose in the bloodstream will cause the pancreas to release insulin. But you are still sitting in your chair. You are not running from a bear or threatening situation.  The result is the insulin allows the glucose to enter the cell and then get stored as fat. Yes, stress can make you fat. As mentioned above, when you are not in perimenopause, the hormones (estrogen and progesterone) help to buffer the effect of excess cortisol, insulin, and glucose.  

That is why when you are 22 years old you can get 5 hours of sleep, work two stressful jobs, go to school and eat burgers and milkshakes without missing a beat or gaining weight. When you are 46 years old, and on Sunday eat a dinner of Mexican food, skipping the chips and salsa (maybe one glass of wine).   Come Monday, you slept terribly and wake up 3-5 lbs heavier (and boy, do you feel it!).

Now, the difference between perimenopause and PMS is, in PMS this insulin issue happens during 3-14 days before your period. But in perimenopause, this is an issue the entire month.

Thyroid: Now we cannot forget the thyroid hormones when comparing perimenopause to PMS.  The thyroid is a whole different animal in terms of hormones. Low thyroid can actually cause exaggerated PMS.  So if your PMS is pretty bad, please have your thyroid levels checks. And if you have low thyroid or Hashimoto’s, your PMS can be intense, but that is another blog itself.  But to keep it simple, in PMS the thyroid is not as much of an issue as it is in perimenopause. The thyroid function itself can decrease with time/age. In perimenopause when the progesterone has dived, and the estrogen is present but slightly decrease.  This can cause a lot of pressure on the thyroid, causing the thyroid function to drop.

Androgens – Testosterone and DHEA: In PMS and perimenopause, there are complaints of feeling irritable, acne and hair loss.  Now, this is not the complete answer, but it can be due to androgens. Testosterone and DHEA are both androgens.  Men have quite a bit more androgens (testosterone and DHEA) than women. But if the other hormones are not balancing the androgen, you can have symptoms of high androgens.  In PMS, anywhere from 3-14 days before a period, the low progesterone cannot buffer the androgens. In perimenopause, the lower hormones cannot buffer the androgen all month long.  Hence, feeling testy, acne and hair loss can occur at this time.

Hormone Lab Testing:

After reading all of this, you might be wondering: How do I test if I have Perimenopause or PMS? While I cannot speak for most doctors, I will tell you how we test for PMS and perimenopause

Blood Test: We have been using blood testing for many years.  But as mentioned above, in perimenopause and PMS the hormones are changing daily.  I like to test the blood from day 19-25 of the cycle. If you test earlier in the cycle, the progesterone might not be accurate.  I like to test, FSH, LH, Estradiol, Progesterone, DHEA-s, Testosterone, Pregnenolone. I will explain in another podcast, what the levels should be, and what the pregnenolone means:)  

What happens if I’ve had a hysterectomy and cannot know what day of the cycle I am in?  Then we just tell them to test any time of the month, and from experience, I know where they are in their cycle and where the levels are at.  

Saliva Test: Saliva testing is common and extremely sensitive.  So you can really get a measure of where the hormone levels are at using a saliva test.  But the drawback is for me, the saliva tests are too sensitive. So when someone is on hormone therapy/BHRT, the saliva test is so sensitive the levels read extremely high.  This makes it hard to dose a woman’s hormone prescription, supplements, glandulars on a saliva test as the levels can be hard to interpret.

DUTCH Test: The DUTCH test is very popular right now.  And they are really amazing and can provide a lot of information.  Unfortunately, a lot of doctors will order the test and do not know how to interpret the results or provide recommendations based on the results. DUTCH tests do not test progesterone. But they do test progesterone metabolites that can be an accurate reflection of progesterone levels. The one really great key value in a DUTCH test is the estrogen metabolites.  There are no other tests out there that can give such an accurate measure of estrogen metabolites. DUTCH tests are not usually covered by insurance and can be a bit pricey out of pocket.

Unfortunately, there are not a lot of options to treat PMS or perimenopause conventionally.  If you go to your PCP, general practitioner, gynecologist, the most common options are birth control pills, antidepressants and/or an IUD or perhaps anti-anxiety meds.  But there are many healthy, natural options for both PMS and perimenopause. In the future, we will go into more depth and also options to help to alleviate the symptoms.

We hope this podcast shed some light on the differences between PMS and perimenopause. Any questions or concerns, please feel free to post a comment below or send an email to [email protected]