Welcome back, everyone. I am so happy to do the final episode of our Sexual Health and Anxiety Series. It has been so rewarding. Not only has it been so rewarding, I actually have learned more in these last five weeks than I have learned in a long time. I have found that this series has opened me up to really understanding the depth of the struggles that happen for people with anxiety and how it does impact our sexual health, our reproductive health, our overall well-being. I just have so much gratitude for everyone who came on as guests and for you guys, how amazing you've been at giving me feedback on what was helpful, how it was helpful, what you learn, and so forth.
Today, we are talking about PMS and anxiety, and it is so hopeful to know that there are people out there who are specifically researching PMS and anxiety and depression, and really taking into consideration how it's impacting us, how it's affecting treatment, how it's changing treatment, how we need to consider it in regards to how we look at the whole person.
Today, we have the amazing Crystal Edler Schiller on. She is a Psychologist, Assistant Professor, and Associate Director of Behavioral Health for the University of North Carolina Center for Women's Mood Disorders. She provides therapy for women who experience mood and anxiety symptoms across the lifespan. She talks about her specific research and expertise in reproductive-related mood disorders. She was literally the perfect person for the show, so I'm so excited.
In today's episode, we talked about PMS, PMDD, the treatments for these two struggles. We also just talked about those who tend to have an increase in symptoms of their own anxiety disorder or mood disorder when at different stages of their menstrual cycle. I found this to be so interesting and I didn't realize there were so many treatment options. We talked about how we can implement them and how we may adjust that depending on where you are in terms of your own recovery already.
I'm going to leave it there and get straight over to the show. Thank you again to Crystal Schiller for coming on, and I hope you guys enjoy it just as much as I did.
Kimberley: Thank you so much for being here, Crystal. This is a delight. Can you just share quickly anything about you that you want to share and what you do?
Crystal: Sure. I'm a clinical psychologist at UNC Chapel Hill. I'm an Associate Director of the UNC Center for Women's Mood Disorders, where we provide treatment to people with reproductive hormones across the lifespan—starting in adolescence, going through pregnancy, postpartum, and all the way up through the transition to menopause. We also do research. My research focuses on how hormones trigger depression and anxiety symptoms in women. I do that by administering hormones, so actually giving women hormones and looking at the impact on their brain using brain imaging and then also studying specific symptoms that they have with that treatment. We've given hormones that mimic pregnancy and postpartum, and we also use hormones to treat symptoms as women transition through menopause and look at, like I said, how that impacts how their brain is responding to certain kinds of things in the environment and also how they report that changes their mood.
Kimberley: Wow. You couldn't be more perfect for this episode. You've just confirmed it right there. Thank you for being here. Before we get started, mostly we're talking about what we call PMS, but I know that's actually maybe not even a very good clinical term and so forth. Can you share with us what is PMS and What is the difference btween PMS and PMDD?
Crystal: Yeah. PMS stands for premenstrual syndrome. It actually is a medical diagnosis and it includes a host or a range of physical symptoms as well as some mild psychological symptoms. It can be things like breast tenderness or swelling, bloating, cramps, menstrual pain, as well as some anxiety, low mood, mood fluctuations. But those tend to be mild in a PMS diagnosis. PMS is really common in the general population. Some studies estimate 30, 40, 50% of women experience these symptoms. Very, very common. On the other hand, premenstrual dysphoric disorder is a condition that is associated with more severe depression and anxiety symptoms. The mood symptoms are more at the forefront, although those physiologic symptoms like the breast tenderness, swelling, pain, cramps can certainly be a part of it.
Most women with PMDD do have those physical symptoms as well. Pain is a commonly reported symptom in folks with PMDD, but the mood fluctuations are more severe. People spend about half their menstrual cycle usually with pretty severe symptoms. And then once the period starts, those symptoms go away in PMDD. That's actually part of the criteria for the disorder that the symptoms have to what we call clear out or remit soon after menstrual bleeding starts. So, that's for the formal diagnosis of PMDD.
But then all sorts of people with anxiety or depression have what we call a premenstrual exacerbation of symptoms, so it's also possible to have, let's say generalized anxiety disorder or panic disorder, OCD, and have those symptoms get worse during certain periods of the menstrual cycle. We wouldn't say that that person has PMDD; they just have a premenstrual worsening of symptoms. For some women, that occurs during that time, the week or two leading up to a period, but others have symptoms that are more around ovulation. Other women have symptoms that persist through the period. That's the interesting thing. But also, the really complicated thing about this space is that there's so many individual differences where some people have symptoms that sometimes, but not others. And then if you look at symptoms across the menstrual cycle and the next person, it may show a totally different pattern. But then over time, that pattern is maintained. It is clearly a pattern and a function of hormone change, but it can look different between different people.
Kimberley: Why is it so different for different people? Do we understand that yet, or do we not have enough research?
Crystal: We don't have enough research. This is a relatively new area that one of my colleagues, Dr. Tory Eisenlohr, has been working on at the University of Illinois at Chicago. What she has been finding is that there are different subgroups or subtypes of people with this premenstrual worsening where, like I said, some people have it right before their period; others more around ovulation. Some people seem to have worsening symptoms when their hormone levels are going up. Other people have worsening symptoms when their hormone levels are going down. Some people have worsening symptoms anytime there's a fluctuation or change. That's what we see in my research as well. When I start administering hormones in some women, they almost immediately start experiencing anxiety and irritability. And then as soon as I take the hormone away, they feel better. Whereas other women feel terrible until their hormones even out again, and I've stopped messing with them so much. It's really individualized and it probably has something to do with genetic predisposition as well as early environment. It's this combination of factors.
Kimberley: Right. I could be so off base here, and please just tell me if I am. While we know it's chemical, hormonal, biological, and genetic, is there also a small percentage of people who have these shifts from a cognitive component to where they've maybe had some depressive symptoms in the past, and so that when it comes on, they're anxious about the symptoms coming on? Does anxiety increase during PMS? Is it as cognitive as well, or are you more looking at just the physiological piece?
Crystal: Both, for sure. First of all, you're not way off base. That's totally what I see in the clinic, that as folks have had these experiences with hormonal shifts and they had some anxiety or symptoms of depression during those times, it raises concern as they go through those similar hormonal shifts in the future. It becomes, in some ways, a self-fulfilling prophecy. Like, "Oh my gosh, this time is going to be so horrible, I must prepare for it. Oh no, here it comes." And then it is terrible because you're expecting it to be terrible on some level.
Crystal: There are great treatment options for PMS and PMDD. That's what we do in cognitive behavioral therapy for these very symptoms, is working through some of those expectations about how things are going to be and what we can actually do to prepare for it so that it doesn't end up being bad just because we think it's going to be bad.
But that's not to say that there isn't also a hormonal driver because for some people, there clearly is. Again, that's what makes this work so interesting and complicated, is that it's both for so many people. And that's what makes treatment somewhat complicated. CBT can go a long way toward helping with these symptoms. Not everybody, of course, can afford to access CBT. There are medication options as well, but the combination of these treatments seems to work the best for that reason.
Kimberley: Yeah. CBT is good for so many things, isn't it?
Crystal: Yeah.
Kimberley: This is a perfect segue into questions I commonly get. I'm not a medical professional, everybody knows that. I'm a therapist. But people will often report to me that their doctor said, "There's nothing you can do. It's your hormones, it's your cycle. You have to ride it out and ride the PMDD or ride out your OCD or ride out your anxiety or your panic and just wait." Would you agree with that? If so, or if not, what treatments would you encourage people to consider?
Crystal: Okay, I want people to know that that is absolutely not true. If a medical provider tells you that, go see someone else because it's just not true. I actually hear the same thing all the time from my own patients and from our research participants too. They raised this concern with their physician; it wasn't taken seriously. That's why I do this work because I think it's really important. We do have good treatments that work. There are a whole bunch of different things that people can try.
Crystal: Because I mentioned there are different ways in which hormones influence mood symptoms across individuals, the unfortunate news is that we have certainly different medication for pmdd + pms treatments that work for a lot of people, but you have to work with a physician that you like to find the combination or the exact right treatment for you. It's not like a one-and-done where you would go in and say, "Okay, great, you're going to put me on this low-dose antidepressant and I will feel better and it will completely take care of this." The thing that I would really encourage people to do is find a physician who's willing to work with them and see them regularly in the beginning, once every few weeks, or even more often as they try these different treatments to see what's going to work. I already mentioned cognitive behavioral therapy. That's a first-line treatment option for PMDD as well as for this premenstrual exacerbation or cyclic exacerbation of underlying anxiety or depression.
The other thing that works well for PMDD is selective serotonin reuptake inhibitors. SSRIs that are used to treat depression and anxiety work well for PMDD but the mechanism is different, which is really interesting. A lot of people I hear from are reluctant to take SSRIs because they've heard that they're difficult to come off of eventually if they wanted to, that you can become dependent on them. The good news for PMDD, for people who are worried about those studies, is actually, you don't have any dependence on it because you only take it during that period of the menstrual cycle that's problematic for you. You can take it just those two weeks leading up to the beginning of your period and then stop taking it once the period starts. That has been shown to fully prevent PMDD symptoms in some women. And then some other people take it all the time, like around the whole menstrual cycle just because it's hard to remember to start it, or because they're not exactly sure when their period is going to start. If you're not super regular, it's hard to know and you might miss that window of opportunity to start it before the mood symptoms. That's another option. But SSRIs are another first-line treatment option.
And then some women have really good success with oral contraceptives. Low-dose combined estrogen-progestin contraceptives are what's recommended. Yaz is the only one that's FDA-approved to treat PMDD, but it's not all that dissimilar from any other low-dose combined oral contraceptive. Sometimes it isn't covered by all insurances. If that one is not covered, I tell people to ask their doctor about what are the other alternatives because you shouldn't be paying tons and tons of money for your oral contraceptive.
And then the other thing that often helps, for women who have some symptom relief with Yaz or other oral contraceptives, is to take it continuously because, as I mentioned, it is often that hormone change that seems to provoke symptoms in folks. If you don't have a period, then you don't have any hormone change. It's those placebo pills that cause a period, it's the switching from a low-dose hormone to then having that withdrawal of progestin that causes a period. But you don't medically need one. You can ask your doctor to prescribe the hormone continuously and not have a period at all. And that works well for a lot of folks with PMDD as well. And then you can combine all these different treatments.
And then, in addition, some other non-pharmacologic lifestyle changes to help PMS anxiety and PMDD. Exercise has been shown to help. Regular exercise I think enhances all of our moods. It has the same effect within PMDD. There's some studies showing that taking calcium seems to reduce symptoms as well. For most of our patients, I just have them start taking a multivitamin and try to boost up that calcium a little bit. But like I said, a lot of people need a combination of treatments. Different SSRIs work in slightly different ways and may be more effective for some people than others. Just because the first SSRI doesn't work doesn't mean that you couldn't try another one. Again, it's just a matter of finding a physician that's willing to work with you to find the right combination and dose of these various treatments. Also possible for some people that none of these things work and those cyclic mood symptoms persist. And then there are other more invasive options for folks who don't have good success with any of these.
Kimberley: Right. I have a couple of questions about that. You've just given us an amazing treatment plan, or treatment options for someone who is experiencing PMDD or they're having more onset of anxiety not to maybe that degree. I just want to clarify, for those who also have a chronic anxiety disorder, I'm assuming, but please again correct me, that they wouldn't be one of the people who should be coming off of their SSRIs; they should stay on them if you've got an additional psychiatric or a mental illness on the side.
Crystal: Correct. I would never advise someone to come off of their SSRI if they're still having some breakthrough cyclicity in their symptom exacerbation. What I would suggest instead is to try adding on some of these other options. If you're already on an SSRI and not doing CBT, that's maybe where I would start, is to first track your mood symptoms relative to your period. This is a step that many people skip. The only way to diagnose PMDD, but also an important indicator for this cyclic exacerbation of symptoms, is to track every day your mood symptoms. You can just do this really easily on a calendar, even in the Notes app on your phone. I just have my patients make a mood rating of 0 to 10. 0 is feeling terrible, awful, worst I've ever felt; 10 is the best I've ever felt. It can be as simple as that. Or you can even use a smiley face symptom like, okay, feeling happy, feeling terrible. It doesn't have to be anything special. There are apps and things you can use as well to do this. But what we're looking for is a regular pattern of mood change relative to the menstrual cycle. Once you've established there is a regular pattern, then a CBT therapist can help you, like I said, prepare for those times and use some coping skills or strategies to manage those mood symptoms.
But I think the treatments are largely the same for people with PMDD versus other anxiety and depressive disorders. But if you have more of a chronic picture that just has some change in symptoms around the menstrual cycle, then you wouldn't come off your SSRI. That's just for people with pure PMDD.
Kimberley: I'm thinking about questions I'm assuming people will ask, and what comes to mind is, as myself as an OCD Specialist and as an anxiety specialist, we use CBT, but there are different types of CBT. We do a lot of exposure and response prevention for OCD and so forth. When we are talking about CBT, I want us to really be clear about what that looks like compared to all these other forms. What would that look like specific to somebody who has these symptoms, particularly around their menstrual cycle? Would it be more focused on the cognitive component or would it be an equal balance between managing cognitive distortions and behavioral activation? If we did behavioral activations, what would that look like?
Crystal: I'm just going to lay my bias out on the table that I tend to lean more on the B side of CBT. I tend to be a behaviorist, and I do a lot of behavioral activation because, in my experience, it tends to work well in this space and for this population of folks. We do some behavioral planning. We track behaviors and mood symptoms. What did you do or not do when you were having that feeling of frustration or irritability and how did that work out for you? We get pretty in the weeds of like, what did you say, and then what happened next, and that sort of thing, and then we figure out like, okay, how do we prevent this kind of exchange from happening in the future when you're feeling really frustrated or irritable, if it caused problems, because sometimes it doesn't. Sometimes anger, frustration, or irritability serves as fuel to make a behavior change that needs to be made. It's a signal that something isn't working well. I don't want to pathologize all negative emotions because they're not always bad.
Anyways, we look at what happened and where are the points at which we could have intervened and we rewind back in time to say, "Okay, how did you sleep the night before that thing happened that didn't go so well? Were you eating that day? What was that like? Were you already pretty depleted going into this negative interaction with your boss?" How do we prepare for the next cycle to make sure that you are allotting enough time to sleep and protecting that sleep time, not staying up super late, getting emails done or something, but really taking good care of yourself, eating well, drinking enough water, taking care of yourself the way you would take care of a child? And then from there, we talk about, "Okay, let's say this frustrating thing happens again and you're noticing yourself getting anxious or frustrated in that moment. What are some tools or skills we could use to respond?" Here, we might use something like taking a break, like, "All right, I noticed I'm getting really upset. I need to take a break from this interaction so that I don't say something that I might regret." We might practice a skill like, "Thank you for that feedback. I'm feeling myself just getting flustered. I'm going to take five minutes and then I'd like to come back and have this conversation with you later, or an hour," or "Can we come back and have this conversation next week," depending on what it is and how out of sorts the person is feeling. And then using some skills to calm down. These might be mindfulness skills or any kind of self-care, emotion regulation skill that a person could use.
We tend to start with skills that folks have already had good success with. I'm not teaching Buddhist meditation on the first day of treatment, but instead, it might be simple things like, "Oh, I feel better when I get some sunshine and take a walk outside," so that might be a good skill we could just use right off the bat. It's pretty skill-based. And then we create a behavioral plan around that time of the month that tends to be more problematic so that we can keep people feeling well and well supported. A lot of times, that's all it takes. It doesn't require much more than that.
Kimberley: I love that. I love that you're bringing in the mindfulness piece and a lot of self-care. This is really more of a question of curiosity, but I remember as a young teen, having a lot of PMS, being told you have to drink a lot of water. Is that like an old wives' tale? Because now I'm telling my daughter. I'm curious, is that an old wives' tale or is that actually a treatment or a part of the work?
Crystal: I don't know. I mean, I think Americans probably go a little overboard on water consumption, but I think it's a good part of self-care to stay well-hydrated as well as well-fed and well-rested. You do lose some water through menstruation, and so it's probably good practice in general just to keep yourself well hydrated. That doesn't mean drinking a certain amount of water every day, but just noticing when you're thirsty and drinking something when you are.
Kimberley: Okay, I'll be better about that because, like I said, as I tell my daughter, I'm always like, "This is probably an old wives' tale." Maybe we could talk this one through together. Let's say I'm treating somebody. They've got severe OCD, severe panic disorder or severe health anxiety, severe social anxiety. They know and they've tracked using an app or, as you said, the notes on their phone or on paper, they've tracked it. They know around approximately that such and such day of the month, they're going to probably have an onset of treatment. How prepared should they be in terms of what would that preparation time look like? Is there a strategy you would give people? I know for us, on the clinical side, I'm amping up homework skills for them to manage the actual disorder, but is there something they could be doing on the PMS side that we should remember to do?
Crystal: I think it's in my mind really specific to the individual and the symptoms that they're having that they find tend to get worse as well as the physical symptoms. If they're having a lot of pain around that time, then we want to also work on some pain management. Because when you're feeling a lot of pain, that can make your anxiety worse. That would be something I would think about in addition to the standardized ramping up of homework that you would ordinarily be doing. Pain management can again look more like mindfulness, some meditative practice, or it can mean talking with one's doctor about how to manage pain because there are non-addictive ways of managing pain as well.
Kimberley: Right. You mentioned before talking to your doctor. Are you speaking specifically about just a GP or should they be going more to a reproductive doctor, OB-GYN? What kind of medical professional would you encourage people to reach out to?
Crystal: I think if you have a doctor that you trust, whether it's a GP, OB-GYN, or even a psychiatrist, all of those are good options. Any of them can help treat these symptoms. Sometimes if the symptoms are really severe, then going to a specialist in reproductive mental health—that person would be a psychiatrist—can be helpful. There aren't that many of us out there though. I have a number of really wonderful colleagues that I work alongside in our clinic and we treat patients together. I provide the psychotherapy and then they provide the pharmacotherapy and then I also have an OB-GYN on the team who provides the hormonal treatment. Not everyone can access this highly skilled team, however, and I do recognize that. I think starting with a GP or your OB-GYN is a good place to start. Again, if they're not as knowledgeable as they need to be and they're telling you, you just have to suck it up and deal with it, that's not the right person.
Kimberley: I appreciate you saying that because I do think—I'll be transparent—even to get somebody as skilled as yourself on the show for this was a really difficult thing. I was surprised how few people really understand it and are knowledgeable about the treatment options. It was harder than I thought and I'm so grateful for you to be here and talk about it with us.
Crystal: I'm really sorry to hear that. I think there are a growing number of people interested in this, and I have a number of wonderful colleagues. But like you mentioned, there aren't that many of us out there. The bright spot, I would say, is that we have a training program at UNC Chapel Hill with lots and lots of applicants every year. We're training clinical psychologists and social workers and psychiatrists to do this work.
Kimberley: Amazing. Thank you. Last question: Any final advice you would give someone who is experiencing symptoms of PMS and PMDD in regards to getting better or seeking treatment and help?
Crystal: You're not alone. It's not all in your head. You deserve access to treatments that work. There are lots of treatments that work. Unfortunately, our medical system is really complex and sometimes you have to really advocate for yourself in this space. But if you are persistent and know what you're looking for in a provider, you, I hope, will be able to find one that can be a good advocate and supporter of you to recovery because you don't have to experience these symptoms by yourself or forever.
Kimberley: Thank you so much for saying that. I think a lot of people feel like they're crazy or they've been told they're being crazy, which doesn't help.
Crystal: Yeah. I mean, the word "hysteria" came from studying or psychiatrists working with women who they felt were hysterical and their uterus was traveling around their bodies. The roots of all of this are in this really misogynistic place where many of us are working really hard to overcome that unfortunate history, but there's often still a lot of stigma and misinformation out there.
Kimberley: I remember in my master's degree, that was the first part of the history of Psychology, that women who were just having PMS were being totally hyper-pathologized. Horrible.
Crystal: Yeah. Really horrible. I hope that the work that we do makes a difference. I'm so glad that you're tackling this topic on your podcast. I think this will, I hope, reach a lot of people.
Kimberley: Thank you. Can you tell us where people can get ahold of you, where they might learn about you and the work that you're doing?
Crystal: Yeah. I have a website, it's CrystalSchiller.com. C-R-Y-S-T-A-L S-C-H-I-L-L-E-R.com. I'm actually starting to write a book on this topic, so I really appreciate you reaching out and to know that people have questions about this because that's what I see where I'm at too. And then the UNC Center for Women's Mood Disorders, if you just Google that, you'll find our website and you can read more about the different research studies that we're doing and about our treatment program as well.
Kimberley: Thank you so much and congratulations on writing a book. It's a big challenge and a big accomplishment.
Crystal: Thanks.
Kimberley: Thank you so much for coming on. It's been an absolute pleasure.Crystal: It was wonderful being with you today. Thank you so much. Take care.