“Explaining PMS: From Premenstrual Symptoms to Premenstrual Syndrome: – with Dr. Caroline Friedman

Dr. Caroline Friedman explains PMS. While commonly used to describe any symptoms a woman might have before her period, an OB/GYN will diagnose PMS if these symptoms interfere with daily life. In this episode, Dr. Friedman and Dr. Fox explain how this diagnosis is made and when patients should seek treatment.

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Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB-GYN and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness. All right. Dr. Caroline Friedman, welcome back to “Healthful Woman.” So happy to have you, how’re you doing? 


Dr. Friedman: Good. Thanks for having me again. It’s good to be back. 


Dr. Fox: Thanks for having you? Come in every day if you want. It’d be great. You know, we’re going to be talking about a gynecologic topic today that is very common. 


Dr. Friedman: Right. We’re going to be focusing on some premenstrual syndrome type issues that probably most women listening to this have had a little bit of experience with either themselves or someone close to them. 


Dr. Fox: Right. And there’s a lot of names for this. I mean, sort of the technical names that, you know, we use medically. There’s the premenstrual syndrome, then there’s premenstrual dysphoric disorder, and there’s also people sort of lump into this, some people call like hormone imbalance and, you know, there’s a lot of stuff that’s thrown about terminology-wise. And so, I thought it’d be really helpful to get your perspective on it. Sort of, you know, what do you see? What do you treat? What do you not treat? You know, what can help women and whatnot? Just go through everything. So, let’s get rolling. So, obviously, it’s very common for women to have symptoms before they get their period. What would you consider like normal, meaning as opposed to like giving someone a label of a diagnosis or something, what is something that you just say, “Hey, that’s normal.”? 


Dr. Friedman: Things like breast soreness, breast tenderness, mild bloating, you know, feeling a little tired. That kind of stuff, you know, probably at least 50% of women have one or more symptoms for, you know, some of their cycles or all their cycles. And as long as they’re kind of mild and don’t really stop you from doing what you’re normally doing, then that’s pretty much what we would consider normal. 


Dr. Fox: When does this sort of cross the line into something that either we give a name to, or we start treatment for? 


Dr. Friedman: Typically, when symptoms start causing some kind of, you know, impact or dysfunction in your regular day-to-day life, whether it’s impacting your sleep, your ability to go to school or go to work, your interpersonal relationship, getting your normal day-to-day chores done, things like that, that’s when we generally start to think about maybe it meets criteria for something a little bit more severe. 


Dr. Fox: Right. And what you’re describing there, where it starts to affect someone’s life, that’s where it sort of jumps into the premenstrual syndrome or actually gets like a name, correct? 


Dr. Friedman: Right. 


Dr. Fox: Got it. But that’s much less common. I mean, if 50 plus percent of women have symptoms, what percentage of women, give or take, would actually have PMS, like meet that criteria? 


Dr. Friedman: Probably less than 10%, probably somewhere around, like, 5% or so. So, you know, I think that as a society, we tend to throw out the term PMS very frequently, you know, women do, men do all sorts of things. But in reality, what most of us are experiencing is probably pretty normal. 


Dr. Fox: Right. And then there are forms where it’s quite severe, that’s where the term premenstrual dysphoric disorder, like the PMDD. And that’s like a psychiatric term to say dysphoric disorder. And that’s where it really, like, goes into a more severe form. So, what’s that like? 


Dr. Friedman: Right. So, that is, as you said, the most severe, and also luckily the most rare, but, you know, not so rare, probably about 2% of women suffer from this at times. And that’s when similar types of symptoms, but also more along the spectrum of life, depression, anxiety, irritability, insomnia, so effective things like that. And also some physical issues such as hot flashes, severe headaches, other things more than just your typical bloating or breast tenderness and things like that. And usually, in order to meet criteria for that, it’s got to really impact your life and it’s got to happen pretty much every cycle for, you know, a year or so or more until someone’s really ready to totally take that diagnosis on. 


Dr. Fox: Right. And I think it’s interesting because there’s two sort of categories of symptoms we’re talking about. And, you know, you refer to some of them as either, like, physical symptoms or sometimes medically we call them somatic symptoms, which are things like, you know, breast pain, and bloating, and swelling, and headaches, and, you know, hot flashes, those are sort of your body feels them. But then there’s what you refer to as the effective symptoms, which are basically, you know, mood. So, you know, mood swings, and depression, and irritability, and anxiety. And what’s difficult with those is even not related to menstrual, you know, syndromes, just in life, there’s so much difficulty for people to sometimes know if I have some anxiety, or some irritability, or some mood swings, am I just normal and having a bad day or a bad week, or just, you know, responding to a life stressor with some difficulty which happens all the time, or do I actually have a diagnosis? Like, do I have anxiety like with a capital A or depression? 


And it’s hard because those terms are both symptoms that people can have, and they’re also diagnoses. And so, you know, when a psychologist, or psychiatrist, or someone sort of give someone a diagnosis, it’s not just that they have some anxiety so, therefore, they have anxiety. It’s that it affects their life to a certain degree and there’s criteria and how long. And so, there’s like thresholds that people cross in order to go into that diagnosis. And it sort of works the same way here where people can have symptoms here and there, they come and they go, some are worse, some are better, but when they start becoming pervasive, affecting your life, affecting, you know, how you interact with others and it crosses those lines, that’s when it gets labeled as a diagnosis. And the importance of that is not so much whether you have the diagnosis or not, but it sort of indicates probably what we need to do about it as opposed to just maybe waiting, maybe you get a little more aggressive with treatments. 


Dr. Friedman: Right. Exactly. And knowing, you know, when to seek additional evaluation and when to seek additional help rather than just [inaudible 00:05:59] it all to “normal.” 


Dr. Fox: At what point would you recommend someone seek out either help evaluation or, you know, see their gynecologist or whoever? 


Dr. Friedman: Yeah. Well, certainly, I think, you know, right off the bat, you should seek some help emergently if you’re feeling like whatever you’re feeling currently is really impacting your life, or you’re having feelings of thoughts of hurting yourself, hurting others, or even suicidal thoughts. You know, that’s something that requires emergent evaluation. If you’re just kind of trying to decide, you know, if these are normal symptoms, are they more severe, maybe some treatment or evaluations help, you can start by kind of writing down what symptoms you’re having and when you’re having them, kind of keeping a little diary to assess the timing. Because I think what sets the syndromes we’re talking about today apart from some of the other regular anxiety, or even, you know, more severe depression is the timing. 


And in that sense, what we’re talking about today is something that really comes with cycles, the last half of your cycle every month or most months, as opposed to most days or every day of the month. And so, if you find that you’re having these symptoms every month and then they’re getting better but they’re really getting severe, I think it’s worth talking to either a mental health provider or your gynecologist. 


Dr. Fox: What you said is so true that in terms of the etiology of why this is happening, when it is related to your period, which could be a hormonal issue, it’s going to follow a pattern typically where the symptoms are there in the second half of the cycle and not there in the first half. So, I mean, once someone gets their period for that week and the next week typically they’re okay, and then the third and fourth week of the month, they’ll start getting the symptoms. And whereas if it’s an actual, let’s say a diagnosis of anxiety or depression, that’s not related, it’s going to be, you know, pretty much all the time. 


I think it’s also important to realize that women don’t have to spend too much time trying to figure out “Who should I see?” Because anyone who sees an OB-GYN, you can see her or him for either of those. And the same thing if you see a mental health provider, you can see them for either of those as well. If the mental health provider thinks that it may be more related to menstrual, you know, and she or he wants you to see a gynecologist, they can have you see that person second and vice versa. So, you know, it’s not so critical which one you see first, but you should see somebody if you’re having these types of symptoms. 


Dr. Friedman: Right. Exactly. 


Dr. Fox: And then if someone came to you with those symptoms, how would you even evaluate them other than what you were saying sort of check what their symptoms are and what the timing is and how severe they are? Is there any, like, blood tests you can do or exam you can do to try to figure this out? 


Dr. Friedman: So, there’s not really a blood test that diagnoses this kind of thing, but I think it is important to make sure you’re thinking about other potential issues that could be going on and ruling those out. And so, if someone comes in and is complaining of severe fatigue as their biggest symptom, and maybe it’s a little worse around their period but not really sure, I would certainly want to make sure things like their thyroid are functioning normally, and that, you know, they’re not too anemic and that their blood counts are okay. So, I would probably do blood tests to check those things, but again, not necessarily to rule in a diagnosis of PMDD or PMS. But you also want to, you know, take a thorough history, see if anything’s changed in terms of new medications or anything else going on in their life that may be contributing to some of the symptoms the patient’s having and sort of go from there. 


Dr. Fox: Is there any value in actually checking someone’s hormone levels, like their estrogen level, their progesterone level, is that something that’s valuable? 


Dr. Friedman: Yeah, not really. And the reason is that when the hormone levels were looked at in some study comparing patients who have these diagnoses versus those who do not suffer from such symptoms, the values were really very similar. And so, the thought is that one potential reason why certain women suffer so much is that it’s actually how their body is reacting to the hormones rather than the absolute number or amount of hormones going through their body at a given time. 


Dr. Fox: Right. And so, we don’t really understand why someone’s body would react a certain way and another one’s wouldn’t, that’s pretty much unknown now, right? 


Dr. Friedman: Right. 


Dr. Fox: I mean, almost the same thing like for a mental health condition, we don’t understand, you know, why one person may suffer from depression and another person wouldn’t. Obviously, if there’s a major life stressor that would maybe explain why it presented, but many people with…or most people with these conditions, it’s not from a life stressor, they have the condition. And we don’t really understand that so well. Hopefully, we’ll learn more. And there’s a lot of, you know, interest in various neurotransmitters and that’s sort of how the therapies related to the mental health aspect came about, but we still don’t really understand it. 


Dr. Friedman: Yeah, unfortunately, not. 


Dr. Fox: Okay. So, you see someone and you’re evaluating them and you make sure that, you know, it’s not some other medical condition that could be presenting potentially as one of these ways, and you’re pretty sure someone is along this spectrum. Are there rigid criteria to define if it’s from normal to the premenstrual syndrome to the premenstrual dysphoric disorder, or is it hard rules, or is it a little bit blurred? 


Dr. Friedman: You know, like most things in medicine, it’s not so black and white. Premenstrual dysphoric disorder specifically is what we call, like, a validated psychiatric diagnosis. And so, there is a code written by psychiatrists to definitively make diagnoses for that disorder. Same way that, you know, depression, or bipolar disorder, or schizophrenia, or anything like that are diagnosed. And it usually requires a certain number of symptoms for a certain length of time, you know, impacting a patient’s life in a certain kind of way. And so, in that sense, there is. 


However, it’s not so strict in the sense that if I think a patient could benefit from treatment as I would treat someone who, you know, makes that exact diagnosis, I would probably recommend treatment. And again, like, I don’t necessarily need a patient who’s been noticing these symptoms for six months to give it another six months before we start treatment. So, there’s definitely some wiggle room. It is definitely a spectrum. But, you know, it’s kind of good to know that there are criteria in the sense that it gives a little bit of a framework to work with. 


Dr. Fox: Yeah. And I think that one of the clues that I always tell people in medicine is whenever there’s something that ends with the word syndrome, that sort of means we don’t really know exactly what it is or, you know, where the lines are drawn. It’s more like a constellation of symptoms. And there’s a lot of leeway in those diagnoses and managements because typically, there’s a whole bunch of things that might work, might not work, and you can try them based on how severe the symptoms are. You know, if they’re less severe, you can try the, you know, less invasive or less aggressive treatments, and if they’re more severe, move to those. And there’s many different strategies based on exactly what the symptoms are, how severe are they? You know, what are the treatments? What are women willing to try first and not willing to try first? And so, there’s a lot of overlap with this and definitely, you’ll see people trying different treatments for different things at different times. 


Dr. Friedman: Right. 


Dr. Fox: And so, what are the treatments you might…let’s start with, like, the least aggressive to the most aggressive for this whole, you know, spectrum of difficulties that women might have. What do you start with in terms of the simplest? 


Dr. Friedman: Well, so we start with just counseling on the general lifestyle things that can help, specifically when it comes to exercising, staying active, and trying some relaxation techniques. The data’s not so good that this does help or not. But given that I think these are all beneficial things to do regardless of the situation, I always recommend them to my patients. And so, that’s trying to be active, you know, most days of the week for at least 30 minutes, finding exercises that bring you happiness and routines that, you know, are things that make you excited to do them and not just feel like it’s work. And trying out things like meditation, mindfulness, things like that, because I think those are always helpful and it makes sense that it might help to calm, you know, someone down or relieve a little bit of anxiety if that’s where their symptoms are mostly focused. 


Dr. Fox: Right. And in terms of exercise, do you find that that would be more helpful for the physical symptoms or the mood symptoms, or both, or sort of unpredictable? 


Dr. Friedman: It’s a little unpredictable, but I think really for both symptoms, I think that there’s good data that being active definitely helps with mood symptoms. And in regards to specific physical symptoms, certainly things like bloating, I know women can feel much, much better if they get up and move around. 


Dr. Fox: Yeah, and I think that in terms of the relaxation techniques and, you know, meditation, it’s really interesting because there are so many different modalities, right? There’s meditation on your own, various apps, where people are good at it or people go to classes or groups, and then there’s things like yoga, which has a meditative aspect, there’s different types of massage and acupuncture and all of these are…they sort of get lumped together, but there’s so much about it that we don’t understand. And so, it’s hard to study. And so, when we say, you know, we don’t really know what the data, which is true, but so many people will report, “Oh, I tried this and it really worked for me,” or “I tried that and it was amazing for me,” or “I tried this and it didn’t help at all.” 


And so, I’m generally very encouraging for women to try all of them and just see what happens, right? They’re not dangerous, obviously. And they’re beneficial in many other ways and try something. And if it works for you, great. If it doesn’t, move on to the next one. It’s hard to study, so it’s hard for us to say, you know, this for sure works or this for sure doesn’t work. And so, when we say, “Oh, we don’t know if it works,” that it’s not like we’re blowing it off, it’s that we just can’t be certain about each of these for each individual person. 


Dr. Friedman: Exactly. 


Dr. Fox: Okay. So, let’s say that’s not helping, so people are trying a lot of these things and either are helping a little bit but not enough or it’s not helping at all, are there any other treatments that you would go to for the next level, let’s say? 


Dr. Friedman: Yeah. So, the next level would be to think about certain medications. And there are kind of two major types of medications that can be helpful in this situation. And it depends on the individual patient’s, I guess, life situation, sort of what they want to start trying, but the first group is actually birth control pills. And so, this is a really good option for women who are looking to use birth control pills as contraception, because they’re getting a two for one deal on that, or, you know, don’t necessarily need it for contraception, but aren’t actively trying to get pregnant or are worried about using the pills in that sense. There’s also the concern birth control pills have estrogen and progesterone in them. And so, there are some medical situations in which women can’t take the estrogen component of that. And so, we would have to go to the other group of medication for that group of women. 


Dr. Fox: Right. And so, in terms of the birth control pills, it’s interesting because one would think that if there’s, you know, hormonal issues that giving someone hormones would exacerbate it, would make it worse, but in fact, it tends to make it better. Why would that be? 


Dr. Friedman: Well, the thought is actually that, you know, these symptoms arise due to the changing in the levels of the hormones throughout the menstrual cycle. And really the estrogen/progesterone goes through various peaks and valleys throughout the course of the menstrual cycle. And so, birth control actually works to sort of suppress that. And so, you’re getting more of a constant steady state of hormones for pretty much every day throughout the cycle, which can really help temper those symptoms. 


Dr. Fox: It’s really fascinating because, number one, you know, most birth control, like, you know, oral contraceptive preparations are a month at a time or four weeks at a time, that the first three weeks you’re getting the same amount of hormone. There are some that change the level of hormones, but basically, most of them have the same amount the first few weeks. And then the last week, or the last five days, you get no hormone, which mimics what happens in your body naturally. Your hormones drop, you get your period. Okay. So, like you said, that sort of levels out, you don’t have those, like, peaks or troughs. You just have a level amount of hormone and people tend to do well with those. 


There are also preparations that are several months at a time where you don’t get any period, you know, for three months, four months, however, basically people take it, which seems to work also. But and also, you know, oral contraceptives work for other conditions that we think are hormonally related. You know, things like endometriosis, it works for some women and, you know, there’s a lot of other conditions where removing those peaks and troughs of the hormone levels do seem to help women. So, there’s some reason, you know, some plausible reason why it would work. And in your experience for women who have either PMS or even maybe more severe form like PMDD, do the oral contraceptives really work? 


Dr. Friedman: Yeah. I think for a lot of women they really, really do. Some women do find even with taking like a shorter course of a placebo, like some of the pills come with, you know, 24 days of hormone pills and four days only of the placebo pills, so that works for some, and then they get still a short period, but the symptoms are under control or someone will take it continuously. You know, the issue is that in certain women, again, we don’t really know why birth control pills can actually worsen the mood. And so, we do need to keep that in mind and monitor these patients closely when we are starting this treatment. 


Dr. Fox: Right. But again, for most people, it’s going to be helpful to some degree, particularly, if they’re…and the only woman again, unless there’s like a medical reason not to give the hormones, really the biggest downside is just that if she’s trying to get pregnant obviously, this would not be the right treatment for her. 


Dr. Friedman: Right. 


Dr. Fox: Got it. Okay. So, let’s say what would be the next line of therapy if the oral contraceptives aren’t working or it’s something she can’t take or isn’t interested in taking? 


Dr. Friedman: Yeah. So, the other group of medication that’s been found to be useful is a type of antidepressant. They’re usually referred to as SSRI or selective serotonin reuptake inhibitors for the fancy words. And they work on the hormone serotonin in your brain, which is what we think is responsible for a lot of things like anxiety, depression, and in this case, the symptoms associated with the second half of the woman cycle. 


Dr. Fox: Right. And these are medications that most people are already familiar with. I mean, these are very, very commonly used. You’re talking about, you know, brand names like Prozac, or Zoloft, or, you know, Paxil, or Effexor, these are very common medications. People take for many reasons like, you know, depression, anxiety, or, you know, somewhere in that realm. But so you’re saying that they could be used specifically for someone who just has these symptoms right before her period comes on and she doesn’t have the diagnosis of anxiety or depression, but she has those symptoms around the end of her cycle that they could be effective as well. 


Dr. Friedman: Right. Exactly. And in some cases, you know, these medications can actually be taken only in the second half of the cycle as opposed to when women are taking it for anxiety or depression, they take it every day. 


Dr. Fox: How would someone know whether they should be taking this every day, or just the end of the cycle, or just with symptoms? Is it trial and error, or is there a way to sort of predict that, or is there any other way to figure that out? 


Dr. Friedman: You know, it’s definitely something you should talk about with the doctor to help determine what seems to make the most sense. It’s definitely some trial and error, but, in general, if you’re kind of having some sort of mild symptoms most days of the month or every day of the month, probably makes sense to just take it every day. It’s also easier to remember if you’re going to take it every day and safe to do. If your symptoms are pretty predictable and you kind of know when they’re going to start, a lot of people will then choose to just do the second half of the month or the second half of the cycle type of dosing. And some people, you know, really, like, can feel their symptoms may be less predictable, but they really know exactly when they’re starting. And in that case, you can actually do what’s called a symptom onset dosage where you really just start taking it for a few days once you know the symptoms are coming and then you stop it when you’re feeling better, 


Dr. Fox: All right. And it’s typically a low dose, meaning it’s not something where people have to keep going up and up on the dose. Like usually, it works or it doesn’t, yes? 


Dr. Friedman: It’s usually beneficial right away, but the dose can be increased. So, it’s not an all or nothing thing. 


Dr. Fox: Got it. And then in your experience, two questions, the first is how often is it that someone has one of these conditions and just none of the treatments work, right? Or is it basically pretty much by the time someone’s on a birth control pill and one of these medications, they’re feeling mostly better? 


Dr. Friedman: Yeah. It’s the second. Most people feel better with one of these two treatments roughly. 


Dr. Fox: Got it. And so, it’s unusual that someone would have these symptoms, seek treatment, get treated, and it wouldn’t work. That’s an unusual thing? 


Dr. Friedman: Correct. 


Dr. Fox: So, that’s reassuring. That’s good to know. The second question is in terms of when you’re seeing women for their annual exams or, you know, visits for other reasons, how often is it that you’re the one eliciting one of these conditions in women? Meaning not that she came to you saying, “Oh, I have this, I have this. And, you know, what do I do? What is it?” And you’re answering. Versus you find out just on your questions that she’s had this for years and she never even thought to seek treatment for it? 


Dr. Friedman: Yeah. You know, it’s interesting I actually feel like I don’t get that so often. I mean, a lot of women I think when I really probe about it will admit to having some symptoms and either downplay it or say that it’s not really such a big deal. I find that a lot of times what comes up is a [inaudible 00:22:15] talking about like, in general, the anxiety and things like that. And then we get into more of the nitty-gritty of it and realize that maybe it’s not all the time that maybe it’s associated with the cycles, but a lot of women don’t really think about it on their own. 


Dr. Fox: Interesting. So, you’re saying that most of the time, it’s something that they do bring to you or most of the time it’s something that they didn’t even know they should bring to you? 


Dr. Friedman: The latter, that they didn’t really even know. 


Dr. Fox: Right. I think it’s also so interesting that women, I mean, men too, but not, you know, for other issues obviously, but specifically for this, women so frequently have it and just chalk it up to this is it, this is who I am, you know, tough luck, and that’s not really necessary. It’s not needed. The treatments are, you know, pretty basic. I mean, all of these treatments are really safe, very straightforward. I mean, the first, you know, just, you know, relaxation, and meditation, and exercise, obviously, is pretty straightforward. Oral contraceptive pills or birth control pills, so many women either take anyways, or have taken, or are comfortable taking, or can take. The SSRIs, you know, okay, it’s “a psychiatric medication,” but again, there’s so little stigma around taking them nowadays and they’re so available and safe, and there’s so much data that there’s really no reason women have to suffer with these symptoms. 


Dr. Friedman: Yeah. A hundred percent. 


Dr. Fox: Wow. Have you found anything related to, let’s say, diet and there’s so much about, you know, this diet and that diet and, you know, what affects hormones and what doesn’t, what do you know about this or what is known about that? 


Dr. Friedman: You know, not that much. I think there’s a lot of conflicting information out there about diet, vitamins, all things you can do to try to help manage these symptoms. And some people might find that, you know, eating a healthy, balanced diet low in sugar is helpful. Again, I think that’s a good thing, not from testing. But not something that I would say if you want to feel better then that’s absolutely what you must do because the data’s not really there to support that. 


Dr. Fox: I really believe that there’s so much to be learned in terms of various diets and not so much supplements, I would say, but just sort of what components are in your diet and what aren’t, and cutting foods out and adding foods in. And I believe that there are combinations that are really gonna be helpful for many different conditions. We know for like severe ones, you know, we know for hypertension and diabetes, like we have a pretty good sense of what it is. But for these other, you know, in terms of mood disorders, in terms of, you know, menstrual symptoms and there’s so many other things that we just don’t know. And so, I think there’s so much to be learned. 


There’s definitely people who will state like, “If you’re on this diet, you’ll get better.” And I think that’s probably a little too confident based on where we are currently, but it’s probably true that there are various diets for various people that’s going to help. And so, that’s something sort of, like, I feel with, you know, meditation, relaxation, try different things. You know, maybe someone’s going to be better on a low carb diet, maybe someone would be better on a, you know, more paleo diet or a gluten-free diet and, you know, toy around with these things, why not? 


And as long as you’re getting, you know, the right nutrients, and if you’re not sure, or if you have specific dietary restrictions or allergies, you could certainly meet with a nutritionist to go over this. And a lot of this is trial and error. See what works for you and see what doesn’t and, you know, someone might be pleasantly surprised. For women who have this, is it something that typically persists for all of their reproductive years, or are these things that come and go? What’s the natural course of this in general? 


Dr. Friedman: In general, it probably persists for most of a woman’s reproductive life in some form, not always as severe, you know, maybe a little bit better here and there, but not always. So, you know, like most things, it’s individual to each patient, but certainly, it’s a possibility that women would need to be treated potentially until they go through menopause. 


Dr. Fox: Right. Because once someone goes into menopause, you know, there’s other issues, obviously, the menopause, but these types of symptoms you know, and conditions would go away because she’s not having regular cycles or any cycles at that point? 


Dr. Friedman: Right. 


Dr. Fox: Got it. Wow. Caroline, this is great. What a great review of these, you know, we call them disorders, but it’s such a harsh word because they’re so common, either the symptoms or, you know, the syndromes. And I think the only one I would really classify as a true disorder is the one that’s severe, the premenstrual dysphoric disorder. And importance of bringing it up with your doctor, if you have these symptoms and if they in any way concern you and it’s possible he or she will just say, “No, this is really typical. You probably don’t need any treatment.” But if they’re really starting to get persistent and they’re bothering you or they’re affecting your life, then for sure, like, there’s really not much downside in trying certain treatments because it’s about quality of life here. 


Dr. Friedman: Absolutely. You should never feel bad bringing any of this stuff, it’s all really important. 


Dr. Fox: Right. And I would say that’s even true, you know, for much younger patients. So, you know, teenagers, you know, girls from puberty until their 20s, like, for sure can have a lot of these and should also be comfortable bringing it up even for their pediatrician. And if the pediatrician is uncomfortable treating, they can either send, you know, her to one of us, to a gynecologist, or even a pediatric gynecologist, or even just call us and we can talk about these things. 


Dr. Friedman: Right. Yeah. Absolutely. 


Dr. Fox: Amazing. Well, thank you so much for coming on to talk about this and I’m certain, we will have you on many, many more times. 


Dr. Friedman: My pleasure. Good to be here. 


Dr. Fox: Thank you for listening to the “Healthful Woman Podcast.” To learn more about our podcast, please visit our website at www.healthfulwoman.com. That’s healthfulwoman.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at hw@helpfulwoman.com. Have a great day. The information discussed in “Healthful Woman” is intended for educational uses only. It does not replace medical care from your physician. “Healthful Woman” is meant to expand your knowledge of women’s health and does not replace ongoing care from your regular physician or gynecologist. We encourage you to speak with your doctor about specific diagnoses and treatment options for an effective treatment plan.