(Pre)menstrual Inflammation- PMI

What's PMI?

What's PMI?

Menstrual physiology

Menstrual physiology

PMI versus PMS

PMI versus PMS

Tips and tricks

Tips and tricks

Premenstrual Inflammation

(Pre)menstrual Inflammation...

Formerly known as 'PMS' or 'PMT', PMI is a temporary condition rather than an 'illness' and can usually be treated without the need for expert medical advice.

Inflammation is caused by the normal and healthy biological changes involved in maintaining the female reproductive system. Ovulation, the thickening of the womb lining, and menstruation (the period) are all inflammatory events, which can lead to various cyclical 'side effects' (see physiology section below) [1].

Ultimately, the menstrual cycle helps to ensure the continuation of the human species and prevent dangerous pregnancies that could otherwise prove fatal [2]. While menstrual blood loss is costly in terms of the reduction in iron stores, it is less costly than the loss of a female adult of reproductive age to the community/ species!

If you regularly experience moderate and/ or occasionally severe cyclical symptoms, it is likely that your underlying levels of inflammation are already relatively high [3]. This could be due to external factors such as a poor diet; current work, relationship or financial stress; past trauma; or an underlying condition such as depression, anxiety, fibroids, anaemia or endometriosis.

The good news is that anti-inflammatory approaches (outlined in the 'tips and tricks' section below) should significantly alleviate all PMI symptoms. If not, it is much more likely that you have an underlying condition that requires medical advice and treatment.

What's PMI?

These changes vary between individuals, are temporary, and typically worse during times of stress and better when feeling more relaxed (e.g. on holiday!)

They should respond to anti-inflammatory approaches (see 'tips and tricks' below). If not, you may have an underlying health issue...

[Click on individual symptoms to find more specific tips and tricks]
  1. Abdominal (period) pain
  2. Irritability/ anger
  3. Digestive changes: bloating, constipation, diarrhoea, powerful food cravings, nausea/ vomiting
  4. Back/ muscle/ joint pain
  5. Breast tenderness
  6. Fatigue
  7. Headache
  8. Low mood/ self esteem
  9. Anxiety/ tension
  10. Blood loss regularly around 80ml (160ml fluid) per period
External factors can increase systemic inflammation!
External factors can increase systemic inflammation!

Menstrual physiology...

Watch this space for more info about menstrual physiology... coming soonish in 2021!

Image source: Menstrual Matters. Data sources [4]
Image source: Menstrual Matters. Data sources [4]

PMI versus PMS...

You have probably never heard of 'PMI' before... This is because (pre)menstrual inflammation is a term coined by Menstrual Matters founder, Sally King. Based on the available evidence (i.e. the data found in good quality clinical studies) describing cyclical changes in relation to inflammatory processes, is not only more accurate [5], but also less stigmatising than previous definitions of these experiences e.g. 'Premenstrual Tension- PMT' or 'Premenstrual Syndrome- PMS' [6].

These past names wrongly imply that cyclical changes are necessarily negative, debilitating, and more psychological than physiological in origin and experience [6]. As a result, they have also been used in relation to a gender stereotype that positions 'all women' as inherently emotionally and intellectually impaired by the female reproductive system i.e. the myth of the 'irrational' or 'hysterical' female [7] (even those who are menopausal- see cartoon below) [8].

There are now also brackets around the (pre) part of (pre)menstrual in PMI. This is because these changes often occur around ovulation, just before menstruation and also during or after menstruation [9], rather than only 'before menstruation' as was previously implied. They also vary a lot between individuals, with age, and in relation to external stressors, and so the timing or type of changes is not predictable based on 'typical menstrual physiology' only.

Sexist cartoon: Pat Oliphant [8]
Sexist cartoon: Pat Oliphant [8]

Tips and tricks...

If you would like to reduce your PMI, you can try the following anti-inflammatory approaches:

1. Taking anti-inflammatory medications such as Ibuprofen, or Naproxen, 2-4 days (400-1200mg per day) before you expect your period, will substantially reduce PMI symptoms, especially period pain and blood loss [9].

2. Taking high strength Omega 3 oils every day can also reduce pain and blood loss [10].

3. Taking hormonal (contraceptive) medications, which typically alleviate all (pre)menstrual symptoms [11]. You may need to try a few different types before you find the one that works best for you- each person responds differently!

4. If you prefer not to take medications (and/ or dietary supplements), the good news is that menstrual health responds very well to some simple lifestyle changes.

By following these four steps, many people will notice a significant improvement in their health and wellbeing. Better still, even if these approaches do not completely prevent all of your symptoms, they will definitely help, and won't make things any worse, since they are all health-promoting interventions.

4 steps to health

1. Diet- what you eat can affect your menstrual health considerably.
Please see this blog post for more information, and to see the clinical research behind these 8 general recommendations:

1. Eat lots of fresh fruit and vegetables
2. Eat lots of fibre (and drink water with it!)
3. Eat oily foods (mainly unsaturated fats)
4. Reduce meat and dairy products
5. Avoid sugary foods and drinks
6. Avoid caffeine
7. Avoid alcohol
8. Take nutritional supplements, if needed (e.g. Omega oils, calcium, iron, magnesium, vitamins, or zinc)

Note: An 'anti-inflammatory' diet is recommended for the management of several chronic health conditions, including those that are known to be triggered, or worsened, at certain points in the menstrual cycle.

Exercise

2. Exercise- Don't panic! You do not have to run a marathon, or take up competitive sports (unless you want to?) What's most important is that you regularly spend time moving your body, developing your strength, and getting slightly out of breath. The key to success is finding an activity that you enjoy doing, perhaps with others, to provide the motivation to keep going.

The NHS recommends that adults spend [12];

- at least 2.5 hours of moderate aerobic activity such as cycling or fast walking every week, and

strength exercises on two or more days a week that work all the major muscles (legs, hips, back, abdomen, chest, shoulders and arms).

Obviously, there are many reasons why moderate exercise is good for your health, but in terms of menstrual health it can improve self-esteem and low mood, and metabolic conditions such as PCOS (Polycystic Ovary Syndrome) or amenorrhea (a lack of regular periods).

Self-esteem

3. Improve self-esteem- in a sexist (patriarchal) society it is very easy to develop negative feelings towards the menstrual cycle, or female body. The pressure we feel to hide our periods can make them appear disruptive to work, socialising, exercise, care for others, or other enjoyable activities. This can lower mood and self-esteem, and increase anxiety levels.

Getting to know and trust your body, especially the taboo bits (i.e. the vulva and vagina) can boost self-esteem. Making peace with your body can make a surprisingly big difference in improving menstrual health and well-being.

Happily, improving self-esteem is a relatively easy thing to do!

It involves noticing any negative internal thoughts, and analysing them to prove to yourself that they are not actually true, or reflective of who you really are (i.e. a human being of equal worth to all other human beings). Some people might benefit from the support of a professional counsellor, but a good (and cheap) starting point is this amazing booklet from the Oxford Cognitive Therapy Centre.

Learning more about the menstrual cycle, using a menstrual cup, and tracking changes over time, can also help boost self-esteem. For example, a menstrual cup encourages the user to get to know (and like!) their reproductive anatomy better, and to observe menstrual fluid up close. Cycle tracking helps you to know what is normal for you, and so feel more in control of health and well-being.

De-stress

4. Reduce stress - Although we have become used to differentiating between ‘mental' and ‘physical' health, this is an artificial separation, especially when thinking about menstrual health.

For example, it is known that the menstrual cycle interacts with the HPA (Hypothalamic–Pituitary–Adrenal) axis, better known as the ‘stress axis’ [13]. If you experience an increase in stress, you will feel anxious- your ‘fight or flight’ response is triggered. This is what we have evolved to do, regardless of the fact that this response might have been triggered by healthy changes in the menstrual cycle, rather than a scary, dangerous, or otherwise stressful situation.

Interestingly, research shows that cyclical changes are strongly affected by external (stress) factors, as well as physiological changes [14]. For example, irritability, is nearly always in response to an experience of 'injustice'  or 'frustration' of some sort- e.g. shouting at the kids whilst trying to get them ready for school, if your partner does not equally share in this responsibility. In fact, being single, or having a supportive partner can significantly improve menstrual health, by simply reducing the sense of 'injustice' regarding personal responsibilities during the premenstrual/ menstrual phase [15]!

A top tip is to ask your partner to cook dinner, or to be in charge of childcare just before and/ or during your period...

Another is to set a regular sleep pattern- use an alarm for when you should start to get ready for bed, switch off any screen devices, and try and wake up at a similar time each day. This will help regulate your body clock, which is also involved in the stress/ inflammation responses and the menstrual cycle!

By tracking changes over time, and getting to know when you are likely to feel more anxious, or sensitive to stress,  you can feel more in control, and ‘resist’ those first fluttery feelings in the pit of your stomach.

Take note of any triggering experiences- this will help you to identify the cause(s) of your stress e.g. work, home, or finances etc. Relaxation techniques or mindfulness practice can help to calm your breathing, and body, to break out of a downward spiral of emotional distress.

Then talk to the people in your life about the triggers that contribute to stress. Perhaps they could help in some way e.g. provide childcare support, help you to manage debt, or simply allow you some more space (e.g. at certain times in your cycle)?

Page last reviewed: Dec 2020

References...

[1] Bertone-Johnson ER, Ronnenberg AG, Houghton SC, Nobles C, Zagarins SE, Takashima-Uebelhoer BB, Faraj JL, Whitcomb BW. Association of inflammation markers with menstrual symptom severity and premenstrual syndrome in young women. Hum Reprod. 2014 Sep;29(9):1987-94. doi: 10.1093/humrep/deu170. Epub 2014 Jul 17. PMID: 25035435.

[2] Critchley HOD, Babayev E, Bulun SE, Clark S, Garcia-Grau I, Gregersen PK, Kilcoyne A, Kim JJ, Lavender M, Marsh EE, Matteson KA, Maybin JA, Metz CN, Moreno I, Silk K, Sommer M, Simon C, Tariyal R, Taylor HS, Wagner GP, Griffith LG. Menstruation: science and society. Am J Obstet Gynecol. 2020 Nov;223(5):624-664. doi: 10.1016/j.ajog.2020.06.004. Epub 2020 Jul 21. PMID: 32707266; PMCID: PMC7661839.

[3] Bertone-Johnson ER, Ronnenberg AG, Houghton SC, Nobles C, Zagarins SE, Takashima-Uebelhoer BB, Faraj JL, Whitcomb BW. Association of inflammation markers with menstrual symptom severity and premenstrual syndrome in young women. Hum Reprod. 2014 Sep;29(9):1987-94. doi: 10.1093/humrep/deu170. Epub 2014 Jul 17. PMID: 25035435.

[4] This diagram was developed by MM but using the data from:

  • Salamonsen LA, Woolley DE. Menstruation: induction by matrix metalloproteinases and inflammatory cells. J. Reprod. Immunol. 44(1–2), 1–27 (1999).
  • Angeli, A., Lainé, F., Lavenu, A. et al. Joint Model of Iron and Hepcidin During the Menstrual Cycle in Healthy Women. AAPS J 18, 490–504 (2016). https://doi.org/10.1208/s12248-016-9875-4
  • Yeung EH, Zhang C, Mumford SL, Ye A, Trevisan M, Chen L, Browne RW, Wactawski-Wende J, Schisterman EF. Longitudinal study of insulin resistance and sex hormones over the menstrual cycle: the BioCycle Study. J Clin Endocrinol Metab. 2010 Dec;95(12):5435-42. doi: 10.1210/jc.2010-0702. Epub 2010 Sep 15. PMID: 20843950; PMCID: PMC2999972.
  • E. Montero-Lopez, A. Santos-Ruiz, M.C. Garcia-Rios, M. Rodriguez-Blazquez, H.L. Rogers, M.I. Peralta-RamirezThe relationship between the menstrual cycle and cortisol secretion: daily and stress-invoked cortisol patterns Int. J. Psychophysiol., 131 (2018), pp. 67-72
  • White, C. P., Hitchcock, C. L., Vigna, Y. M., & Prior, J. C. (2011). Fluid Retention over the Menstrual Cycle: 1-Year Data from the Prospective Ovulation Cohort. Obstetrics and gynecology international2011, 138451. https://doi.org/10.1155/2011/138451
  • Emera, D., Romero, R., & Wagner, G. (2012). The evolution of menstruation: a new model for genetic assimilation: explaining molecular origins of maternal responses to fetal invasiveness. BioEssays : news and reviews in molecular, cellular and developmental biology34(1), 26–35. https://doi.org/10.1002/bies.201100099
[5] Bertone-Johnson, E (2016) "Chronic Inflammation and Premenstrual Syndrome: A Missing Link Found?." Journal of Women's Health, 25(9), pp. 857–858 https://doi.org/10.1089/jwh.2016.5937

[6] Chapter 4- 'The menstrual cycle; attitudes and behavioural concomitants' by Chrisler, J & Gorman, JA. in Ussher, J.M., Chrisler, J.C., & Perz, J. (Eds.). (2019). Routledge International Handbook of Women’s Sexual and Reproductive Health (1st ed.). Routledge. https://doi.org/10.4324/9781351035620

[7] King S. (2020) Premenstrual Syndrome (PMS) and the Myth of the Irrational Female. In: Bobel C., Winkler I.T., Fahs B., Hasson K.A., Kissling E.A., Roberts TA. (eds) The Palgrave Handbook of Critical Menstruation Studies. Palgrave Macmillan, Singapore. https://doi.org/10.1007/978-981-15-0614-7_23

[8] This cartoon drawn by Pat Oliphant (https://en.wikipedia.org/wiki/Pat_Oliphant) was published in the lead up to the 2008 US election, when Hilary Clinton was running for president alongside fellow Democrat candidate, Barack Obama. She was 59 years old and no longer had a menstrual cycle. Facts never seem to get in the way of a good gender myth, though! Check out this interesting blog on the topic- https://www.dailykos.com/stories/2008/1/11/434904/-

[9] Feng X, Wang X. Comparison of the efficacy and safety of non-steroidal anti-inflammatory drugs for patients with primary dysmenorrhea: A network meta-analysis. Mol Pain. 2018 Jan-Dec;14:1744806918770320. doi: 10.1177/1744806918770320. Epub 2018 Mar 27. PMID: 29587566; PMCID: PMC5987898.

[10] Behboudi-Gandevani S, Hariri FZ, Moghaddam-Banaem L. The effect of omega 3 fatty acid supplementation on premenstrual syndrome and health-related quality of life: a randomized clinical trial. J Psychosom Obstet Gynaecol. 2018 Dec;39(4):266-272. doi: 10.1080/0167482X.2017.1348496. Epub 2017 Jul 14. PMID: 28707491.

[11] Jarosz AC, Jamnik J, El-Sohemy A. Hormonal contraceptive use and prevalence of premenstrual symptoms in a multiethnic Canadian population. BMC Womens Health. 2017 Sep 26;17(1):87. doi: 10.1186/s12905-017-0450-7. PMID: 28950854; PMCID: PMC5615478.

[12] NHS. (2011) Physical Activity Factsheet. [ONLINE] Available at: http://www.nhs.uk/Livewell/fitness/Documents/adults-19-64-years.pdf. [Accessed 22 March 2017].

[13] Goel N, Workman JL, Lee TT, Innala L, Viau V. (2014) 'Sex differences in the HPA axis'. Comparative Physiology 4(3):1121-55. doi:10.1002/cphy.c130054. Review. PubMed PMID: 24944032.

[14] Kirschbaum C, Kudielka BM, Gaab J, Schommer NC, Hellhammer DH. (1999) 'Impact of gender, menstrual cycle phase, and oral contraceptives on the activity of the hypothalamus-pituitary-adrenal axis'. Psychosomatic Medicine 61(2):154-62. PubMed PMID: 10204967.

[15] Ussher, JM, Perz, J & Mooney-Somers, J (2007) 'The Experience and Positioning of Affect in the Context of Intersubjectivity: The Case of Premenstrual Syndrome'. International Journal of Critical Psychology (now Subjectivity), 21: 144-165