01How she was feeling when she came to us

If your mood shifts in the week before your period, and lately for longer, her story may sound familiar. In her early 40s, she came to us for a functional medicine and hormone review after several years of worsening symptoms, at their hardest over the previous six to twelve months. Mood swings troubled her most, followed by overwhelm and crying, anxiety, brain fog, feeling less able to cope with stress, tiredness and losing her motivation.

About three years earlier it had started as typical premenstrual symptoms that eased once her period arrived. Now they lasted longer and hit harder. Small things could leave her overwhelmed and in tears, and both work and home life were feeling the strain. Her digestion suffered when she was stressed, and her periods had become shorter. Behind it all were two years of family illness, loss and caregiving.

She was already doing a lot right. She exercised, ate mostly whole foods and slept well, and she had tried iron tablets and an iron infusion with little change to her iron stores.

02What her tests showed

Her results came back about a month later, from hormone and cortisol tests timed to her cycle. They did not point to perimenopause, so we looked elsewhere. Her blood sugar (HbA1c 5.4%, down from 5.7% at an earlier test), cholesterol and inflammation markers were all in good shape.

Three things stood out. Her morning cortisol was at the top end of the laboratory range. One reading is never a diagnosis, but it fitted two years of strain. In the second half of her cycle, her progesterone was low compared with her oestrogen. And her iron stores were still below where we would like them, with a low alkaline phosphatase hinting that she might be short of zinc.

A genetic report helped us choose her supplements, for example a methylated B-complex in place of standard folic acid. Gene results like these are not a diagnosis. They gave us one more clue as to why her symptoms peaked before her period while her hormone levels sat within range.

03PMS or PMDD? How the difference was weighed

Premenstrual syndrome (PMS) brings mood and physical symptoms in the days before a period that ease once it starts. Premenstrual dysphoric disorder (PMDD) is a more severe form, diagnosed against set criteria. Her symptoms began as typical PMS and had lately spread across more of her cycle. Keeping a symptom diary for two cycles is the clearest way to tell these apart. For her, the timing of her symptoms mattered more than the label, and her plan was shaped around it, with the stress she had been carrying in mind.

Why not HRT? Hormone replacement therapy treats the symptoms of perimenopause and menopause. Her tests did not point to perimenopause and her periods were continuing, so oestrogen was not what she needed. The focus was the second half of her cycle, where her symptoms were and where her progesterone was low.

04The plan we made together

Her plan had five strands: supporting progesterone in the second half of her cycle, calming her stress response, nutrition for mood and energy, helping her body clear hormones, and absorbing minerals well. Dr Nirusha prescribed a pharmacy-prepared progesterone cream for the evenings from day 12 to day 26 of her cycle, matched to when her symptoms were worst. Other recognised options for PMS are covered in the questions below.

Evenings became a time to wind down, with magnesium and a supplement blend aimed at cortisol regulation, quieter activities and less time on screens. She took iron daily, away from tea and coffee, along with a trace-mineral complex with zinc, a methylated B-complex with choline, and glutathione two or three times a week. Her days were built around one morning coffee, morning light, regular meals with enough protein and fibre, daily movement and a steady sleep routine, with a walk or slow breathing when anxiety rose. A stool test was suggested to look at her gut health.

05How she was feeling three months on

At her follow-up, 11 to 12 weeks into the plan, she had kept to it well after a small change to her morning coffee early on. The low mood that used to come just before sleep had eased within about a week of starting her bedtime routine. Work was still busy, but it no longer felt overwhelming, and her energy and clarity had improved. Most importantly to her, the premenstrual mood swings and emotional lows had almost completely settled. Once or twice she felt the old feelings creeping back, and they passed quickly with a walk or a distraction. Some cramps and a dip in energy around her period remained, milder than the mood symptoms had been.

In one cycle her period came early, possibly because the amount of cream varied as the bottle ran low. She stopped the cream for that cycle, and we asked her to keep to the prescribed amount and to get in touch if she had another early period, heavy bleeding, spotting or any return of her symptoms. Her morning cortisol was lower at this review, and her progesterone in the second half of her cycle was 56.25 nmol/L.

06What comes next for her

Her progesterone continues at the same dose, and a broccoli-derived supplement was added to support how her body processes oestrogen. The rest of her routine carries on. She eats mostly whole foods, adjusted around her training and her cycle, with support from our functional nutrition team using her genetic report and a food diary. A full blood panel is planned next, including her iron stores, so we can check how they are responding.