PMS Symptoms: Why They Aren’t “Normal” and What Your Cycle Is Telling You
A functional medicine perspective on PMS, PMDD, and cycle-related hormone imbalance
Many women are told—directly or indirectly—that premenstrual symptoms are simply part of being female. Bloating, irritability, anxiety, fatigue, pelvic discomfort, or emotional sensitivity are often framed as something to tolerate, manage around, or suppress with medication.
But PMS is not a character flaw, and it is not random.
While hormonal fluctuations are a normal part of the menstrual cycle, significant or disruptive PMS symptoms are not. When symptoms worsen month after month, interfere with daily life, or escalate into pronounced mood or physical changes, they reflect underlying physiological strain, not a body that is malfunctioning.
From a functional medicine perspective, PMS is best understood as feedback. It reflects how effectively ovulation is occurring, how hormones are being regulated and cleared, how the nervous system is responding to stress, and how resilient the body is under metabolic and environmental load. When these systems are supported, PMS often improves—sometimes dramatically.
This article explores what PMS actually represents, why common symptom-focused approaches often fall short, and how a root-cause, systems-based framework can help restore more predictable, stable cycles. More severe presentations, including PMDD, are also addressed, along with why suppressing symptoms is not the same as resolving the underlying imbalance.
PMS Is a Signal, Not a Flaw
PMS is often framed as something to endure, work around, or manage symptom by symptom. From a physiological standpoint, however, it is more accurately understood as feedback.
The menstrual cycle is a coordinated communication loop involving the brain, ovaries, adrenal glands, thyroid, liver, gut, and nervous system (1). When signaling between these systems is stable, hormonal shifts across the cycle tend to feel subtle and predictable. When regulatory capacity is strained, symptoms emerge—often cyclically and with increasing intensity (2).
PMS is one of the clearest ways the body communicates that something within this network requires attention.
This does not mean the body is failing. It means the body is responding—to chronic stress, metabolic demand, disrupted ovulation, impaired hormone clearance, or prolonged nervous system activation (3). These responses are adaptive in the short term, but when sustained, they manifest as cyclical symptoms rather than hormonal resilience.
Many women notice consistent patterns, such as:
symptoms that reliably intensify in the days before menstruation
mood changes that feel disproportionate to external circumstances
physical discomfort that resolves quickly once bleeding begins
cycles that become harder to tolerate over time rather than easier
These patterns are not coincidental. They are timing clues.
When symptoms follow a predictable luteal-phase pattern, they are hormonally mediated, most often reflecting altered progesterone signaling, estrogen–progesterone imbalance, or heightened neuroendocrine sensitivity (4). When symptoms worsen with age, stress, illness, sleep disruption, or lifestyle changes, they point toward declining system resilience—particularly within the stress axis and metabolic–hormonal interface (5).
Reframing PMS as a signal—rather than a nuisance—changes the clinical question. Instead of asking, “How do I stop this from happening?” the focus becomes, “What is my cycle communicating about how my body is functioning?”
That shift is where meaningful, lasting improvement begins.
What PMS Actually Is (And Why It Happens)
Premenstrual syndrome (PMS) refers to a cluster of physical, emotional, and cognitive symptoms that occur during the luteal phase of the menstrual cycle—the window between ovulation and the onset of menstruation (6). This timing is not incidental; it is central to understanding why PMS develops.
After ovulation, progesterone should rise and work in coordination with estrogen to stabilize mood, support sleep, regulate inflammation, and prepare the uterine lining. When this balance is disrupted—whether through inadequate progesterone production, exaggerated estrogenic signaling, or impaired hormone regulation—premenstrual symptoms emerge (7).
Importantly, PMS is not caused by hormones simply fluctuating. Hormonal fluctuations occur in every ovulatory cycle. PMS develops when the body’s response to those fluctuations becomes dysregulated, particularly at the level of the nervous system and stress-response pathways (8).
Research consistently shows that many women with PMS do not have abnormally high estrogen levels when measured in isolation. Instead, symptoms often reflect:
altered estrogen–progesterone balance
impaired luteal phase support
heightened sensitivity of the nervous system to hormonal shifts
interaction between reproductive hormones, stress physiology, inflammation, and metabolic strain (7,9)
This framework helps explain why PMS commonly worsens during periods of chronic stress, sleep disruption, illness, blood sugar instability, or major life transitions. These factors may not dramatically change hormone levels, but they significantly influence how hormones are produced, metabolized, and perceived by the body (10).
PMS is also cyclical for a reason. Symptoms often resolve rapidly once menstruation begins because estrogen and progesterone fall together, temporarily removing the imbalance that drove symptoms during the luteal phase (6). That relief is a key diagnostic clue, reinforcing that PMS is hormonally mediated rather than random or psychological.
From a functional perspective, PMS reflects hormonal resilience under load. When ovulation is consistent, progesterone signaling is adequate, stress physiology is regulated, and hormone clearance pathways are functioning efficiently, PMS symptoms are typically mild or absent. When these systems are strained, PMS becomes louder.
Understanding PMS in this way opens the door to meaningful intervention—not by suppressing the cycle, but by supporting the systems that regulate it.
Common Hormonal Patterns Behind PMS
While PMS symptoms vary from person to person, they most often arise from recurring physiological patterns, not random imbalance. Identifying these patterns explains why symptoms are predictable, cyclical, and frequently worsen with stress, metabolic strain, or age.
Estrogen–Progesterone Imbalance
In clinical practice, PMS is more often a progesterone adequacy issue than a problem of estrogen overproduction.
Progesterone is produced only after ovulation. When ovulation is delayed, inconsistent, or suppressed, progesterone output declines. Estrogen levels may still fall within conventional reference ranges, but without progesterone’s stabilizing influence, estrogenic effects become amplified (11).
This pattern can contribute to:
breast tenderness and fluid retention
bloating and pelvic discomfort
anxiety or emotional reactivity
sleep disruption
migraines clustering before menstruation
This phenomenon is often labeled estrogen dominance, though in many cases estrogen itself is not excessive—it is functionally unopposed (12).
Impaired Ovulation and Luteal Phase Support
Because progesterone is produced only after ovulation, PMS is frequently linked to suboptimal ovulatory function.
Chronic stress, under-fueling, excessive exercise, inflammation, blood sugar instability, and hypothalamic–pituitary–adrenal (HPA) axis dysregulation can all suppress or weaken ovulation (13). When this occurs, progesterone production falls even if estrogen output appears unchanged.
This helps explain why many women are told their hormones are “normal” while continuing to experience significant PMS. Standard blood testing may capture estrogen values but often fails to reflect whether ovulation is occurring consistently or whether luteal-phase progesterone support is sufficient (11,13).
Nervous System Sensitivity to Hormonal Shifts
PMS is not exclusively a reproductive hormone issue—it is also a neurohormonal one.
Estrogen and progesterone interact directly with neurotransmitter systems, including serotonin, GABA, and dopamine. When hormonal signaling becomes unstable, the nervous system can become more reactive to otherwise normal cyclical changes (14).
This heightened sensitivity helps explain why symptoms such as anxiety, irritability, low mood, or emotional overwhelm often intensify in the days before menstruation, even in individuals without a baseline mood disorder. The issue is not psychological weakness; it is neuroendocrine sensitivity.
This mechanism is particularly relevant in more severe presentations, including PMDD.
Stress, Blood Sugar, and Metabolic Load
Hormonal balance does not operate in isolation. Cortisol, insulin, and inflammatory signaling strongly influence how estrogen and progesterone are produced, metabolized, and perceived by the body (15).
Chronic stress and blood sugar instability can:
suppress ovulation
reduce progesterone availability
impair estrogen clearance
amplify inflammatory signaling
Over time, this creates a hormonal environment in which PMS becomes more intense and less predictable, even in the absence of dramatic changes in reproductive hormone levels.
Why These Patterns Matter
These patterns explain why PMS is rarely resolved through symptom suppression alone. They also clarify why two individuals with similar laboratory values may experience vastly different symptoms.
PMS reflects how multiple systems are interacting, not simply how much estrogen is present. Addressing those interactions—rather than overriding them—is what allows cycles to become more stable and more tolerable over time.
When PMS Is More Severe: Understanding PMDD
For some women, PMS is not simply uncomfortable—it is debilitating.
Premenstrual dysphoric disorder (PMDD) represents the severe end of the PMS spectrum and is characterized by intense mood and neurocognitive symptoms that reliably emerge during the luteal phase and resolve shortly after menstruation begins (16). These symptoms may include severe anxiety, irritability, anger, depression, hopelessness, emotional withdrawal, or feeling fundamentally unlike oneself for a predictable window each month.
What distinguishes PMDD is not abnormal hormone levels, but a heightened sensitivity to normal hormonal shifts (17).
Multiple studies show that many women with PMDD have estrogen and progesterone levels that fall within standard reference ranges. The difference lies in how the brain and nervous system respond to cyclical changes in these hormones—particularly their downstream effects on serotonin, GABA, and stress-regulation pathways (18).
This distinction is clinically important.
PMDD is often framed as a primary psychiatric disorder, yet its defining feature is precise cyclical timing. Symptoms intensify after ovulation, peak in the days preceding menstruation, and lift rapidly once bleeding begins. This pattern strongly implicates neuroendocrine regulation rather than a fixed mood disorder (16,19).
From a functional perspective, PMDD reflects a convergence of factors, including:
exaggerated neurohormonal sensitivity
impaired progesterone signaling or ovulatory disruption
stress-system dysregulation
inflammatory or metabolic strain interacting with hormonal shifts (17,18,20)
These mechanisms can amplify emotional and cognitive symptoms without altering baseline mental health outside the luteal phase.
Understanding PMDD as part of a hormonal sensitivity spectrum—rather than a character flaw or purely psychiatric condition—changes the therapeutic focus. Rather than suppressing symptoms in isolation, care can be directed toward improving hormonal stability, supporting ovulation and progesterone signaling, regulating stress physiology, and stabilizing the nervous system’s response to cyclical change.
For many women, this reframing alone is profoundly validating. Severe premenstrual symptoms are not a personal failure—they are a signal that the system regulating hormones and stress is under significant strain.
How PMS Is Properly Evaluated
PMS cannot be accurately understood by looking at a single hormone value in isolation. It is a pattern, not a number.
In conventional care, hormone evaluation is often limited to basic blood testing performed at a single point in time. While this approach can identify overt abnormalities, it frequently misses the regulatory dynamics that drive cyclical symptoms such as PMS (18).
From a functional medicine perspective, proper evaluation focuses on why symptoms are occurring, not simply whether a hormone falls within a reference range.
→ Understanding Hormone Imbalances in Women
Key elements of an effective PMS evaluation include:
Ovulatory function and luteal phase adequacy
Progesterone is produced only after ovulation. If ovulation is inconsistent or suppressed, progesterone may be insufficient even when estrogen appears normal (6,19).Estrogen–progesterone balance and clearance
PMS is often driven by exaggerated estrogenic signaling rather than absolute estrogen excess. Impaired metabolism or clearance can amplify symptoms without altering serum levels (20).Stress physiology and cortisol rhythm
Chronic stress can suppress ovulation, alter progesterone availability, and increase nervous system sensitivity to hormonal shifts (21).Blood sugar regulation and metabolic load
Insulin resistance and glucose instability can worsen PMS by increasing inflammatory signaling and disrupting hormone balance (10,22).Gut health and estrogen recirculation
The gut plays a direct role in estrogen metabolism and elimination. Disruption in this system can lead to estrogen recirculation and persistent symptoms (23).Nutrient status and genetic influences
Deficiencies and genetic variations affecting methylation and detoxification pathways can impair hormone regulation over time (24).
This systems-based approach explains why many women are told their labs are “normal” while continuing to experience significant PMS. Without assessing ovulation, timing, clearance pathways, and stress physiology, key drivers remain invisible.
A thorough evaluation allows care to be targeted and proportional, rather than reactive or suppressive. It also creates a framework for tracking progress over time as systems are supported and symptoms improve.
Why Hormonal Birth Control Often Masks PMS Instead of Fixing It
Hormonal birth control is one of the most commonly offered interventions for PMS. For some women, symptoms appear to improve temporarily. For others, they change in character. And for many, symptoms return—sometimes more intensely—after discontinuation.
This pattern is not accidental.
Most hormonal contraceptives work by suppressing ovulation and overriding the body’s endogenous hormonal rhythm (21). While this can blunt cyclical symptoms in the short term, it does not address the regulatory systems that contribute to PMS in the first place.
Without ovulation, endogenous progesterone is not produced. Instead of the cyclical rise and fall of estrogen and progesterone, the body is exposed to steady levels of synthetic hormones. The monthly bleed that occurs during placebo weeks is not a true menstrual cycle but withdrawal bleeding (22).
Because PMS is closely linked to ovulatory signaling, luteal-phase progesterone activity, stress physiology, and hormone clearance, suppressing the cycle can mask symptoms without resolving underlying drivers (23). This helps explain why some women feel initially better on birth control, yet experience a return—or escalation—of symptoms once it is discontinued.
In clinical practice, it is common to see women who were placed on hormonal birth control for PMS, acne, irregular cycles, or mood symptoms, only to later discover that ovulatory dysfunction, progesterone insufficiency, metabolic strain, or impaired estrogen clearance were never addressed (21,24).
This does not mean hormonal birth control is inherently inappropriate. In some cases, it may serve a short-term role. However, it is often presented as a corrective solution for PMS when it is more accurately a symptom-management strategy, not a restorative one.
Understanding this distinction matters. Suppressing cyclical signaling can quiet symptoms, but it does not rebuild the systems responsible for hormonal resilience. For women seeking long-term improvement in PMS, those systems must be evaluated and supported directly (25).
How PMS Is Properly Evaluated
PMS cannot be accurately understood by looking at a single hormone value in isolation. It is a pattern, not a number.
In conventional care, hormone evaluation is often limited to basic blood testing performed at a single point in time. While this approach can identify overt abnormalities, it frequently misses the regulatory dynamics that drive cyclical symptoms such as PMS (26). As a result, many women are told their labs are “normal” despite persistent, predictable symptoms.
From a functional medicine perspective, proper evaluation focuses on why symptoms are occurring, not simply whether a hormone falls within a reference range.
Key elements of a comprehensive PMS evaluation include:
Ovulatory Function and Luteal Phase Adequacy
Progesterone is produced only after ovulation. If ovulation is inconsistent, delayed, or suppressed, progesterone support during the luteal phase may be insufficient—even when estrogen appears normal on standard testing (27).
Estrogen–Progesterone Balance and Clearance
PMS is often driven by exaggerated estrogenic signaling, not absolute estrogen excess. Impaired metabolism or clearance can amplify symptoms without significantly altering serum estrogen levels (28).
Stress Physiology and Cortisol Rhythm
Chronic stress can suppress ovulation, reduce progesterone availability, and heighten nervous system sensitivity to hormonal shifts. Disruption of cortisol rhythm is a common upstream driver of worsening PMS (29).
Blood Sugar Regulation and Metabolic Load
Insulin resistance and glucose instability can worsen PMS by increasing inflammatory signaling and disrupting hormone production and clearance. These effects often intensify premenstrual symptoms even in the absence of overt metabolic disease (30).
Gut Function and Estrogen Recirculation
The gut plays a direct role in estrogen metabolism and elimination. Impaired motility, dysbiosis, or inflammation can lead to estrogen recirculation, contributing to persistent PMS despite otherwise “normal” hormone values (28,30).
Taken together, these factors explain why isolated hormone testing frequently fails to capture the drivers of PMS. Without evaluating ovulation, timing, clearance pathways, metabolic status, and stress physiology, the most influential contributors remain invisible.
→ Hormone & Metabolic Optimization
A structured, systems-based evaluation allows care to be targeted and proportional, rather than reactive or suppressive. It also provides clear markers for tracking progress as regulatory capacity improves and symptoms begin to ease.
How PMS Improves When the Root Cause Is Addressed
Because PMS reflects how multiple systems are interacting, improvement rarely comes from a single intervention. Symptoms tend to ease as the body regains regulatory capacity—when ovulation becomes more consistent, progesterone signaling stabilizes, stress physiology quiets, and hormone clearance improves.
Rather than forcing the cycle into submission, a functional approach focuses on supporting the systems that regulate it.
→ Women’s Health & Fertility Support
Restoring Hormonal Stability and Ovulatory Support
When ovulation is consistent and luteal-phase progesterone support is adequate, many hallmark PMS symptoms begin to soften. Progesterone has stabilizing effects on the nervous system, supports sleep quality, modulates inflammation, and buffers estrogenic signaling during the luteal phase (31).
This is why PMS often improves as:
chronic stress load decreases
energy availability and fueling improve
excessive training or under-eating is corrected
inflammatory and metabolic strain is reduced
These changes support ovulation indirectly, without overriding the cycle itself (31,32).
Regulating the Nervous System Response
PMS is as much a nervous system issue as it is a reproductive hormone issue.
Chronic sympathetic activation, poor sleep, trauma exposure, and prolonged stress can heighten sensitivity to otherwise normal hormonal shifts (33). When the nervous system remains in a state of vigilance, luteal-phase changes are more likely to be experienced as anxiety, irritability, emotional reactivity, or sleep disruption.
Supporting parasympathetic tone—the body’s “rest and regulate” state—often reduces:
premenstrual anxiety
emotional volatility
irritability
sleep disturbance
This mechanism is particularly relevant in women with PMDD-like symptoms, where neurohormonal sensitivity is central (32,33).
Improving Metabolic and Blood Sugar Resilience
Blood sugar instability and insulin resistance can worsen PMS by increasing inflammatory signaling and disrupting hormone production and clearance (34).
As glucose regulation improves, many women notice:
fewer premenstrual cravings
more stable mood
improved energy
reduced bloating and headaches
This metabolic–hormonal connection is often overlooked, yet it is one of the most powerful levers for improving cycle-related symptoms.
Supporting Gut and Detoxification Pathways
Estrogen regulation does not end with hormone production. It depends on effective processing and elimination through the liver and gut.
When gut motility is impaired, inflammation is present, or estrogen is recirculated rather than cleared, PMS symptoms may persist even when hormone levels appear normal (35). Supporting digestion, bowel regularity, and detoxification capacity often plays a quiet but meaningful role in symptom resolution.
Acupuncture and Whole-System Regulation
Acupuncture supports PMS by working upstream—regulating the nervous system, influencing neuroendocrine signaling, and improving communication between the brain and hormonal organs (33,35).
Research shows acupuncture can:
modulate stress physiology
influence hypothalamic–ovarian signaling
improve cycle regularity
reduce pain and mood symptoms associated with PMS
In clinical practice, acupuncture is most effective when integrated with metabolic, lifestyle, and hormonal support rather than used in isolation.
When these systems are supported together, PMS often becomes less intense, less disruptive, and more predictable. For many women, symptoms that once felt inevitable begin to soften or resolve entirely.
Care is individualized, paced, and responsive to how the body adapts over time—working with the cycle’s biology rather than suppressing it.
You Don’t Have to Suffer Every Month
Many women spend years organizing their lives around their cycle—anticipating a predictable window of discomfort, emotional strain, fatigue, or disruption. Over time, this pattern can begin to feel inevitable.
But PMS is not something the body does without reason.
When symptoms show up month after month, they reflect how the hormonal system is responding to stress, metabolic demand, nervous system regulation, ovulation, and hormone clearance. These systems are adaptive. When they are supported appropriately, PMS often changes—sometimes gradually, sometimes dramatically.
This does not require suppressing the menstrual cycle or overriding hormonal signaling. It requires understanding what the cycle is communicating and responding at the systems level.
For women with mild PMS, improvement may come from targeted adjustments that restore resilience. For those with severe or PMDD-level symptoms, a deeper evaluation and more structured support are often necessary. In both cases, the goal is the same: a cycle that feels predictable, tolerable, and supportive rather than disruptive.
PMS is not a personal failing, and it is not something to simply push through. It is information—and when that information is addressed thoughtfully, meaningful change is possible.
You may request a free 15-minute consultation with Dr. Martina Sturm to review your health concerns and outline appropriate next steps within a root-cause, systems-based framework.
Frequently Asked Questions About PMS
What is PMS and when does it occur in the menstrual cycle?
PMS, or premenstrual syndrome, refers to a group of physical, emotional, and cognitive symptoms that occur after ovulation and before menstruation begins. Symptoms typically improve or resolve shortly after bleeding starts.
What causes PMS?
PMS is most often caused by how the body responds to normal hormonal shifts during the luteal phase. Common contributors include low progesterone due to impaired ovulation, exaggerated estrogen effects, nervous system sensitivity, stress physiology disruption, blood sugar instability, inflammation, and impaired hormone clearance.
Is PMS normal?
Mild cyclical changes can be common, but significant PMS that interferes with daily life, work, relationships, or emotional well-being is not something you should have to tolerate. Persistent or worsening symptoms are a signal that the cycle is under strain and deserves evaluation.
What is the difference between PMS and PMDD?
PMDD is a more severe form of premenstrual symptoms that primarily affects mood and emotional regulation. Symptoms are intense, predictable, occur after ovulation, and improve shortly after menstruation begins. PMDD is often driven by heightened sensitivity to hormonal shifts rather than abnormal hormone levels.
Can hormonal birth control fix PMS?
Hormonal birth control may reduce PMS symptoms for some individuals by suppressing ovulation and flattening hormonal fluctuations. However, it typically does not address underlying drivers such as ovulatory dysfunction, stress physiology, metabolic imbalance, or hormone clearance issues.
Why does PMS get worse with age or stress?
PMS often worsens as stress load increases, sleep quality declines, metabolic health shifts, or inflammation rises. These factors can suppress ovulation, reduce progesterone support, and increase nervous system reactivity to hormonal changes, making premenstrual symptoms more pronounced over time.
How long does it take to improve PMS naturally?
Some women notice improvement within one to three cycles once key contributors are addressed, while longer-standing patterns may require several months of consistent support. Timelines depend on ovulation consistency, stress regulation, metabolic resilience, gut health, and hormone clearance.
When should I seek help for PMS?
Consider seeking support if PMS symptoms are worsening, affecting work or relationships, disrupting sleep, causing severe mood changes, or making you feel unlike yourself for a predictable window each month.
Still Have Questions?
If the topics above reflect ongoing symptoms or unanswered concerns, a brief conversation can help clarify whether a root-cause approach is appropriate.
Resources
American College of Obstetricians and Gynecologists – Premenstrual Syndrome (PMS)
Endocrine Reviews – Neuroendocrine mechanisms underlying premenstrual syndrome and premenstrual dysphoric disorder
Nature Reviews Endocrinology – Hormonal sensitivity and neurobiological mechanisms in premenstrual disorders
The Lancet Psychiatry – Premenstrual dysphoric disorder: burden of illness and treatment considerations
Frontiers in Neuroendocrinology – Progesterone, neurosteroids, and regulation of mood and stress response
Psychoneuroendocrinology – Estrogen–progesterone interactions and emotional regulation across the menstrual cycle
Journal of Clinical Endocrinology & Metabolism – Hypothalamic–pituitary–ovarian axis disruption and luteal phase insufficiency
Stress – Effects of chronic stress and cortisol on ovulation and reproductive hormone signaling
Frontiers in Endocrinology – Insulin resistance, metabolic stress, and reproductive hormone dysregulation
Gut Microbes – Gut microbiota regulation of estrogen metabolism and enterohepatic circulation
Trends in Endocrinology & Metabolism – Estrogen metabolism, clearance pathways, and hormonal balance
Biological Psychiatry – Serotonin, GABA, and neuroendocrine sensitivity in PMDD
Journal of Affective Disorders – Neurobiological mechanisms distinguishing PMDD from major depressive disorder
Contraception – Effects of hormonal contraceptives on ovulation, endogenous progesterone, and cycle physiology
Frontiers in Immunology – Neuroendocrine–immune network interactions in women’s health
Evidence-Based Complementary and Alternative Medicine – Acupuncture modulation of neuroendocrine and stress pathways in PMS