PREMENSTRUAL SYNDROME & PREMENSTRUAL DYSPHORIC DISORDER

Understanding PMS and PMDD

Many women experience physical and emotional changes in the lead-up to their period. For some, these changes can be severe enough to interfere with daily life, work, and relationships. This is known as Premenstrual Syndrome (PMS). A more severe form, with significant mood symptoms, is called Premenstrual Dysphoric Disorder (PMDD).

Symptoms of PMDD

Physical

Symptoms of PMDD can also present as physical symptoms. There can include:

Fatigue or low energy
Sleep disturbances (insomnia or excessive sleep)
Joint or muscle pain
Headaches or migraines
Bloating or weight gain
Breast tenderness or swelling
Acne

Menstrual

Heavy or painful periods are often associated with PMDD

Genitourinary

Low libido is commonly associated with PMDD

Psychological

Severe mood swings
Irritability or anger
Depression or sadness
Anxiety or tension

Symptoms of PMS & PMDD

Mood swings, irritability, anxiety or depression

Fatigue and sleep disturbances

Breast tenderness, bloating, headaches

Changes in appetite or libido

Oestrogen

When replacing estrogen during perimenopause or menopause, transdermal (through the skin) application is considered one of the safest and most effective options.

At Aesthetic Astute, we often prescribe compounded MHT or Estrogel (E2), a body-identical oestradiol gel that mimics the natural estrogen your body produces before menopause.

Oestrogen patches are also a good option but are not currently available.

Oestrogen is well-absorbed through the skin and allows for more consistent hormone levels with fewer fluctuations than some tablet forms. Importantly, it bypasses the liver, reducing the risk of metabolic and clotting-related side effects.

How to Use Estrogel/Compounded Hormone Creams:

Apply daily, around the same time each day
Apply to clean, dry skin and wait at least 1 hour before showering or swimming.
Use the inner forearm or wrist to apply and spread the dose, this area reduces the chance of the gel being washed off accidentally
Allow to dry completely before dressing. Absorption is complete after approximately one hour
Always wash hands with soap and water after application

Estrogel Dose:

Each pump delivers 0.75mg of estradiol. Your starting dose is usually 1 to 2 pumps per day, applied across one or both arms. Your dose may be adjusted depending on symptom response or blood levels. The maximum dose advised is 4 pumps.

If you're prescribed a higher dose and find the amount of gel required each day inconvenient or difficult to absorb, a compounded estradiol cream may be a suitable alternative. Compounding allows for more concentrated doses in a smaller volume, which may improve ease of use and treatment adherence. This option can be discussed during your consultation to ensure the formulation is safe and effective for your needs.

Stability of Estrogel:
Once opened, Estrogel remains stable for up to 6 months when stored below 25°C with the cap tightly closed. Avoid freezing or excessive heat.

Progesterone

When using oestrogen in hormone replacement therapy, progesterone is essential for protecting the uterine lining. Oestrogen alone can cause the endometrium (lining of the uterus) to thicken, increasing the risk of endometrial cancer over time. Micronised progesterone, taken in combination with oestrogen, helps keep the lining thin and stable. This applies to all women who still have a uterus, even if their periods have stopped years ago. It’s a critical part of safe hormone therapy.

Do I still need progesterone if I’ve had a hysterectomy?

If your uterus has been removed, progesterone is not required for endometrial protection. However, some women may still benefit from progesterone, particularly if they experience:

Difficulty sleeping or staying asleep
Anxiety or mood fluctuations
A history of endometriosis (including after hysterectomy)

In these cases, micronised progesterone (Prometrium®) can still be prescribed to support mood, reduce night-time cortisol, and improve sleep quality—even without a uterus.

How is progesterone taken?

The most common and evidence-based form of progesterone used in MHT is micronised progesterone, taken orally at night. This route not only provides endometrial protection but also has a calming, sedating effect that helps improve sleep, one of the key benefits for many women.

For women who are still having menstrual cycles, a cyclical (sequential) MHT regimen is recommended. In this approach, progesterone is taken for part of the month, resulting in a regular bleed. This shedding of the uterine lining offers an additional layer of protection against endometrial thickening.

For women who are postmenopausal and no longer experiencing periods, a continuous combined regimen is usually prescribed, where oestrogen and progesterone are taken daily without a monthly bleed.

Can I use vaginal progesterone?

If oral progesterone causes side effects, such as dizziness, bloating, or hangover-like fatigue, vaginal progesterone pessaries may be a well-tolerated alternative. This method delivers the hormone directly to the uterus with less systemic absorption, which can help reduce side effects.

However, vaginal progesterone does not offer the same sleep-enhancing benefits as oral progesterone. It also requires more frequent handling and may be less convenient.

Testosterone

Testosterone is not routinely included in standard menopausal hormone therapy. In Australia, it is currently only approved for use in women to treat hypoactive sexual desire disorder (HSDD)—a condition characterised by persistent low libido that causes distress.

While this is the only current TGA approved indication, emerging evidence supports potential benefits of testosterone in areas such as mood, energy, and cognitive function. At Aesthetic Astute, Dr. Danielle Richards may consider testosterone therapy on a case-by-case basis, guided by your symptoms, hormone levels, and overall health.

How is testosterone taken?

The most common and well-tolerated method is a transdermal cream, applied to the skin once daily—usually to the inner thigh, hip or buttock area.

How long until it works?

Testosterone’s effects may take several weeks to become noticeable, with maximum benefits often felt after 8–12 weeks of consistent use. Libido and mood are often the first areas to improve.

Important considerations:

Testosterone must be used in female-specific doses. Too much can cause side effects such as acne, excess hair growth, or voice changes—though these are rare when treatment is properly monitored.

Your treatment will always be overseen by Dr. Danielle Richards, with regular reviews and blood tests to ensure optimal outcomes.