The patient: “Lily,” a 41-year-old small business owner and mother of two.

Why she came to see me: Lily arrived at my office complaining of intermittent heart palpitations—a racing sensation, or “fluttering,” as she put it, that came on suddenly and persisted off and on for roughly seven to 10 days per month. Two weeks earlier, the palpitations had felt especially peculiar and, at her husband’s insistence, she’d gone to the ER. They’d performed an electrocardiogram (ECG) and a series of blood tests but eventually sent her home with the assurance that nothing was wrong.

Her primary care physician had referred her to a cardiologist who couldn’t identify anything amiss either and prescribed the anti-anxiety medication Xanax. While the benzodiazepine offered Lily “temporary relief,” she was concerned that the symptoms that accompanied her heart palpitations—chiefly severe anger, interim weight gain and breast tenderness—signified a graver problem, which she wanted to handle without the use of pharmaceuticals.

How I evaluated her: Lily and I officially began our work together by discussing her medical and personal history.

Lily and Mark (her college sweetheart) had been married for 11 years and had two children under the age of 10. Lily had the pleasure of working from home—operating a small business that sold gift baskets to spas, resorts and private recipients—which allowed her to spend a great deal of time with her children and go cycling six mornings a week. Stress was a natural part of motherhood, she believed, and while she spent at least one night a week working until 2am to complete her orders, overall she felt “mostly” happy and healthy—save, that is, for the physical and emotional symptoms that struck her once a month.

They’d begun 13 months earlier. At first, Lily had blown off the breast tenderness, headaches, bloating and unexplainable fits of anger as “typical PMS”—something she’d experienced since she started menstruating at 14. Then her symptoms began reaching record highs. Given that she’d adopted a wholesome lifestyle with the birth of her first child—one that included frequent, intense workouts, an organic diet and scant alcohol—this frustrated her to no end. Her symptoms were also far worse than mere PMS. They rendered her “incapable of functioning” and “rageful,” and often created conflicts with her husband and children. A period app had begun helping her and her husband recognize when these symptoms were about to begin (and why they were happening), but her issues had gotten so bad that she claimed she felt “nearly suicidal” before her last two cycles.

The onset of heart palpitations only aggravated her more, but they, as well as her other complications, usually dissipated within two to three days of starting her period. They would then vanish completely—at least for a time—before striking her again approximately seven to 10 days before her next period. By then, however, the damage would have been done—she would feel “deeply ashamed” by her behavior towards her husband, apologetic to the clients she’d been on edge with and confused and scared about her overall wellbeing. What’s more, her children seemed fearful of her, which took time to repair before it all started again. “My cycle is a vicious cycle,” she claimed, “and it feels like it will never go away.”

To ensure that it would in fact go away—or at the very least diminish—I recommended a full physical and that we test her hormones, including her female hormones, as well as her Thyroid hormone levels. Finally, I had her mental health evaluated by a psychiatrist.

What my evaluation revealed: Lily’s physical, pelvic and thyroid exams revealed a woman in sound health. The low progesterone levels she showed in her hormone test, combined with the opinion of the psychiatrist I referred her to, confirmed my diagnosis: Premenstrual Dysphoric Disorder.

Dubbed PMDD for short, the disorder differs from PMS primarily in terms of adaptability. Nearly all women—as in 85%—endure PMS (and its attendant misery) but only about 5% experience it so acutely that it’s in another category entirely, due to its timing, severity, and type. Among its symptoms are irritability, agitation, anger, anxiety, bloating, breast tenderness and, yes, heart palpitations, which I believed were exacerbated by Lily’s entry to perimenopause. (Heart palpitations frequently occur in women who are nearing perimenopause, a period of time before menopause that’s characterized by shifting hormone levels. These changes can lead to an overstimulation of the heart and may result in the fluttering, racing and irregularity Lily was experiencing.)

While the causes of PMDD are not completely understood, experts believe that it may be triggered by an atypical response to ALLO, a main progesterone metabolite that is produced when progesterone is broken down as a normal part of a woman’s menstrual cycle. (Progesterone also impacts serotonin levels, which plays a critical role in mood.) I assured Lily that few know about PMDD because it wasn’t recognized as a formal psychiatric disorder until 2013, with the release of the latest edition of the Diagnostic and Statistical Manual of Mental Disorders. I also assured her that PMDD could be successfully treated—and naturally, at that.

How I addressed her problem: To return Lily to hormone equilibrium and to diminish her symptoms, I prescribed 80mg of Chasteberry daily. Also known as Vitex, this herbal supplement has rightfully earned a sterling reputation as one of the most effective natural solutions for PMS and PMDD. The herb can naturally boost progesterone levels. I also explained to her that if the Chasteberry didn’t provide enough relief, I would consider giving her bio-identical natural progesterone.

In addition, I urged Lily to begin taking a combination of Vitamin E, Vitamin B6, and Evening Primrose Oil. Known as a progesterone-enhancing compound, and brimming with essentially fatty acids, Evening Primrose Oil (or EPO to its biggest fans) has been shown to reduce breast tenderness, while Vitamins E and B6 have demonstrated tremendous efficacy in treating PMS and PMDD symptoms.

Furthermore, I suggested that Lily should take St. John’s Wort. While many doctors often prescribe SSRIs such as Celexa and Lexapro to treat PMDD, I wanted to honor Lily’s decision to forgo pharmaceuticals unless absolutely necessary. St. John’s Wort can be a safe and well-known alternative for combatting mood swings, depression and anxiety.

I also encouraged Lily to not only continue with her healthy lifestyle of exercising and eating well but to also balance out her running routine with more grounding, meditative exercises such as yoga. As I pointed out to her, a 2016 study published by the National Institutes of Health showed that just 12 weeks of yoga could boost mental health, significantly diminish breast tenderness, cramps and bloating, and improve menstrual pain and physical function. On this note, I also asked Lily to start prioritizing sleep, and explained that even a single late night per week could worsen her PMDD symptoms.

Lastly, I advised her to seek out Cognitive Behavior Therapy (CBT), which would help her build a “toolkit” of coping strategies when her physical and emotional symptoms became intolerable.

The patient’s progress: Eight weeks later, Lily returned to my office with more vibrancy in her step. Her heart palpitations had not just subsided—they’d gone away completely. This, she said, allowed her to feel the full effects of the other strategies I’d recommended. Weekly CBT sessions had enabled her to become a more present and compassionate wife, mother and business owner…and mixing up her running routine with yoga gave her a greater sense of space and radically-reduced anger. While she still had bouts of irritability and cramps in the week leading up to her period, they seemed “normal” and more like “the good, old PMS I knew in my teens, twenties, and early thirties.” In response, her relationship with her husband had dramatically improved, and her children no longer cowered away from her the week before her period. “My heart was trying to tell me something,” she said. “I just didn’t realize it was pointing me in the direction towards health.”

Click here to buy Dr. Laurie Steelsmith’s books, Natural Choices for Women’s Health, Great Sex, Naturally and Growing Younger Every Day: The Three Essential Steps for Creating Youthful Hormone Balance at Any Age.