PMDD and Perimenopause: Why You’re Struggling and What Can Help

Dr Sameena Rahman (: 00:01

Hey, y'all, it's me, Dr. Samina Rahman, gyno girl. Welcome back to another episode of Gyno Girl Presents, Sex, Drugs, and Hormones. I'm Dr. Samina Rahman. I am your friendly neighborhood gynecologist who happens to be specialized in sexual medicine and menopause care. And I can really help you guys navigate through some difficult journeys. Or if you're a clinician, help you navigate your patient's journeys. Because I have a lot of clinician.

colleagues that listen and tell me, you know, things that they want to learn more about because they don't have the time or ability to get deep into some of these things. But you know what? I'm so happy to be here for another episode of Gynecologist Presents Sex Drugs and Hormones. I'm located in downtown Chicago. I have licensed in different states, including California. So I do see patients virtually. I'm in the process of changing my practice format and I'm launching soon with a

wonderful group called Ms. Medicine, so stay tuned to hear more details about that. also available on GynoGirl TV and I am launching a book, hopefully that will come out by the fall, on sexual health or sexual dysfunction in different populations but focused on the South Asian lens. So everyone can benefit from reading it.

But particularly if you are South Asian and haven't heard about how it impacts you, I will be addressing that issue in depth along with other general issues. Anyway, so today I was trying to think about, you know, what to talk about because I've had so many issues in the office coming up with different patients coming up with different stories, different interesting things happening to them.

But I gotta tell you, know, mood disruption is such a predominant issue in period menopause, right? Like we all know that mood disruption can be, you know, fourfold worse in this midlife period of transition. And so what I wanted to discuss really is, you know, PMS, premenstrual syndrome, and PMDD, premenstrual dysphoric disorder.

Dr Sameena Rahman (: 02:21

and how it may manifest in perimenopause and how perimenopause may actually exacerbate it. I have so many patients that come to me just completely.

Dr Sameena Rahman (: 02:40

I have so many patients come to me just completely exhausted, irritated. Remember, I have talked to you guys about this study that came out from the Mayo about women who don't feel like themselves. And that is the common feeling in perimenopause. was actually, let me just hold on a second.

udy that came out in March of: 2024

a study that came out March,: 2024

over 50 % of the time in the last three months. So over half of the last three months, they did not feel like themselves. And the symptoms were anywhere from fatigue, feeling overwhelmed, feeling unable to cope, feeling really low, feeling really anxious, feeling very nervous, very irritable, very hard time concentrating, difficult time making decisions, feeling like rumination, forgetfulness, tearfulness, worrying. So.

this feeling of not feeling like myself was predominant. over 60 % of the people, 60 % of the people that were interviewed said that over 50 % of the last three months they hadn't felt like themselves. So then I started thinking a little bit more about some of these perimenopausal patients that I'm seeing and that really have significant premenstrual issues.

Dr Sameena Rahman (: 04:56

And so I want to kind of delve into that because, you know, I feel like this is an under discussed topic in the arena of perimenopause. mean, mood stuff definitely is when we talk about how like an early perimenopause, your cycles might become a little shorter, right? Initially, you might have 21 day cycles, you might have 20 day cycles. And then in late perimenopause as ovulation habits change.

You know when you go from these loop cycles right those loop cycles or those luteal out-of-phase cycles where your body is almost super ovulating It's recruiting a lot of follicles at once that those follicles are making a lot of estrogen So these surges of estrogen that people get that might shorten their interval between cycles and then later When you're not ovulating and you're not producing a lot of estrogen and you don't have a lot of eggs left over And then you skip cycles, right?

But in this cycle of time where you're maybe having your period every three weeks and you have this seven to 10 day lead up of that cycle where you just feel tremendous amount of psychological symptoms, physical symptoms and behavioral symptoms, this can coalesce and just feel like a shit storm of bad stuff happening to you, really. I always say that like,

You know, we have so many patients that come in nowadays and think everything is perimenopause. And they're like, well, is everything really perimenopause? Well, you know, yes and no, right? Like everything is perimenopause because, you know, everything is happening to midlife women, right? Like you're bearing a lot of the weight of the world on your shoulders. Maybe, I always say this, like you might be in that sandwich generation where you're dealing with elderly parents or in-laws. You might be dealing with younger kids that are.

puberty themselves. When I watched Inside Out 2, the first thing I thought about is like, let's not even talk about these characters going through puberty. Let's talk about what happens when they're going through puberty and you're going through peri at the same time creates a lot of craziness in the household. warned my husband about this years ago. My daughter, all this has not had her period yet, but like, you know, it's going to be coming soon and my period is going to be leaving. And so then it's going to be, you know, yeah.

Dr Sameena Rahman (: 07:12

Anyway, so you have all of these things that you're dealing with as a midlife person, right? You might be having in the middle of a divorce. You might have dealt with death in the family. You might be at the pinnacle of your career. You might be transitioning your career. You might be dropping out of stuff and starting new stuff. A lot of things happening at once. And then just throw in a little bit of perimenopausal havoc where you're on a roller coaster of emotions.

not even emotions, I'm sorry, roller coaster of hormones, right? Ups, downs, lefts, rights, everything, all at once. And you're gonna tell me that you don't feel like shit? The majority of the people do. And so that's just the unfortunate part is that not recognizing the fact that yes, this is hormonally mediated and we don't wanna, you know, just scapegoat hormones all the time, but it is, you know, your hormones mediate a lot of parts of your brain and the physical symptoms. And then upon that we, we,

put on stress, put on lack of sleep, we put on all of these other factors that contribute to a really bad time, honestly. Like people really struggle in this time. And I think that people that have PMS or PMDD are struggling a lot more. And then sometimes you develop PMS symptoms and PMDD symptoms because of these, you all of a sudden become a little more sensitive to this hormonal flux that's happening. This roller coaster of hormones.

has finally beaten you down and now you're having the psychological symptoms. Those symptoms of anger, irritability, depression, anxiety, increased sensitivity, right? That all of a sudden you're ruminating like crazy. You you have the physical symptoms. What are the physical symptoms? Headaches, muscle aches, fluid retention, changes in sleep, changes in appetite. And then really some other behavioral symptoms around poor concentration and forgetfulness to brain fog, right? And so we have this happening.

to women in general, At least 30 to 80%, depending on what you read, of reproductive age women will have some form of PMS symptoms. And the way you know it's PMS and not major depression, major anxiety, any of that, is because the pattern of really physical and emotional and behavioral symptoms that is really during this luteal phase, the two weeks before menstruation. I'm wanting to think back to biology class, or if you're in medicine, back to med school.

Dr Sameena Rahman (: 09:33

Think about that menstrual cycle picture that you have, what's happening with estrogen progesterone, what's happening in the ovaries, what's happening in the uterus, all of this at the same time when you're getting to learn why women menstruate and how your body gets ready for a pregnancy, right? And so you have these people that really suffer and then 5 % of the time, and most people can function really well and they have no interference in relationships, but then you have this 5%.

that really struggle with the most severe symptoms that is causing distress in their life that they are no longer able to maintain relationships. They can't work at work. So this is like, you maybe 5 % of the women that suffer in childbearing from PMS, right? You're talking about up to 80 % people have PMS symptoms. 5 % might have PMDD, that premenstrual disorder. And then you 20 % are easy breezy, right? They're not having anything. They're lucky.

they're not as sensitive. And it really is, I like to think of it as your body's sensitivity to your natural hormones. It's not like your hormones are out of whack. Your hormones are not imbalanced because your hormones are never really totally balanced, you know? But it is a feeling of dysregulation because you have a unique sensitivity to these transitions. And it has all to do with how your nerve receptor, your neurotransmitters,

and estrogen receptors and progesterones, all of these respond to this fluctuations that happen naturally in a cycle, right? These fluctuations are natural. Think about that. Tour it for a minute and now, you you get these hot, you have the increasing levels of estrogen, we're building that lining of the uterus, you know, then you've recruited the follicle, you're making some progesterone, no pregnancy happens, progesterone decreases, go through withdrawal from that progesterone and you bleed, right?

And what happens in the cycle is as you really withdraw from some of the progesterone and you bleed, that's when during that time of menstruation, a lot of people's symptoms improve. And that's the key to distinguishing it from other, you know, psychological conditions like depression or anxiety in general, right? If it happens throughout the cycle all the time, then this is not related to the hormonal flux. But when it is related to your natural hormonal flux and in perimenopause,

Dr Sameena Rahman (: 11:56

It's not just a flux, it's a roller coaster. Cue in the pictures of all the people, the, cue in the picture of perimenopause as like this really erratic up and down shit show event. Then of course, you're gonna be a lot more sensitive because there's a lot more delta happening, a lot more delta of estrogen, a lot more continuous reduction of progesterone throughout your perimenopausal years.

So, I mean, how do we like even talk about PMDD? You know, if you look at sort of the DSM like five criteria, it's really a matter of having five out of 11 symptoms, right? And you have to have at least one of these major symptoms. I'm gonna review this list with you guys so you know. But okay, there are symptoms of marked depression, hopelessness and self-deprecation, right? That's one. Marked anxiety, tension.

feeling like things are always keyed up, you're on edge, you're ruminating a lot, right? I call those brain hiccups. There's feelings of like lability of how your affect is, right? You're laughing, you're crying, you're up and down. There's persistent anger or irritability. I mean, you are pissed off. I always think that like, are the Karens of the world just not treated for their PMS, PMDD or perimenopause?

It's possible, Because they're pissed off and they're angry a lot. And so are lot of women. And this is also a time where like you've gotten accustomed to dealing with so much in your life that maybe you don't care. You know, my patients always tell me they have no F's left to give. And so maybe if that's the case, then they're giving out a lot more irritability and anger than they're keeping in. So, which is okay too.

There's decreased interest in usual activities. There's a feeling of sort of anhedonia, this lack of desire to do things. There's a subjective sense of not being able to concentrate or just difficulty focusing or concentrating. There's feelings of like fatigue and really just lack of energy and just general lethargy, right? You're just not, you don't have the energy to get up. You don't have the energy to do anything. There's changes in appetites. You get food cravings. You might have really, you know, a lot of overeating.

Dr Sameena Rahman (: 14:14

You might have under eating, you might sleep too much, you might sleep too little. And then other physical symptoms, breast tenderness, headaches, joint pain, muscle pain, bloating, weight gain, all of these things, right? So these symptoms really have to be present most of the time during that last week of the luteophilus. So like the 10 days leading up to your cycle and then they...

They go away within the first few days. People say a switch hits and they're just like all of a sudden they feel better. Hold on a second.

Dr Sameena Rahman (: 14:54

Okay, so you know when the cycle starts and you start to bleed, that's it. Everything gets better. All of a sudden you feel wonderful. And it's a whole Jekyll and Hyde feeling, right? People are getting diagnosed with bipolar, they're getting diagnosed with all these things, and it's really like perimenopause all of a sudden bringing forward that 5 % of women really struggling with PMDD. Now remember, you have to have really, the symptoms are significant enough to interfere with social work.

Sexual and scholastic functioning, right? So it's all about Just like when we talk about hypoactive sexual desire disorder, right people have low libido But a lot of people are not bothered by low libido and neither there neither is their partner But when it bothers you and it actually is significantly impairing your quality of life That's when you know PMDD, you know, we think more about the PMDD whereas a lot of people can live with PMS and it's not like, you know

interfering with their ability to maintain relationships or friendships or sexual relationships or school or anything like that. And it also must be strictly related to the menstrual cycle and not just like worsening of another underlying disorder, right? It can't just make me like depression is getting worse or panic is getting worse or dysthymia or personality disorder. This is strictly timed with the menstrual cycle. That's why we do a lot of menstrual diary assessments, you know, and so

That's really important too.

And so what we usually tell patients is like, here's a menstrual diary, we're gonna look at the next two months, you're gonna rate these, and so we're gonna confirm this. But it sounds very much like you're suffering from PMDD. I tell patients all the time, you know, there was a big international study that showed almost a third of women affected by PMDD in the questionnaire had attempted suicide. This is huge, guys. This is really distressing. This is so upsetting.

Dr Sameena Rahman (: 16:54

And it's so dismissed, right? It's so dismissed. It's an F code with the ICD-10, meaning that when we diagnose a patient with it, anything that's given an F code is usually not, you know, reimbursed or, you know, insurance companies consider it like anything worth treating and they won't even, you know, that's why it's so difficult with mental health struggles for women. So it's really difficult. It's not even acknowledged and it's cyclical, like I said.

So usually five out of those 11 symptoms, you usually have to have at least.

Dr Sameena Rahman (: 17:34

I'm sorry, usually it's five out of those 11 symptoms that are already discussed and at least one of those top four that are like the major depression, mood, the major anxiety, the major lability, the major anger, the major irritability. So that including some of those physical symptoms relating to sleep, breast tenderness, weight gain, know, food cravings, all of that. So it does, you know, we make women diary this thing and come back in, you know, a lot of women, you know, have the symptoms around their 30 to 39 year old.

period of time, but know, first treatment can be as early as in their twenties.

we just know that it can worsen over time and guess why? Because that perimenopause comes into the equation and it's very distressing. Most of the risk factors have to do with, you know, if you have a family history of someone PMS, PMDD, you know, maybe you remember your mom going through it, maybe you have a sister that went through it. If you yourself have a history of depression or postpartum depression or if you had really noticed mood changes because of birth control pills, right, these are all risk factors. And so

I think these are so very important to remember.

Dr Sameena Rahman (: 18:53

You know, it has to be different, like, because about 40 % of women that are screened for PMDD actually have like an underlying mood disorder, right? They have like depression, anxiety, da da da. And so it, then what happens is the premenstrual period of time might exacerbate it. And so that's very difficult. So that's why these premenstrual daily symptom charts are so important, right? Because you can rate mood changes, tension, sadness,

you know, activities, feeling overwhelmed, difficulty concentrating, food cravings, energy, all of those things you can rate on a day-to-day basis. And you can see just like the menstrual cycle where you have a steady level of estrogen that's going up and then down and then up, but then down again. Whereas in the progesterone, you have like really just low levels, a surge, and then it goes down. So you'll see these changes that are kind of consistent with the menstrual cycle. So

Again, we don't really consider this really a hormonal dysregulation as more of a difficulty in the response to your normally cycling hormones.

And we know this because when we suppress women's cycles with something like a GnRH agonist, right, like something called a Luperlide or Lupron, which puts you into a medical menopause, PMDC symptoms really do go away. And they can come back when you try to give them back some estrogen and progesterone. So that's really important. And it's important because we know that estrogen and progesterone have an effect on your neurotransmissions, right?

your dopamine, your norepinephrine, your serotonin, that neuroendrogenic symptoms.

Dr Sameena Rahman (: 20:44

But really something with PMDD is that the serotonin transmission is totally thrown off to the sensitivity of these hormones, at least is what we think is happening, right? So I think that's important to understand.

Dr Sameena Rahman (: 21:04

And we think a lot of this has to do with when we think about progesterone and there's a metabolite of progesterone called allopregnum alone. And it modulates these receptors in your brain called the GABA receptors, which are really important to monitor your mood. And so that's even the basis of one of the newer post-partum depression medications. That's why progesterone is so unique and cool to understand because a lot of this has to do

with sensitivity to progesterone and how people deal with it.

Dr Sameena Rahman (: 21:44

we know that when people get treated with something to block allopregnenolone during the luteal phase of their cycle, it actually reduces the PMDD score. So that's where we think the physiology is around one of the progesterone metabolites. And therefore, a lot of us consider PMDD to be more so related to not necessarily the fact that your hormones are fluctuating, but more so like

the fact that you have a certain sensitivity to progesterones. That's why for some people, when they go on progesterones that are synthetic, that are classically progesterones, the north endrone, the, you know, I'm blanking out on my progesterones. That's why when people go on progesterones and progestogens, they actually get worsening symptoms. So people always say like, you just have to treat PMDD with birth control.

Now it's very specific what type of birth control you want to treat PMDD because again, we do believe that some of this has to do with how patients are sensitive to certain types of progesterone. So that's why like the one medication that's approved to treating PMDD when it comes to birth control is what you may have heard of as YAS, which is essentially, ethnoestradiol intraspirinone. Intraspirinone,

is an analog to something called aldactone. And so it actually acts on progesterone receptors and androgen receptors actually, but it's not a true progestin or progestin. So progesterone or progestin. So it's not a true, truly in that category. And so that's why people sometimes do pretty well.

when they take oral contraceptive pill in the form of Yaz, which would be ethanol estradiol and Drasperinone.

Dr Sameena Rahman (: 24:30

And so the question really remains is, is Yaz the only one? I mean, I have patients who I think, you know, get treated with PMDD on other progesterones and maybe their primary PMNDD issue isn't 100 % related to progesterone sensitivity or they're not as sensitive. But I think that, you know, that's really the only one that's been studied with good evidence to support that it helps with PMDD symptoms.

And for most, a lot of patients with PMDD when they're pregnant actually, they actually feel better.

Dr Sameena Rahman (: 25:57

OK, I'm sorry. I just lost my trans up. OK, so that's something to consider in terms of overall PMDD. But there was a study, I think that was a very interesting study that came out in JAMA, I think it was in 2023, talking about premenstrual disorders and whether or not it impacts the severity of vasomotor symptoms and the timing of menopause, which nobody's really studied, right? But really,

We know that people with premenstrual syndrome and premenstrual dysphoric disorder really have a long lasting negative impact on their quality of life, right? And people when they enter menopause, they do tend to get better symptomatically from this, right? And so...

Dr Sameena Rahman (: 26:47

They also like people that have basal motor symptoms, the people that enter early menopause and the people with premenstrual symptoms.

or premenstrual disorders in general, all have other risk factors that they care.

dy that was done at a JAMA in: 2023

earlier menopause. So they had early menopause compared to those that did not have premenstrual disorders.

Dr Sameena Rahman (: 27:55

Hold on one second, I'm gonna tell you when.

Dr Sameena Rahman (: 28:12

So they actually, okay, sorry, this study that was in JAMA, just go back, Carrie, if you don't mind. The study in JAMA that I was referring to actually showed an increased association of early menopause and moderate to severe vasomotor symptoms, right? And if you guys have listened to my other podcast about early menopause and about vasomotor symptoms and their severity, we know the combination of the two increase your risk for weight gain, metabolic dysfunction, diabetes, heart disease,

and early cardiovascular disease and early death. people that therefore, if you have PMMS, PMDD, like really some premenstrual disorders and you're gonna have earlier menopause and most severe vasomotor symptoms, we should be acutely aware of these patients because we need to make sure they get on treatment that will help them and help them navigate their journey so that they don't have worse outcomes, right? We don't want them to suffer from central obesity, diabetes.

heart disease, coronary vascular disease, all the things that we know put them at risk for a shorter life expectancy, quite frankly. So that was, I think, a very interesting study.

And so I think it's very important to identify PMS and PMDD specifically patients, right? Because we already know they have higher rates of suicidal ideation. And so, you know, that's very important to identify these patients and especially if they come up in perimenopause for the first time, right? Perimenopause, you that roller coaster of hormones, you got the progesterone that's decreasing. And so other than like something like a Yaz that has a Drisperinone, a sprinolactone type of...

for just your own, for just a gin, What else can we treat patients with? Obviously cognitive behavioral therapy is huge. Some studies have shown magnesium and calcium, some of these things help. Lifestyle modifications, avoiding alcohol, aerobic exercise, de-stressing, all the things. But you can't really just tell patients to exercise, stop drinking and...

Dr Sameena Rahman (: 30:26

and go do yoga or something. Most of them have already kind of worked these things into their life. They're trying to improve their quality of life in other ways. And so they're coming to you for more aggressive therapy. So cognitive behavioral therapy for sure helps. know that from a pharmacologic perspective. We know that luteal phase, SSRI, so there's selective serotonin receptor medications.

specifically like fluoxetine and sertraline that are low dose and they rapidly respond actually have a great benefit and fluoxetine specifically is FDA approved for PMDD. And so I think that is an antidepressant that has done wonders for so many of my patients when they take it again during that lullio phase and sometimes they take it for 10 to 14 days right before leading up to their cycle, right? Because usually

They know the minute they get their period, they feel good, they feel normal, they feel like themselves again. So most of the time they take it intermittently. Sometimes if you have an underlying depression, anxiety issue, then you might double it during the luteal phase and that's okay too. You know, again, we talked about the birth control thing. You know, I do have some patients that really just like, they just suffer. They suffer so much.

so much from this disorder that we've tried everything left and right. And so sometimes the final stage is obviously, you know, if they're in this perimenopausal state, we might want to just get them through a couple of years. You know, we can give them something like a loop relied, right? Loop, which is that GnRH antagonist, it works at the level of your brain, it shuts down your ovaries, it puts you into a medical menopause.

The problem is always the add back therapy, right? Because you're gonna put someone to medical menopause, you're gonna give them hot flashes, vaginal dryness, osteoporosis. So you wanna give them something back to prevent that, right? Because we already talked about how bad these menopausal symptoms are for your quality of life, but also for your longevity and cardiovascular health. So when you give them back some of these symptoms, I mean, when you give them back estrogen and progesterone, if they have a uterus, then of course what happens? Sometimes their symptoms come back.

Dr Sameena Rahman (: 32:45

So I learned this from my friend Tammy Rowan, who was that wonderful gynecologist who I interviewed a while back, who's at UCSF, but using Luperolide or Lupron to put them into that medical menopause, right? And then giving them back something like DUAVE, D-U-A-V-E-E. That is conjugated equine estrogen, which is, hello, Premarin, right? Premarin is that.

you know, God forsaken estrogen from the horse's mare, which is probably the most studied estrogens that we have on the market to date, period, full stop. But it's that, it has basically the conjugated equine estrogen, and then it has benzotoxicene, which if you think about medications like that, you have tamoxifen, you have these medications that are selective estrogen receptor modulators.

So they're anti-estrogen at the uterus, right? So you don't need a progesterone. Usually when you give someone, you put them into a menopausal state, either surgically or medically, you give them back estrogen. And if they have a uterus, you have to give them back progesterone. But if these people have a progesterone sensitivity, it doesn't always help them. So we give them back estrogen and then an anti...

estrogen at the uterus and it also happens to be anti estrogen at your breast too. So it actually like is really good for patients if you can look back at my previous podcast where I talked to

Dr Sameena Rahman (: 34:25

A couple of the other docs that do a lot of menopause care, we talk about how we use DuAve a lot with patients that either have like just, you know, irritable bleeding from the uterine lining that is not precancerous, cancerous, or a polyp. That that's why DuAve shuts down those vessels at the uterus and is very helpful. Or people that have a concern about breast cancer and using those progesterones. And so, you know, if you have a family history,

Duave is anti-estrogen at the breast, so it doesn't activate any of those receptors up there. So I think that, you know, that is a good option for patients with PMDD too, right? You're gonna give them a little bit of something to put them in a medically induced menopausal state, and you're gonna add back with Duave. And that's kind of like, you know, worst case scenarios, right? We don't wanna do that for everybody, but we will if you are not able to find.

SSRI that works in your literal phase if you're not able to find cognitive behavioral therapy that's been helpful for you. If you're not able to do any kind of hypnosis that helps you. If you're not able to you know use Yaz or any other birth control pill that we know reduces and suppresses ovulation but also does not excite things by giving you back a progesterone that you're sensitive to.

Anyway, that's my story around premenstrual dysphoric disorder. It is a very debilitating disease state for so many women. PMDD sucks. It affects about 5, up to 7 % if you depending on the study of women who have, you know, PMS like symptoms. It's cyclical. You gotta do the work and do the diary, the menstrual diary. You gotta look at all your symptoms. You gotta chart it and then you can get adequate treatment.

And you know, maybe one day if we ever get an FDA that's running again and an NIH that wants to fund it, we can do some more research on this arena because in this arena because it is needed. Just like every other arena of women's health and midlife health. Anyway, I was just thinking about some of my PMDD patients who are so pissed off and they just so angry and they're irritable and they just destroyed, you know,

Dr Sameena Rahman (: 36:45

marriages and relationships and all the things and it's because you know they weren't able to find adequate treatment for some of these conditions and you know you know modify diet modify lifestyles modify stress all the things that we know can benefit their overall quality of life anyway i guess i'll stop here i could go on and on but that's i just wanted to address a little bit about pmdd and i wanted to address

perimenopause and how perimenopause can exacerbate all of this and it can really be a difficult time for women especially who suffer from mood disorders that are cyclical. So keep an eye out for yourself, keep an eye out for your patients, keep an eye out for your friends, you know be there, be a level of support for them, you know try to understand what they're going through, advocate for them, you know help educate them, help them you know chart

whatever the case is, be there for someone and they'll be there for you too one day. Just the simple golden rules of life, Anyway, again, my name is Dr. Smita Raman. I am Gyno Girl. That was another episode of Gyno Girl Presents, Sex, Drugs, and Hormones. Remember, I'm here to educate so you can advocate for yourself. Please join me next week for another episode. Thanks.