Premenstrual Dysphoric Disorder (PMDD)

This article provides an overview of premenstrual dysphoric disorder, including the causes, symptoms, proper diagnosis, treatment, and self-help tips to more easily manage this condition.

Key Takeaways:

• Premenstrual dysphoric disorder is a more severe form of premenstrual syndrome that causes significant disruptions to daily life and general well-being

• It is highlighted particularly by low mood, anxiety, and irritability, although many other behavioral and physical symptoms are often present

• There isn’t a true cure, but many treatments and strategies can help manage or reduce symptoms. This includes medication, natural remedies, lifestyle changes, and therapy.

Understanding Premenstrual Dysphoric Disorder (PMDD)

Premenstrual dysphoric disorder (PMDD) is a mental disorder in reproductive-age women that occurs in a cyclical pattern before the menstrual period. It is primarily characterized by mood disturbances, including mood swings, depression, irritability, and anxiety. Within the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (DSM-5), it falls underneath the category of Depressive Disorders.

People with PMDD often experience symptoms during the week prior to the start of menstruation, with symptoms decreasing notably after a few days and essentially resolving after the menstruation period. However, there are often many accompanying symptoms too, such as fatigue, changes in sleep patterns, and/or physical symptoms, such as breast tenderness.^[1][2]

Prevalence

Estimates show that PMDD affects between 3 to 8% of women. A much higher percentage (80 to 90%) of women experience general symptoms around this time, but most don’t experience severe enough symptoms to reach an official PMDD diagnosis.^[2]

PMDD vs PMS (Premenstrual Syndrome)

PMDD is a more severe form of premenstrual syndrome (PMS). People with PMS experience a variety of mental/emotional and physical symptoms, such as irritability, mood swings, bloating, fatigue, headaches, and trouble concentrating.

However, these symptoms are milder and usually don’t interfere too much with daily life, whereas PMDD causes moderate to severe distress and impairments in daily functioning. This is especially due to the notable psychiatric symptoms, such as anxiety and depression.^[3]

Causes of PMDD

The exact causes of PMDD aren’t entirely known. However, many established factors seem to play a role, including hormonal sensitivity, neurotransmitter differences, family history, as well as overall health and lifestyle habits.

Firstly, people with PMDD seem to have a heightened sensitivity to the hormonal changes that occur during the menstrual cycle, such as estrogen and progesterone. This greater sensitivity may lead to exacerbated mood, behavioral, and physical symptoms. Other hormones may also play a role too, such as allopregnanolone, cortisol, melatonin, and thyroid hormone.^[1][4]

Differences in neurotransmitters, which are brain chemicals that help regulate key bodily functions, may also play a role. For example, researchers have found abnormalities in people with PMDD with regard to serotonin, gamma-aminobutyric acid (GABA), and glutamate, all of which are involved in mood and behavior.^[1][2]

In addition to these, there are established risk factors, including:^[1][3][4]

• History of trauma

• Family history of PMS or PMDD

• Pre-existing anxiety disorders

• Personal or family history of depression or mood disorders

• Stress

• Seasonal changes

• Cigarette smoking

• Obesity

• Genetic factors, particularly related to serotonin and estrogen receptors

Is PMDD Preventable?

In general, PMDD may not be preventable since it is often the result of the way your hormones work. Also, the exact treatment strategies differ depending on a variety of individual factors, so there is no “best prevention strategy” for all individuals.

With that said, there are many things you can do to decrease the risk of developing PMDD, such as:^[1][3][5]

• Regular exercise (especially aerobic)

• Maintain a consistent sleep schedule

• Increased consumption of complex carbohydrates and protein

• Decrease or eliminate alcohol, caffeine, nicotine, and sugar intake

• Stress management, such as yoga, meditation, and breathing techniques

• Possible supplements (e.g., calcium, vitamin B6, chasteberry)

PMDD Symptoms

Individuals with PMDD often experience a variety of mood, behavioral, and physical symptoms, with those related to mood being predominant. Common PMDD symptoms include:^[1][2][3]

• Depressed mood, sadness, or hopelessness

• Mood swings

• Irritability or anger

• Anxiety, tension, or feeling on edge

• Heightened sensitivity to rejection

• Fatigue or low energy

• Poor focus or concentration

• Changes in appetite, especially overeating or specific food cravings

• Changes in sleep patterns (e.g., excessive sleep or insomnia)

• Decreased pleasure and interest in activities

• Self-critical thoughts

• Feeling overwhelmed

• Physical symptoms, such as:

• Breast tenderness or swelling

• Joint or muscle pain

• Headache

• Bloating

Due to the drastic mood changes, people with PMDD may also be more prone to withdraw and isolate from others. Conflicts with family, friends, or coworkers also become more likely during this time.

How Long Does a PMDD Episode Last?

PMDD symptoms often last a few days to two weeks. Most individuals start to experience noticeable symptoms around one week before the start of menstruation, with the most severe symptoms usually occurring two days before menstruation onset. Also, out of all of these symptoms, the most impactful ones are anger and irritability, which typically show up first as well.^[1]

Diagnosis for PMDD

Diagnosing PMDD is one of the lengthier processes compared to other mental disorders, in part because of the need to rule out other causes, such as physical conditions or other mental health disorders. Therefore, PMDD diagnosis involves several steps, including a comprehensive medical exam, psychiatric exam, and daily charting of symptoms, which is compared against official diagnostic criteria.

First, a thorough medical exam, including a gynecological examination, should be implemented. Your doctor will also conduct a physical exam to rule out physical causes, which may include:^[1]

• Blood work to test for anemia, hypothyroidism, or potassium deficiency, since these can all cause fatigue

• Examination for intracranial lesions, which can cause headache and mood changes

• Medical history to identify issues that often get worse before or during menstruation, such as irritable bowel syndrome, chronic fatigue syndrome, and pelvic or bladder pain

In addition, a psychiatric evaluation is used to assess for mental disorders that may be causing symptoms, such as major depressive disorder, panic disorder, bipolar disorder, or dysthymic disorder. These disorders can occur alongside PMDD but cannot be the sole reason for symptoms for a PMDD diagnosis.^[1]

PMDD Assessments and Tests

If PMDD is still possible, a variety of tests and assessments are used to confirm the diagnosis. Most often, PMDD symptoms are evaluated using daily charting, as this is the most accurate way to achieve a diagnosis. This process should occur for at least two menstrual cycles to provide a diagnosis. Examples of PMDD assessments include:^[1][5]

• Calendar of Premenstrual Experiences

• Premenstrual Symptom Screening Tool

• Daily Record of Severity of Problems

Symptoms are compared to the diagnostic criteria listed in theDSM-5, which are:

• Presence of at least five symptoms in the final week before menstruation, which start to improve a few days after the time of menstruation, and become minimal or absent the week after.

• One or more of the following symptoms must occur:

• Significant affective lability, such as mood swings or sudden sadness

• Marked irritability, anger, or increased conflicts

• Depressed mood, hopelessness, or self-critical thoughts

• Marked anxiety, tension, or feeling on edge

• One or more of the following symptoms must also be present, which must total at least five when combined with the above list:

• Decreased interest in usual activities

• Difficulty concentrating

• Notable fatigue or lack of energy

• Overeating or specific food cravings

• Sleeping too much or trouble sleeping (insomnia)

• Feeling overwhelmed or out of control

• Physical symptoms, such as breast tenderness or swelling, joint or muscle pain, bloating, or weight gain

• Symptoms cause significant distress or interfere with work, school, relationships, and daily life.

• Symptoms are not solely attributable to another mental disorder

• Symptoms are confirmed by prospective daily ratings for at least two cycles

• Symptoms are not caused by drug use, a medication, or a medical condition

Who Can Give a PMDD Diagnosis?

Several qualified healthcare professionals can give a PMDD diagnosis, including primary care physicians, gynecologists, psychiatrists, psychologists, or a licensed therapist. Oftentimes, multiple professionals will collaborate to ensure the most accurate diagnosis and to generate an effective, comprehensive treatment plan.^[1]

Risks and Complications

There are several risks and complications to consider with PMDD. For example, PMDD can cause a number of issues in social functioning and relationship quality. It may increase conflicts with romantic partners, family, and friends.^[1][2][3]

In addition, PMDD makes it very difficult or impossible to function normally and do all of the things one could typically do. It can affect school and work performance, and may lead to absences from school or work on the more severe days.^[1][2][3]

PMDD can also affect overall life quality and mental well-being. People with PMDD are at an increased likelihood of anxiety, depression, and other mental health issues. The specific period before menstruation also poses an increased risk of suicidal ideation. Listed below are some rates of other comorbid mental disorders in people with PMDD:^[6]

• Panic disorder: 25%

• Social anxiety disorder: Around 20%

• Depressive disorders: 12 to 69%

• Generalized anxiety disorder: 4 to 38%

Treatment for PMDD

There are many established treatments for PMDD, including medications, natural remedies, psychotherapy, and general healthy lifestyle habits. If you’re looking to get treated for PMDD, your doctor and other involved healthcare professionals will work together to create an individualized treatment plan that is best for your unique needs.

Medications

There are several medications that may be implemented, including various psychotropic medications to improve mood, as well as ovulation suppressors and/or other hormonal agents.

Examples of psychotropic medications for PMDD include:^[1][5]

• Selective-serotonin reuptake inhibitors (SSRIs), which are a class of antidepressants

• E.g., escitalopram, citalopram

• Tricyclic antidepressants, such as clomipramine

• Benzodiazepines, which are anti-anxiety agents that may be used for severe anxiety and insomnia, are typically only on a short-term basis

• E.g. alprazolam, clonazepam

Examples of ovulation suppressors/hormonal agents include:^[1][5]

• Gonadotropin-releasing hormone agonists, which suppress ovarian function

• E.g., leuprolide, goserelin

• Androgen agonists, such as danazol

• Oral contraceptives, especially drospirenone

Natural Remedies

A variety of vitamins, minerals, and herbal supplements may also be beneficial for PMDD. Examples of well-researched natural remedies include:^[1][3][5]

• Calcium

• Vitamin B6

• Chasteberry

There is also some evidence for the benefits of magnesium, vitamin E, ginkgo biloba, evening primrose oil, and black cohosh, among others, but more research is needed. Always consult your doctor before taking any supplement, especially if you take medications or have any chronic medical conditions.

Psychotherapy

Psychotherapy, also known as talk therapy, may also be helpful for individuals with PMDD. Cognitive behavioral therapy (CBT) is one form of psychotherapy that can help you address any negative thoughts or behaviors that may be contributing to anxiety, irritability, and low mood. CBT helps you adopt a healthier mindset and teaches effective stress management strategies and coping skills.^[5]

Living with PMDD

Living with PMDD can be very stressful and frustrating, but there are many things you can do on a regular basis to feel better and more in control.

First, it’s important not to be too hard on yourself or overly judgmental. PMDD is a legitimate condition that you can’t just “snap out” of. Give yourself grace and compassion as you work through the more difficult symptoms and try to stay focused in the present moment.

Communicating with others you trust can also be very helpful. It can be anxiety-provoking to tell others you are having problems, but letting your family and friends know about your struggles often leads to greater support and understanding, which can help during the more difficult times.

Other things you can do to help manage daily life with PMDD include:

• Learn as much as you can about PMDD

• Join a peer support group

• The International Association for Premenstrual Disorders offers moderated and virtual support groups

• Focus on enjoyable activities (especially when you have enough energy & motivation)

• Mentally prepare yourself before symptomatic periods

• This can include meditation/mindfulness

Final Thoughts

PMDD is a disruptive disorder that can negatively affect someone's mental and physical health, relationships with others, and overall well-being. And while there isn’t a specific cure for PMDD, there are many effective treatments and daily strategies that can help manage symptoms and make daily life a bit easier. If you think that you may be experiencing symptoms of PMDD, it’s important to reach out to your healthcare provider as soon as possible, so you can get the help and support you need.