What is premenstrual dysphoric disorder (PMDD)?

Premenstrual dysphoric disorder (PMDD) is a much more severe form of premenstrual syndrome (PMS). It is a chronic, cyclical, hormone-based mood disorder with symptoms arising during the luteal phase of the menstrual cycle and subsiding within a few days of menstruation. PMDD is thought to be a severe negative reaction to the natural rise and fall of estrogen and progesterone that happens each month between ovulation and menstruation, or one’s period. It affects about 5.5% of women and AFAB individuals of reproductive age. While 

What causes PMDD?

The exact cause of PMDD is not known. Though PMDD is directly connected to the menstrual cycle, it is not caused by a hormone imbalance. It may be an abnormal reaction to normal hormone changes that happen with each menstrual cycle. The hormone changes can cause a serotonin deficiency. Serotonin is a substance found naturally in the brain and intestines that narrows blood vessels and can affect mood and cause physical symptoms.Those with PMDD are at an increased risk for suicidal behavior. 

What are the risk factors for PMDD?

While any woman can develop PMDD, the following may be at increased risk:

• Women with a family history of PMS or PMDD  

• Women with a personal or family history of depression, postpartum depression, or other mood disorders

• Other possible risk factors include lower education and smoking

The Difference Between PMDD and PMS

Though PMS and PMDD are similar in presentation, PMDD is more severe in nature. PMS is largely defined by physical issues while PMDD is diagnosed by its severe mental health implications. Those who suffer from PMDD can become very distressed and the emotional symptoms can be extreme and volatile. With these fluctuations, mood swings may change from one day to the next, and this can lead to severe anxiety to the person suffering as well as their family, friends or colleagues, disrupting interpersonal relationships and leading to major distress.

The symptoms of PMDD can often mimic those of other disorders, including major depressive disorder, generalized anxiety disorder, panic disorder, bipolar disorder, or borderline personality disorder. In PMDD, symptoms that overlap with these disorders occur only on the days between ovulation and the end of menstruation, so tracking symptoms and cycles is crucial. However, many patients are not advised to track their symptoms alongside their menstrual cycle, leading to misdiagnosis and often ineffective treatment for PMDD. 

What are the symptoms of PMDD?

Symptoms of PMDD appear during the week before menstruation and end within a few days after your period starts. These symptoms disrupt daily living tasks. Symptoms of PMDD are so severe that women have trouble functioning at home, at work, and in relationships during this time. This is markedly different than other times during the month. The following are the most common symptoms of PMDD:

• As well as the severe mood swings associated with PMDD symptoms can include:

• Feelings of sadness or despair, or even thoughts of suicide

• Feelings of tension or anxiety

• Panic attacks

• Mood swings or frequent crying

• Lasting irritability or anger that affects other people

• Lack of interest in daily activities and relationships

• Trouble thinking or focusing

• Tiredness or low energy

• Food cravings or binge eating

• Trouble sleeping

• Feeling out of control

• Physical symptoms such as bloating, breast tenderness, headaches and joint or muscle pain.

A diagnosis of PMDD requires the presence of at least five of these symptoms, one of which must be a "core emotional symptom" (*indicated with an asterisk above). It should be noted that the use of oral contraceptives suppresses natural ovulation, which makes it impossible to diagnose PMDD - the diagnosis should not be made unless premenstrual symptoms are reported as present and as severe when a person is not taking an oral contraceptive. 

How is PMDD diagnosed?

Aside from a complete medical history and physical and pelvic exam, there are very few diagnostic tests. Because there are mental health symptoms, your healthcare provider may want you to be evaluated for mental health concerns. In addition, your healthcare provider may ask that you keep a journal or diary of your symptoms for several months. In general, to diagnose PMDD the following symptoms must be present:

• Over the course of a year, during most menstrual cycles, 5 or more of the following symptoms must be present:

  • Depressed mood

  • Anger or irritability

  • Trouble concentrating

  • Lack of interest in activities once enjoyed

  • Moodiness

  • Increased appetite

  • Insomnia or the need for more sleep

  • Feeling overwhelmed or out of control

  • Other physical symptoms, the most common being belly bloating, breast tenderness, and headache

• Symptoms that disturb your ability to function in social, work, or other situations

• Symptoms that are not related to, or exaggerated by, another medical condition

How is PMDD treated?

PMDD is a serious, chronic condition that does need treatment. Several of the following treatment approaches may help relieve or decrease the severity of PMDD symptoms:

• Changes in diet to increase protein and carbohydrates and decrease sugar, salt, caffeine, and alcohol

• Regular exercise

• Stress management

• Vitamin supplements (such as vitamin B6, calcium, and magnesium)

• Anti-inflammatory medicines

• Selective serotonin reuptake inhibitors (SSRI)

• Birth control pills

For some women, the severity of symptoms increases over time and lasts until menopause. For this reason, a woman may need treatment for an extended time. Medicine dosage may change throughout the course of treatment.