A lot of women in their 30s and 40s begin to wonder if they have premenstrual dysphoric disorder. What is it? And, how is it different from premenstrual syndrome (PMS)? You can think of PMDD as a more severe form of PMS. PMS includes symptoms leading up to a womens menses or period, a time period called the luteal phase, and these symptoms include irritability, headaches, pelvic cramping, changes in bowels, changes in dietary patterns, sleep disruptions, ect. These symptoms are usually mitigated by lifestyle changes. PMDD is psychological and somatic (read: body) symptoms that cause a significant amount of distress that disrupts her occupation, school, relationships, or other facets of her life. Symptoms of both PMS and PMDD completely resolve at the start of menstruation or within a day or 2 of her period.

Why does this happen?
Short answer, is we are not exactly sure. We believe that it has to do with an increased sensitivity to the sex hormones, particularly progesterone, in the second half of the cycle. Progesterone and estrogen interact with neurotransmitters such as serotonin, and those with PMDD may have an increased sensitivity to this interaction and/or the fluctuations of the hormones that occur in the second half of the cycle. Furthermore, progesterone gets metabolized to allopregnanolone and the current theory is that this allopregnanolone may be the problem in those with PMDD. Usually allopregnanonlone binds to GABA receptors (think calming and Zen receptors), and leads to a sense of calm and relaxation but the opposite happens in those with PMDD.

Diagnosis
In order to meet diagnostic criteria for PMDD, she must have a minimum of 5 of the 11 symptoms below, with a minimum of one symptom being related to mood, during most menstrual cycles over the previous 12 months. The symptoms must occur during the week before her period, must improve within a few days of her period, and must resolve in the week after her period. The symptoms are:

1) Depressed mood, feelings of hopelessness or self-deprecation
2) Notable tension and/or anxiety
3) Notable affective lability – mood swings, sudden sadness, crying, or increased sensitivity to rejection
4) Notable anger or irritability leading to increased interpersonal conflicts
5) Low interest in common activities such as school, work, hobbies, social activities
6) Difficulty concentrating
7) Lethargy, fatigue, or decreased energy
8) Notable change in appetite
9) Sleeping too little or too much
10) Feeling overwhelmed or out of control
11) Physical symptoms such as breast tenderness or swelling, joint or muscle pain, headache, bloating.

Also, these symptoms must not be a result of any other psychiatric disorder such as major depressive disorder or bipolar disorder.

Diagnosis is made after a woman tracks her cycle no less than 2 months, although the diagnosis can be made based on an evaluation with a healthcare provider and then confirmed after 2 months of tracking. Click here to access a PMDD/hormone symptom tracker.

Treatments
There are a few well studied types of treatments: serotonin reuptake inhibitors (SSRIs) and birth control pills. There are some other less studied, or the data is inconclusive in how effective these treatments are. The most well studied option is SSRIs. These medications can either be used continuously, cyclically, or at the onset of symptoms. Continuous use is taking the medication daily, which is what most people are familiar with. Cyclically is taking the SSRI at the start of the luteal phase, or the second half of the cycle. Onset of symptoms would be taking the SSRI at the onset of the PMDD symptoms. You should never self dose these medications, you must get guidance from a license healthcare clinician.

The other option is birth control pills. This will consistently suppression ovulation, which will therefore suppress the luteal phase hormone fluctuation that is thought to be problematic in women with PMDD. The most well studied birth control for this purpose are those with drospirenone in it so birth control pills such as Yaz or Nexstellis.

Supplements and lifestyle treatments include exercise, prioritizing sleep, prioritizing hydration, increasing complex carbohydrates during the luteal phase, and supplements such as zinc, calcium, and magnesium.

Once the above options do not provide enough control of symptoms, some women may opt to take medications that put them in a temporary menopause state such as Lupron. If all else fails, some women will opt to have a hysterectomy with removal of the ovaries; however, I do caution that this will put a woman in surgical menopause and depending on her age in which this occurs she may require add back hormone therapy.

So, what to do?
Do you think you may have PMDD? Don’t wait to get in with a trusted healthcare provider, start tracking now! Ideally a woman will track for 2 months minimum, but I always recommend tracking your cycle in some sort of way on an ongoing basis. Your menstrual cycle gives you valuable information about your health, and it helps you recognize patterns in your own body.

If you are ready to get started with a healthcare provider who may be able to give insight into PMDD, I would recommend finding someone through one of the following 4 organizations –International Society of Reproductive Psychiatry, Postpartum Support International, The Menopause Society, International Society of the Study of Women’s Sexual Health.
If you ever feel you are having a mental health crisis, contact 911 or 988.

Resources
1. International Association for Premenstrual Disorders – iapmd.org
2. Reilly TJ, Wallman P, Clark I, Knox CL, Craig MC, Taylor D. Intermittent selective serotonin reuptake inhibitors for premenstrual syndromes: A systematic review and meta-analysis of randomised trials. J Psychopharmacol. 2023 Mar;37(3):261-267. doi: 10.1177/02698811221099645. Epub 2022 Jun 10. PMID: 35686687; PMCID: PMC10074750.
3. Leddy MA, Lawrence H, Schulkin J. Obstetrician-gynecologists and women’s mental health: findings of the Collaborative Ambulatory Research Network 2005-2009. Obstet Gynecol Surv. 2011 May;66(5):316-23. doi: 10.1097/OGX.0b013e31822785ee. PMID: 21794195.
4. Ling FW. Recognizing and treating premenstrual dysphoric disorder in the obstetric, gynecologic, and primary care practices. J Clin Psychiatry. 2000;61 Suppl 12:9-16. PMID: 11041379.