What Is PMDD?

If you thought premenstrual syndrome, or PMS, was bad, we’re introducing its more aggressive cousin: premenstrual dysphoric disorder (PMDD).

The research differs between studies, but a 2012 review showed it affects 2-5% of women of reproductive age [1]. Other studies suggest it could be closer to 15%, depending on the criteria [2].

To call PMDD a very severe form of PMS is a bit of an understatement, but it’s still probably the best way to describe it.

PMDD is “a very severe depression that occurs cyclically every four or five weeks,” explains Jayashri Kulkarni, a Professor of Psychiatry at Monash University who works in women's mental health [3].

Of course, there's more to it than that — and as with many women's health issues there are more questions than concrete, studied answers. But we want to raise the profile of PMDD, and that starts with making sure more people can identify it.

What is PMDD?  

PMDD is described as an extreme form of PMS that includes physical and psychological symptoms, often so severe that they can strain social, family, and professional relationships to breaking point.

After years of debate, PMDD finally appeared as a distinct psychiatric condition in the Diagnostic and Statistical Manual of Mental Health Disorders (5th edition) of the American Psychiatric Association in 2013.

Despite the growing body of scientific research into its causes and cures, it’s still a condition that is widely under or misdiagnosed; leaving women to discover it for themselves.

Why is this? The sheer lack of support services for women’s mental health and reproductive support could be one major clue, but medical literature explains the importance of getting the diagnosis right [4].

PMDD is a disorder of consistent yet irregular change in mental health and behaviours, which can make it difficult to diagnose.

What’s incredibly alarming is the link between suicide and PMDD; it’s a huge differentiating factor when compared with PMS.

The International Association For Premenstrual Disorders (IAPMD) says 30% of women with PMDD will attempt suicide in their lifetime while a larger percentage experience suicidal thoughts and self-harm [5].

What are the 11 PMDD symptoms?

There is actually no test used to diagnose PMDD, which makes paying attention to your symptoms even more important — particularly the 11 listed below. It can even be useful to keep a symptom diary so you can keep track.

If you experience 5 or more of these physical and emotional symptoms in a way that impacts your life, you might meet the diagnostic criteria for PMDD:

1. Mood changes
2. Irritability or anger
3. Depression
4. Anxiety
5. Lack of interest in things you usually enjoy
6. Difficulty concentrating
7. Fatigue
8. Change in appetite
9. Insomnia
10. Feelings of overwhelm
11. Bloating and breast tenderness

What are the mental symptoms of PMDD?

Often, people find the mental symptoms of PMDD the most troubling.

These can include cyclical bouts of extreme depression that can interfere with day-to-day life, as well as severe irritability, anxiety, and low mood that usually occurs a week or two before your period.

It is these psychological symptoms of anxiety and suicidal thoughts that distinguish PMDD as a rarer and much more severe hormonal condition than normal PMS. The fact that 15% of women with PMDD attempt suicide gives us insight into how severe the depression is [4].

Normally, the mental symptoms of PMDD will ease once your period starts but the mood swings, anger, and conflict that they cause can develop issues in relationships and general well-being.

For this reason, many women opt to take medication to settle the symptoms and avoid them interfering with their lives.

What are the physical symptoms of PMDD?

PMDD's physical symptoms, like fatigue and migraines, are often misdiagnosed.

They're very similar to PMS symptoms and can often go unnoticed or, at the very least, not appreciated for what they really are.

Women with PMDD will often show symptoms at quite an extreme level, which goes some way towards ensuring a correct diagnosis.

Fatigue, joint or muscle pain and a change in appetite are a few of the main physical symptoms that people experience, but some women also experience physical side effects like nausea, heart palpitations, dizziness, and fainting.

These are essentially side effects of anxiety and tend to fluctuate at different stages of the menstrual cycle.

Why do people get PMDD?

PMDD is related to hormonal changes that happen naturally in the body as a result of the menstrual cycle.

However, researchers have yet to figure out why it affects 5% of the female population.

The exact cause of PMDD isn’t known, although we do know that it has a heritability of around 30-80% [5]. This means that women with a family history of PMS or PMDD are at a higher risk of developing the disorder.

There have been some discoveries made by the researchers at the National Institute of Mental Health (NIMH), that help us understand how genetic factors can contribute to a woman’s susceptibility to experience PMDD.

And it has a lot to do with how a woman responds to the sex hormones produced by the ovaries during the luteal phase.

NIMH’s study has found that women with PMDD have an altered gene complex that processes the body’s response to hormones produced by the ovaries [6].

Why is this important? Well, it has established a biological basis for the mood disturbances of PMDD.

What this means is that the extreme emotional or physiological behaviours of a woman suffering from PMDD are completely out of her voluntary control.  

They’ve also published data that supports the theory that the changes in hormone levels, not just the hormones themselves, trigger the symptoms of PMDD.

Other risk factors include pre-existing mental disorders, high stress levels, trauma, inflammation and immune activation [7]. Some research has also linked smoking to an increased risk of PMDD [8].

Diagnosing PMDD

Diagnosing PMDD isn’t a straightforward path. But 2 main steps can help kick-start the process:

Keeping a menstrual diary

To get a formal diagnosis of PMDD, there is some reliance on the woman to be able to track her daily symptoms for 2 full monthly cycles.

This self-reporting aims to help your doctor differentiate between mild PMS and moderate to severe PMS and PMDD.  

They also check if any of your symptoms could be due to another underlying psychological condition or disorder.

Several self-reporting questionnaires and tools have been listed in medical literature, including [9]:

• The Daily Record of Severity of Problems (DRSP): A 21-item measure that allows women to track 11 symptoms across the menstrual cycle [10].
• Calendar of Premenstrual Experiences (COPE): The COPE diary has been identified as a reliable way to identify fluctuations in behavioural and physical symptoms during the luteal phase [11]. It requires you to complete daily diaries of 22 different behavioural and physical symptoms over 2 consecutive months.
• The Moos Menstrual Distress Questionnaire (MDQ): Despite the wide usage of MDQ, it hasn’t changed much since it was first developed by Moos in 1968 [12]. Because of this, the questionnaire has received a lot of serious criticism. However, it’s still been reported to effectively represent the structure of menstrual cycle symptoms [13].
• The Premenstrual Assessment Form (PAF): Although valid and reliable, it’s very long (95 questions!) which requires a lot of time to complete and has been criticised for potentially being inappropriate for some clinical and research purposes [14]. So, there has been a shortened version of PAF created, with only 10 questions [15].  

Next time you speak with your doctor, you could ask them about these tests and see whether they have a different or similar approach when it comes to tracking symptoms.

Seeking formal diagnosis: The 5-step criteria

The following criteria is most widely known for diagnosing PMDD, and it’s broken down into 5 areas [16]:

1. Timing of symptoms: The symptoms need to be present in the final week before your period (i.e during your luteal phase) and start to improve within a few days after you’ve started your period.
2. The symptoms experienced: Symptoms are broken down into emotional and physical.
3. The severity of symptoms: These symptoms need to be causing you significant distress and interfering with your work, school, social activities and relationships.
4. Considering other psychiatric disorders: A medical professional will want to rule out the possibility that these symptoms are not a result of another disorder — such as major depressive disorder, panic disorder, persistent depressive disorder or a personality disorder.
5. Confirmation of the disorder: The symptoms need to be present for a minimum of 2 consecutive menstrual cycles. The criteria also says that the symptoms need to be checked to confirm they aren’t attributable to the physiological effects of a drug substance or another medical condition.

5 lifestyle changes to help you manage your symptoms

Besides medication, there are also habits you can adopt that may have a positive impact on your symptoms:

1. Incorporate cardio into your fitness routine

Working out is an amazing way of managing both emotional and physical symptoms.

Cardio is particularly effective at increasing your serotonin levels which, similar to the above-mentioned SSRIs, can help with mood disorders and psychological symptoms that are associated with PMDD [17]. Serotonin also plays a role in satiety, which can be helpful if you experience higher hunger levels than usual as a result of PMDD.

If you're not into running or cycling, don't worry: swimming, dancing and even walking all count as cardio!

2. Eat a healthy diet

For women with PMDD, a healthy diet is one rich in high-quality protein, healthy fats, fibre and complex carbs.

Together, all these essential nutrients will help keep your blood sugar levels under control, prevent inflammation, maintain gut health, stabilise your mood and minimise cravings.

You also want to incorporate anti-inflammatory foods into your diet. Turmeric and saffron have both been shown to help with several symptoms of PMDD, so they should become staples in your pantry [18].

It's also a good idea to eat serotonin-boosting foods, as hormone changes can cause a serotonin deficiency, which has historically been associated with depression.

The body needs other nutrients to properly make and use serotonin, including vitamin B6. Another key nutrient for mood is an amino acid called tryptophan which is a precursor to serotonin production.

As for what to avoid, it's best you steer clear of simple carbs, particularly during your luteal phase, as they can cause spikes in blood glucose levels.

3. Consider taking a supplement

We've mentioned that taking certain medications can help reduce PMDD symptoms, and the right supplement can also be beneficial.

A Chinese herbal supplement called Xiao Yao Wan has been widely used as an alternative and effective treatment for depression in China [19].

One study found this supplement does appear to be effective in improving symptoms in patients with depression [20].

However, it has also been pointed out these trials have poor methodological quality and there is a need for more trials to be conducted that follow international standards.

Keep in mind, as well, that a supplement can't and shouldn't replace a balanced diet. Plus, it's always a good idea to speak with your doctor before you start taking it, so make sure it is the right choice for you.

4. Find effective stress management techniques

Stress can worsen PMDD symptoms so it's important you find relaxation techniques that work for you.

This can be something as simple as going on a daily walk in nature, painting, stretching or listening to music. Journalling is also proven to reduce stress, as is breathwork, mindfulness, and yoga [21][22][23][24].

Other methods worth trying include:

• Acupuncture. There is limited evidence that supports the efficacy of alternative medicinal interventions such as acupuncture. However, some studies have shown acupuncture treatment can provide relief in symptoms of PMS and PMDD with a 50% or better reduction [25].
• CBT, a non-drug-based therapy that can help women find new ways to behave by changing their thought patterns. In this case, it helps women navigate their behaviour and emotions related to PMS and PMDD. Studies have experimented with this theory and found there was a significant difference in psychological symptoms before and after CBT [26].

5. Minimise your coffee and alcohol consumption

Drinking coffee can increase your cortisol levels and alcohol leads to a drop in serotonin levels (after an initial boost), which explains why both drinks can negatively impact your mood and mental health.

Medical ways to treat PMDD

The medical options to treat PMDD are the same as treating PMS medically. The main two are:

Using SSRIs to treat PMDD

Multiple studies have confirmed using SSRIs for PMDD treatment is effective [27].

Depending on the severity and timing of your symptoms, your doctor may recommend taking the antidepressant medication in the following ways:

• Continuous: For women who have severe emotional symptoms such as depression, anxiety, anger and mood swings that happen all cycle round, not just exclusively to premenstrual time.
• Luteal phase only: When the medication is taken from day 14 of the cycle (start of ovulation) until the beginning of the period.
• Symptom-onset: Taken at the first sign of PMDD symptoms and continued until a few days after bleeding has started.

Taking the combined pill

Taking the pill has been found to significantly improve the emotional and physical symptoms of PMDD, though it depends on the type of contraceptive pill you take [28].

Treating PMDD requires careful counselling with a doctor to ensure you are properly informed and recommended the right hormonal contraceptive care.

It’s also important to have a plan for follow-up appointments to monitor your symptoms and progress, especially if you’re suffering significant mood symptoms.

What to do if you think you have PMDD

If you think that you might have PMDD, the best thing to do is speak to your doctor and get a diagnosis.

This way, you’ll be able to discover your options and find out if medication may be able to ease your symptoms.

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