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What is Premenstrual Dysphoric Disorder (PMDD)?
Premenstrual Dysphoric Disorder (PMDD) is more than just "PMS," or 'premenstrual syndrome". It is not a condition of the mind. It is a neuroendocrine condition. This means it is a condition where hormones impact the brain in terms of both mood (emotions) and cognition (thinking).
Many women with PMDD also experience body hormone symptoms.
It is a severe form of premenstrual symptoms that significantly impacts a woman's mental and physical health.
PMDD affects approximately 3-8% of menstruating women. It is characterized by intense emotional, cognitive and physical symptoms that disrupt daily life. Understanding PMDD is crucial for improving women's health and mental wellness, particularly around menstrual health.
PMDD is just one menstrual mood disorder. Others include premenstrual exaccerbation of existing mood disorders.
The causes of PMDD are complex.
What Are The 11 PMDD Symptoms?
To better understand PMDD, it's essential to recognize the primary symptoms of PMDD.
To be classified as PMDD, at least 5 of these 11 symptoms should be present in at least the week before the period begins (it can last up to 2 weeks for some women). These symptoms should improve or resolve in the week after the period.
There are the 11 symptoms of premenstrual dysphoric disorder as classified by the DSM-5:
1. Severe Mood Swings
Frequent, extreme and unpredictable changes in mood can make it difficult to maintain stable emotions, impacting personal and professional relationships. Can be disturbing to feel these mood changes, they can feel beyond your control and 'chemically driven'
A mood swing can mean you suddenly feeling sad or tearful, or sensitive to rejection or your feelings were easily hurt.
2. Depression or Feelings of Hopelessness
Intense feelings of sadness, despair, or worthlessness can become overwhelming during the luteal phase of the menstrual cycle. You may find yourself tearful, for no reason. You may also feel down or hopeless.
3. Marked Anxiety or Tension
Anxiety can manifest as constant worry or nervousness. Sometimes this feeling is more physiological than cognitive and is felt more in the body as a feeling of being keyed up, internal tremors or on edge.
4. Persistent Irritability or Anger
You may feel irritable or angry that is out of sync with your typical. Heightened irritability can lead to conflicts with others, irrational responses and an overall sense of frustration and anger with others or with yourself.
5. Decreased Interest in Usual Activities
You may experience a reduction in interest and motivation for daily activities, work, hobbies, and social interactions. This may impact your work output and relationships.
6. Difficulty Concentrating
Mental fog and difficulty focusing on tasks can severely impact your capacity to remember, plan and organise. This can have a significant impact on your work or academic performance.
7. Fatigue or Lack of Energy
Persistent tiredness and low energy levels can make everyday tasks feel exhausting.
8. Changes in Appetite
Some women may experience changes in appetite, binge eating, specific food cravings or a significant decrease in appetite during this time.
9. Sleep Problems
Insomnia or hypersomnia are common. Insomnia is difficulty going to sleep or staying asleep.
Hypersomnia is feeling more tired than normal during the day. Both of these can affect overall sleep quality and lead to further fatigue.
You may find you need to sleep more, take naps, find it hard to get up when you need or want to or have trouble getting to sleep or staying asleep.
10. Feeling Overwhelmed or Out of Control
Feeling overwhelmed can be incredibly stressful. It can cause an inability to handle stress or manage daily responsibilities or relationships.
11. Physical Symptoms
Many women with PMDD experience one or more physical symptoms associated with their luteal/premenstrual phase. These can include breast tenderness or swelling, headaches, joint or muscle pain, bloating, and weight gain.
How Is PMDD Diagnosed?
PMDD is diagnosed according to the DSM-V criteria. It is classified as a depressive disorder.
It is however more accurate to describe premenstrual dysphoric disorder as a neuro-endocrine condition.
Current diagnosis of PMDD requires:
5 or more of the above 11 symptoms to be experienced during the week before the period starts,
the symptoms begin to improve within a few days of the onset of the period and
become minimal or absent during the week after the period.
For PMDD to be diagnosed the symptoms also must significantly impact your quality of life in that they are associated with either:
significant distress or
interference with work or school or usual social activities, or
impaired relationships with others.
How Does PMDD Impact Daily Life
The symptoms of PMDD can have a profound effect on mental wellness, relationships, and work or study performance. Women with PMDD often find it challenging to maintain emotional stability and productivity.
PMDD and Work Life
PMDD can impact various aspects of work life, such as attendance, productivity, and interpersonal relationships. The fluctuation in mood and energy levels can make it difficult to maintain a consistent level of performance. Additionally, the physical symptoms can also affect work productivity.
Studies show that the impacts of PMDD at work include: higher absenteeism and lower productivity.
PMDD and Personal Relationships
The emotional instability and irritability associated with PMDD can strain personal relationships with friends, family, and romantic partners. These symptoms can make it challenging to communicate effectively and manage conflicts.
Research has found that women with PMDD are more likely to experience relationship problems compared to those without the disorder.
PMDD, Self-Harm and Suicidality
Even more serious is the suicidality that can accompany this neuro-endocrine condition. Thoughts of self-harm can be part of the emotional and physical experience of PMDD and can also reflect distress at behaviour that feels out of control.
A study published in 2022 found that among those with a diagnosis of PMDD;
72 % experienced suicidal thoughts,
49% had engaged in suicidal planning,
42% had suicidal intent,
34% had attempted suicide and
51% had carried out non-suicidal self-injury (51%).
It is concerning that suicidality is so prevalent in this group.
Without proper recognition and treatment, the disorder can significantly impact a woman's overall quality of life, and also can have flow on impacts on her relationships.
Seeking Help
If you are experiencing any of these symptoms, relating to your menstrual cycle it's essential to seek help from a healthcare professional. They can provide an accurate diagnosis and offer appropriate treatment options that can significantly improve the quality of life for those with PMDD.
Additionally, seeking support from friends and family can also be beneficial. Educating them about PMDD and its effects can help improve understanding and reduce potential conflicts.
Remember, PMDD is a neuro-endocrine disorder that requires appropriate management and support.
Diagnosis and Management of PMDD
Diagnosis
Currently diagnosing PMDD according to DSM criteria typically involves tracking symptoms over two or more menstrual cycles. Your healthcare provider may ask the patient to keep a detailed diary of their symptoms, noting the severity and timing in relation to their menstrual cycle.
However in reality, by the time most women seek support from their health provider for their mood and wellbeing symptoms, they already recognise a clear pattern of deterioration in mood around the week prior to their period.
The DSM-5 outlines specific criteria for diagnosis, which includes experiencing at least five of the 11 primary symptoms, with one being a key emotional symptom such as mood swings, irritability, or depression.
The symptoms need to be present during the week before the periods and resolve or improve in the week after the period.
Management
Management of PMDD can include a combination of lifestyle changes, psychological therapies, and medical treatments. The International Association For Premenstrual Disorders (IAPMD) outlines evidence-based guidelines for clinicians and patients for managing PMDD.
Treatment Options
Hormone Treatments
1. Estradiol Patches with Cyclical Progesterone/Norethisterone/Mirena IUD
There are 2 studies using estrogen patches (estradiol) to keep estrogen levels more stable and they have been found to be effective in treating PMDD. Studies show that higher stable estrogen is beneficial for brain function and mood stability in people with PMDD.
Some women find this regime very effective for stabilising their luteal phase hormones and preventing the mood, cognitive and physical symptoms in the week leading up to their period.
The estradiol patches are used continuously (changed twice per week). A progestogen is also used in a cyclical manner (for progesterone or norethisterone) or continuous if mirena IUD is used.
Cyclical progestogen use means using either:
natural bioidentical progesterone capsules such as prometrium or utrogestan, used at night during the 10 days before your period (ie every 28 day cycle) or
cyclical norethisterone 1mg for 10 days per cycle during the luteal phase.
Some women choose to use a levonorgestrel containing IUD such as Mirena as the progestogen to treat their PMDD. This is a continuous regime and is helpful if you find it difficult to time taking oral progestogen at different times of your cycle.
Using the Mirena IUD without estradiol is unlikely to be a helpful option for the mood and cognitive symptoms of PMDD as it does not suppress ovulvation in most cases, so it does not suppress the luteal phase estradiol hormone decline.
2. Drospirenone Oral Contraceptive Pills with Short Hormone Free Interval
This combined oral contraceptive pill containing ethinyl estradiol and drospirenone (YAZ or YASMIN) has been approved specifically for PMDD management. It is taken continuously, with a 4-day hormone-free interval every 28 days. It has a 48-61% success rate.
It is not funded in New Zealand.
3. Desogestrel Containing Progestogen Only Contraceptive Pill
This progestogen only birth control pill (Cerezette) works by suppressing ovarian function. It works for some women as it keeps ovarian hormone production low and prevents the estrogen and progesterone hormones from cycling.
It is not funded in New Zealand.
As it supresses estradiol it can give symptoms of low estrogen such as fatigue, low mood so it is not beneficial for everyone.
4. GNRH Analogues +/- HRT
GNRH analogues are hormonal treatments that suppress the menstrual cycle. They can be used with add-back in combination with HRT (hormone replacement therapy) to provide a stable estrogen doses and prevent menopausal symptoms.
GNRH analogues suppress the menstrual cycle and reduce symptoms. They are typically used in the more severe cases or as a last resort due to potential side effects/long term effects of suppressing ovarian function.
Note about Progestogen sensitivity
For women who are most sensitive to hormone changes, especially if they have progestogen sensitivity, these women definately should receive estrogen in conjunction with the progestogen.
For some women who cannot tolerate progestogens even with estrogen, a non-hormonal option may be more suitable for them.
Non-Hormone Options
1.Serotonin Reuptake Inhibitors (SSRIs)
SSRIs are the first line of treatment for PMDD, with fluoxetine being the only FDA-approved medication specifically for this disorder. However, other SSRIs have also shown effectiveness in reducing symptoms.
Serotonin reuptake inhibitors (SSRIs) are the most commonly prescribed medication for PMDD. They can be dosed daily or used at symptom onset or at the start of the luteal phase.
SSRIs have a 60 percent response rate in premenstrual dysphoric disorder.
2.Quetiapine in the Luteal Phase
Low-dose quetiapine in the luteal phase has been found to be a helpful adjunct alongside other treatments for those who have ongoing mood disturbances. It also helps with sleep, concentration.
The down-side are the risks associated with weight gain and metabolic disturbance.
Surgical Options
Ovary and fallopian tube removal + HRT
In cases where all other treatment options have failed, surgical removal of the reproductive organs may be considered.
There are long-term risks associated with this including early onset osteoporosis, early onset cardiovascular disease (including heart attack and stroke) anad early onset dementia so it is important to get good advice and to consider both your current quality of life and the potential long-term health impacts of surgery.
If you do have surgery to remove your ovaries, it is important to use hormone replacement therapy with estrogen and testosterone after this surgery till at least age 51 to prevent premature onset of diseases associated with early menopause.
Some people think that having a hysterectomy (removal of your uterus) is a treatment for PMDD. This surgery will stop your periods, but if your ovaries are not also removed, they will continue to produce the hormonal cycles responsible for the mood and cognitive symptoms of premenstrual dysphoric disorder.
Adjunctive Treatments
Psychology/Therapy
Weekly sessions with a qualified therapist with appropriate training in cognitive behavioural therapy (CBT) and dialectical behavioural therapy (DBT) that can provide skills training and strategies that can help improve everyday functioning is an important treatment alongside addressing the underlying neuroendocrine condition.
CBT is useful for learning skills to improve functioning relating to emotional symptoms.
DBT is useful for learning skills to manage impulsive behaviours, feeling and thinking, particularly suicidality.
Lifestyle Changes
Optimising lifestyle helps the body and brain function in the best way it can. Improved diet and exercise can improve mood, cognitive function and physical health.
Reducing caffeine intake and avoiding alcohol during the luteal phase can also help reduce symptoms of PMDD.
Additionally techiniques for supporting sleep and stress management can help you get through the tough emotional ups and downs.
Supplements
There is emerging evidence that certain supplements may have a positive impact on reducing PMDD symptoms including;
Vitamin B6,
Magnesium and
Vitamin D.
These supplements are certainly low risk and low cost strategies that may help support your mood and cognition in addition to your other treatments.
Related: 8 Natural Treatments for PMDD
Helpful Resources
The more you can learn and understand your condition, the better equipped you are to seek out treatments that suit you. Here are a few resources that can help you along the way.
IAPMD website can provide more information and resources on these supplements.
Frequently Asked Questions about PMDD Treatment
Is Progesterone Cream Effective For Treating PMDD?
Progesterone cream is not well aborbed via the skin and has not been shown in clinical trials to be an effective treatment for PMDD.
Will A Hysterectomy Cure PMDD?
No it will not if the ovaries are not also removed. This is because it is the ovarian hormone cycle that causes the changes in mood and cognition experienced by people with PMDD.
If you have a hysterectomy with oophorectomy (removal of ovaries) it will stop your hormones cycling. It is however important to discuss long-term health risks with your health provider, such as those as outlined above.
The Takeaways: 11 Symptoms of PMDD
PMDD is a severe form of Premenstrual Syndrome.
Women who experience it significantly impacts the mental, emotional, and physical well-being of women. It can be an incredibly hard condition to live with and treatment is available and important to improve quality of life.
The symptoms can affect many aspects of daily life, including work performance, relationships, and self-image.
Seeking help from skilled healthcare professionals is essential for diagnosis and management.
Share this post to raise awareness and encourage others to pursue the help they need.
Together, we can break the stigma surrounding menstrual health and support women's neuro-endocrine health.
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Dr Deb Brunt @ Ōtepoti Integrative Health treats PMDD in New Zealand and would love to explore treatment options with you.
Dr Deb Brunt is a women's health and menopause specialist in Dunedin, New Zealand and also provides health coaching internationally to support optimal health habits so you can live your best life.
Follow on Facebook and Instagram and check out Meno Thrive!
References
Eisenlohr-Moul T & IAPMD Clinical Advisory Board, EVIDENCE-BASED MANAGEMENT OF PREMENSTRUAL DISORDERS (PMD). 2023
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