Premenstrual Dysphoric Disorder (PMDD)

Studies show that about 90% of reproductive aged women report at least one premenstrual symptom, with 20-40% reporting an impact on daily functioning. While many individuals experience some amount of premenstrual symptoms, some experience particularly intense mood and cognitive symptoms that cause immense distress during their premenstrual period. These symptoms bear a heavy resemblance to those seen in depression and anxiety disorders, indicating that they go beyond the typical symptoms experienced in the premenstrual period. In 2013, the writers of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) introduced a new diagnosis: Premenstrual Dysphoric Disorder, or PMDD, to account for these intense mood symptoms related to the menstrual cycle.

The Menstrual Cycle

What distinguishes PMDD from other mood disorders is its relationship with the menstrual cycle and the associated fluctuations in ovarian hormones. The menstrual cycle typically lasts about 28 days and is broken into four phases and is tracked from the beginning of bleeding in one phase to the beginning of bleeding in the next. PMDD is most closely linked with the late luteal phase, which typically begins a week prior to the onset of a period, which is also known as menses. During this time, the hormone progesterone rises as an egg is released from the ovary. If the egg is not fertilized, estrogen and progesterone levels drop and the uterine lining sheds during menses. In people with PMDD, this drop in ovarian hormones coincides with an improvement in symptoms.

What is PMDD?

PMDD is classified as a mood disorder due to its intense emotional symptoms, and it can wreak havoc on someone’s life. Symptoms typically disappear fully until a week prior to the next menses. According to the DSM-5, someone must present with at least five of eleven symptoms in order to be diagnosed with PMDD. Of those five, one of the following must be present:

1. Mood lability (also known as mood swings) or increased sensitivity to rejection

2. Increased irritability, anger, or interpersonal conflict

3. Depressed mood, feelings of helplessness, or self-deprecating thoughts

4. Feeling anxious or on edge

The remaining symptoms can be any of the following: decreased interest in activities of living, difficulty concentrating, lethargy, changes in appetite, sleeping too much or too little, feeling overwhelmed, and physical symptoms such as breast tenderness or bloating. 

Studies investigating the origin of PMDD have found that those diagnosed with PMDD do not have elevated levels of ovarian hormones such as estrogen and progesterone. Instead, they have found that those diagnosed with PMDD have an increased sensitivity to the presence of these hormones, which become elevated in the lead-up to menses; however, the reason for this sensitivity is still unknown.

How is PMDD Diagnosed?

PMDD is typically diagnosed by a gynecologist rather than by a psychiatrist, psychologist, therapist, or social worker, as is the case with most DSM-5 diagnoses. The International Association for Premenstrual Disorders (IAPMD) offers a free screening tool as a preliminary method to identify PMDD, and can be found here.

To officially diagnose PMDD, a doctor will typically request two to three months of symptom tracking and period tracking to ensure that the symptoms correlate with the menstrual cycle and rule out other mood disorders. Some people prefer to track symptoms using an app, and two options with strong data privacy features are Drip and Euki. The IAPMD also offers a diary card available for download, the Daily Record of Severity of Problems, that can be found here. Progress through the menstrual cycle can be tracked by recording body temperature once daily, and it is important to track around the same time to account for natural changes in body temperature throughout the day. A guide to tracking menstrual cycles using body temperature can be found here. Different gynecologists may request different amounts of symptom tracking prior to providing a diagnosis, so it is best practice to follow their guidelines of when to schedule an appointment. 

How is PMDD treated?

Because of the major role of hormones in PMDD, therapy is not recommended as the primary treatment for PMDD. Studies have shown support for a variety of medications, procedures, and lifestyle changes that can be effective in treating or alleviating some of the symptoms of PMDD. The efficacy of these treatments can vary from person to person, and it is important to discuss with a gynecologist to assess which one may be the right fit and how it might interact with other medical and mental health conditions as well as disabilities.

1. Selective Serotonin Reuptake Inhibitors (SSRIs) - SSRIs are a common treatment option for major depressive disorder and various anxiety disorders. They have shown moderate efficacy in treating PMDD, with up to 60% of people reporting a decrease in symptoms.

2. Progestin-Only Oral Contraceptives - These contraceptives interrupt the menstrual cycle by preventing the release of a matured egg. They have demonstrated 48%-61% efficacy in treating PMDD.

3. Gonadotropin-Releasing Hormone (GnRH) - GnRH suppresses the menstrual cycle. While studies have shown its efficacy in treating PMDD symptoms, extended use can lead to intense side effects such as bone density loss. For this reason, this option is typically utilized after other options have been exhausted.

4. Hysterectomy with Bilateral Oophorectomy - This last resort treatment method involves a full removal of the uterus and ovaries to eliminate the menstrual cycle.

5. Diet Changes: Some studies have shown support for eating more complex carbohydrates during the luteal phase.

6. Moderate Aerobic Exercise: Studies have shown preliminary evidence for moderate aerobic exercise in reducing PMDD symptoms, but this research is in its infancy.

Is Therapy Helpful for PMDD?

Therapy is not recommended as the frontline treatment for PMDD due to biological components of the disorder. However, therapy can be helpful in managing the intense mood symptoms of PMDD, and studies have shown symptom improvement among people with PMDD treated with therapy. According to the IAPMD, up to 34% of people diagnosed with PMDD will attempt suicide and are four times more likely to experience suicidal ideation. Therefore, it is imperative for those living with PMDD to receive treatment and social support to navigate their sometimes debilitating symptoms. 

PMDD can be an incredibly isolating disorder due to taboos surrounding menstruation and social stigma about women’s emotions, along with a lack of widespread knowledge about PMDD. Many people living with PMDD may believe that they have no one to lean on when experiencing their symptoms, which can make working with a therapist helpful for accessing social support. Speaking with a trusted loved one as well as connecting with others experiencing PMDD, either through a support group (such as that offered by the IAPMD, which can be found here) or listening to a podcast normalizing PMDD experiences, can be vital. The PMDD Project has a YouTube series discussing living with PMDD, offering tips and helpful perspectives, which can be found here.

PMDD can be confusing to live with due to its cyclical nature and intense mood symptoms. While PMDD can be an isolating condition to live with, there are fantastic resources available. Given the various treatment options available, working with a gynecologist to find an effective treatment can lead to life-changing results. Additionally, working with a therapist who is knowledgeable about women’s health, and PMDD in particular, can reduce feelings of shame and stigma related to the disorder.