Living with
Premenstrual Dysphoric Disorder (PMDD)

Premenstrual Dysphoric Disorder (PMDD)

Premenstrual Dysphoric Disorder (PMDD) is a severe form of premenstrual syndrome (PMS). It differs from PMS, in that the symptoms include a mood disorder like anxiety or depression and it interferes with daily functioning of women to such a degree that they need medical treatment. 

It’s estimated that about 80% of women experience mild premenstrual symptoms, between 20% and 50% have moderate-to-severe premenstrual symptoms, and between 3 and 8% report severe symptoms that would be diagnosed as premenstrual dysphoric disorder (PMDD)*. 

PMDD adversely affects the quality of life of women, impairing their family, social and professional life, stemming mostly from reduced productivity and effectiveness at work or school. 

The condition can be chronic and symptoms of PMDD can last until menopause. PMDD is treated with lifestyle changes, cognitive behavioural therapy and medication. 

*Pearlstein, T., & Steiner, M. (2008). Premenstrual dysphoric disorder: Burden of illness and treatment update. Journal of Psychiatry & Neuroscience. 33(4), 291–301. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2440788/  

What is Premenstrual Dysphoric Disorder?

Premenstrual dysphoric disorder is a severe form of premenstrual syndrome (PMS) that is characterised by intense mood swings and cognitive fluctuations, along with distressing mental and physical symptoms that disrupt normal daily functioning. Like PMS, symptoms occur during the second half of the menstrual cycle (the luteal phase). PMDD is a chronic condition that necessitates treatment when it occurs. 

Symptoms

PMDD symptoms appear a week or two before menstruation and go away within a few days after the period starts. Along with PMS symptoms, the woman may experience: 

• headaches
• fatigue and low energy
• feelings of sadness or hopelessness
• anxiety or panic attacks
• mood changes or increased sensitivity
• feelings of anger or irritability
• apathy to routine activities, which may be associated with social withdrawal
• dysphoria (a feeling of unease or dissatisfaction with life)
• difficulty concentrating
• sleeping problems, excessive sleeping (hypersomnia) or insomnia
• feeling overwhelmed or having a sense of a lack of control
• sensory sensitivity 

Other physical symptoms include: breast tenderness or swelling, joint or muscle pain, abdominal bloating and gastrointestinal upset, increased appetite, backache, muscle spasms, numbness or tingling in the extremities, respiratory complaints, such as allergies and infections, decreased libido, easy bruising, heightened sensitivity. 

Causes

While the exact cause of PMDD and PMS remains unclear, there are various theories to explain why it occurs, including the: 

• Serotonin hypothesis, which theorises that the normal ovarian hormone function (rather than hormone imbalance) is the trigger for PMDD-related biochemical events within the central nervous system (CNS), which causes the dysregulation of the neurotransmitter, serotonin, primarily, as well as other neurotransmitter systems: the opioid, adrenergic, and gamma-aminobutyric acid (GABA) systems. 

• Ovarian hormone hypothesis, which suggests that PMDD is caused by an imbalance in the estrogen-to-progesterone ratio, and a progesterone deficiency. 

• Psychosocial hypothesis, which hypothesises that PMDD or PMS comes from the woman’s own unconscious conflict about femininity and motherhood. 

• Sociocultural theory, which proposes that the onset of menses is an aversive psychological event for women susceptible to PMDD. 

Risk factors

Women who are predisposed to PMDD, include those with: 

• a family history of postpartum depression, PMS, PMDD or mood disorders 

• pre-existing depression or anxiety disorders 

• autism – autistic people generally have greater sensory sensitivity, and therefore may be more likely to be negatively affected by menses-related symptoms. 

• ADHD – since people with ADHD have reduced dopamine levels, hormone fluctuations may be more likely to reduce dopamine to critically low levels, leading to more severe feelings of exhaustion, moodiness, and lack of motivation. 

• elevated stress following traumatic events such as rape, combat, bereavement and motor vehicle accidents. 

• personality traits of neuroticism and perfectionism, because of the link to overall negative mood and vulnerability to stress. 

Studies have shown that PMDD disproportionately affects women with autism and ADHD. 

Complications 

PMDD causes emotional distress that affects relationships and careers. It is also associated with poor quality sleep. Left untreated, PMDD poses a greater risk for depression and anxiety disorders, and in severe cases, can even lead to suicidal tendencies. 

How is it diagnosed? 

When evaluating a patient for PMDD, the first step is to rule out conditions with symptoms similar to those of PMDD, such as thyroid disorders, anaemia, perimenopause, menopause, fibroids, endometriosis, anxiety or depression. Therefore, health care providers will do a physical exam, take a medical history, and other certain diagnostic tests when making a diagnosis. The patient would have to track symptoms for two menstrual cycles to determine any correlation between the symptoms and the menstrual cycle. 

According to the guidelines from the American Psychiatric Association (APA) Diagnostic and Statistical Manual 5th Edition (DSM-V), the symptoms of PMDD must be present for a minimum of two consecutive menstrual cycles before making a diagnosis of PMDD, and must: 

• be present a week before the onset of menses
• resolve after the start and within the first few days of flow
• interfere with normal daily living 

To be diagnosed with PMDD, a woman must experience at least five symptoms (as listed above), including one mood disorder, such as: 

• feelings of sadness or hopelessness 

• feelings of anxiety or tension 

• mood changes or increased sensitivity 

• feelings of anger or irritability 

Some women do find that getting a diagnosis of PMDD can be difficult because, firstly, it’s not well known amongst health care professionals and, secondly, it can take a long time to realise that symptoms follow a cycle and that they are linked to the woman’s period. 

Treatment 

There are several treatment options available and health care providers may use a combination of the following: 

1. Medication: 

• Antidepressant medications (to regulate neurotransmitter levels): fluoxetine, sertraline, paroxetine, citalopram, escitalopram, venlafaxine extended release. 

• Hormone therapy (to suppress ovulation): Hormonal birth control (ethinylestradiol & drospirenone), Gonadotropin-releasing hormone analogs, danazol 

• Anxiolytics (anti-anxiety) such as buspirone 

• Diuretics 

• Other medications for physical symptoms:

• for mastalgia (breast pain): Bromocriptine (a dopamine receptor agonist) 
• for bloating: Spironolactone 
• for cramps, pain: over the counter, nonsteroidal anti-inflammatory medications 
  

2. Surgery: 

In very severe cases, where some patients may want to get rid of their PMDD symptoms permanently, health care professionals could offer a total hysterectomy (an operation to remove your uterus) with bilateral salpingo- oophorectomy (removal of the ovaries and fallopian tubes) or an oophorectomy alone. 

3. Nonpharmacologic treatments: 

• Cognitive Behavioural Therapy (CBT). Based on the rationale that PMDD is an exacerbation of normal premenstrual physiological and mood changes, CBT teaches patients ways of examining negative thought patterns and replacing them with more adaptive ways of viewing life events. CBT for PMDD includes anger control, thought stopping, and reduction of negative emotions through cognitive restructuring. 

• Interpersonal therapy (IPT). This approach uses the ‘buffering’ role of satisfying interpersonal relationships and strong social support on depressive symptoms and mood swings, by enhancing their interpersonal skills, and their partner’s, in order to cope better. 

• Dietary changes, such as cutting back on refined sugar, salty and fatty foods, caffeine and alcohol. 

• Regular exercise, specifically strength training or aerobic exercise, to improve mood. 

• Stress management tools such as deep breathing exercise and meditation. 

• Support groups, where one has access to a mental health professional or a group of women living with PMDD may be helpful. 

• Light therapy, bright white light therapy (sunlight or artificial light that resembles it) showed that the bright light condition significantly reduced depression and premenstrual tension scores when symptoms appear. 

4. Supplementation: 

• vitamin B complex
• calcium
• vitamin E
• magnesium
• kelp
• L-tyrosine
• multivitamin-mineral complex with manganese
• vitamin C with bioflavonoids
• evening primrose oil
• chasteberry
• St. John’s wort
• gingko 

* Please note that supplements are not evaluated by the South African Health Products Regulatory Authority (SAPHRA) for efficacy. Therefore, when choosing your supplement, always check if there is a full list of ingredients on the product, a package insert, a valid company address with contact details and compliance to Good Manufacturing Practices (GMP), which is a prerequisite for health product manufacturing.  

Prevention 

By treating existing depression or anxiety, its less likely that PMS could become PMDD. PMDD is also related to hormones, which makes it difficult to prevent, though treatment can bring relief. 

Living and Managing 

If you’ve been diagnosed with PMDD, here are a few tips to living with your condition: 

1. Know your cycle 

Use a period tracking app or a calendar to track your cycle and the symptoms, so that you can predict when your symptoms will appear (e.g. Me v PMDD Symptom Tracker is specifically for PMDD). You could, for instance, rearrange stressful events, tasks, or travel for another time or plan relaxing activities that you know will improve your mood during that time. 

2. Talk to someone you trust 

Sharing your experiences with family and friends and having someone listen to your experiences and your mental and health problems is important for getting the support you need. 

3. Look after your emotional health 

• Manage your stress by learning coping techniques and doing activities that help you relax. 

• Spend time in nature. When you walk barefoot on the ground, for example, research shows that the Earth’s electrons transfer from the ground into the body, reducing pain and improving sleep. Forest bathing is similar to natural aromatherapy, and has shown to decrease anxiety, depression, and anger in those who spend time in a forest. 

• Try a mindfulness practice. 

4. Look after your physical health 

• Get enough sleep. Poor sleep quality affects mood and your physical health. See our resource on sleep hygiene. 

• Change your diet: o Eat small, frequent meals to combat bloating and stomach upset. 

• Eat plenty of fruits and vegetables. 
• Choose complex carbs such as whole grains over processed carbs. 
• Avoid salt and salty snacks. 
• Avoid caffeine. 
• Avoid alcohol. 
• Eat high-protein foods to help increase tryptophan levels. For healthy diet tips and recipes, see our Cooking from the Heart series. 

• Work some exercise into your schedule. While it may be hard to exercise when you are experiencing physical symptoms, research has shown that exercise can help reduce symptoms of depression. See our resource on exercise ideas.

• If you are a smoker, try to quit smoking. 

Phases of the menstrual cycle 

1. The menstrual phase – from the start of the period till the end (typically about 3 – 8 days). 

2. The follicular phase – from the start of the period (which overlaps with the menstrual phase) till ovulation (between 10 – 16 days). 

3. The ovulation phase – when the mature eggs travels from the ovary down into the womb; typically occurs during the middle of the menstrual cycle (1 day). 

4. The luteal phase – from ovulation to the start of the period; this is when women experience PMS (typically 14 days). 

The length of each phase varies from person to person, and changes over time with age.