Premenstrual Dysphoric Disorder (PMDD)

Premenstrual dysphoric disorder, abbreviated to PMDD, is a severe type of premenstrual syndrome (PMS). The majority of people who menstruate experience cyclical physical and emotional changes in the days leading up to their period, such as tender breasts and mood changes. The type and extent of premenstrual symptoms experienced varies from person to person; PMS may be very mild or more serious. In a small number of women, monthly PMS symptoms may be severe, possibly leading to a diagnosis of PMDD. 1 2

Symptoms of PMDD are generally similar to symptoms of PMS, but are significantly more intense. In PMDD, psychological symptoms may be more prominent. 2 Common symptoms of PMDD include: 3 ref4

• Irritability
• Anger
• Anxiety
• Depression
• Tiredness
• Tension
• Bloating

PMDD symptoms typically develop roughly 5-14 days before menstruation and generally interfere with a person’s wellbeing and daily life, for example by making interpersonal conflict more likely. Symptoms of premenstrual dysphoric disorder should go away within a few days of menstruating. 4 5

Concerned that you or a loved one may have this condition? Start your symptom assessment in the free Ada app.

The exact causes of PMDD are not clearly understood, though there is a clear link to the hormonal changes that a woman experiences as part of her monthly menstrual cycle. Some research suggests that women who have PMS or PMDD may be sensitive to rising levels of the hormone progesterone, the level of which increases after the release of an egg from the ovaries (ovulation) each month. It has been suggested that fluctuating hormone levels, that occur during the menstrual cycle, may affect levels of the neurotransmitter serotonin in the brain and thus impact a person’s mood. 6 5

Treatment for PMDD is available. This may include one or more of the following: 2

• Lifestyle changes
• Supplements and natural remedies
• Psychotherapy
• Antidepressant medication
• Hormone therapy, e.g. birth control pills
• Surgery

With treatment strategies, most women are able to effectively manage the symptoms of PMDD. The condition may seem to come and go, and some months may be worse than others. PMDD will not be present after menopause. 6 5 7

PMDD is thought to affect an estimated 5-8 percent of women of all races and backgrounds. 4 2 8 Because many of the symptoms can be caused by – or mistaken for – other conditions, e.g. depression or thyroiditis, it is necessary to undergo a thorough health check before a diagnosis of premenstrual dysphoric disorder can be made. 6

Symptoms of premenstrual dysphoric disorder may vary from person to person and from one menstrual cycle to the next, but commonly include the following: 3 4 2 6 5 7 8 9

• Severe irritability; this is often the most prevalent symptom 8
• Extreme anger or aggression, rage
• Severe anxiety and/or tension
• Low self-esteem
• Lasting sadness
• Feelings of hopelessness
• Feeling overwhelmed or out of control
• Low mood or depression
• Mood swings
• Loss of interest in activities that are usually enjoyable
• Forgetfulness and difficulty concentrating
• Sleep disturbances, e.g. sleeping more or less than usual
• Appetite changes and/or food cravings

• Tiredness
• Lethargy, lack of energy
• Breast swelling and tenderness or pain
• Bloating
• Nausea
• Diarrhea
• Weight gain
• Headaches
• Muscle and/or joint aches
• Swelling of the hands and/or feet

While mild forms of these psychological and physical symptoms may be experienced in regular PMS, many of them are more extreme in PMDD. Symptoms are typically so severe that they interfere with the person’s ability to go about their daily life, for example, they may experience increased conflict with loved ones or difficulties focusing on work, causing great distress. 10

PMDD symptoms typically develop between a few days and two weeks before menstruation, worsening in the build-up to and peaking about two days before, the period. The symptoms tend to disappear within a few days after the beginning of menstruation and are absent until ovulation has once again occurred.

While it is not yet completely understood what causes symptoms of premenstrual dysphoric disorder or premenstrual syndrome to develop in certain women, it is known that changing hormone levels play a key role. 6 5

It is thought that fluctuations in hormones following the release of an egg (ovulation) as part of the monthly menstrual cycle may affect the levels of serotonin and other neurotransmitters in the brain, causing many of the psychological symptoms that characterize PMDD. Some women may be more sensitive than others to the effects of an increased level of progesterone in the body, which naturally occurs after ovulation, in the luteal phase of the menstrual cycle. 8

Today, it is generally agreed that PMDD is not caused by an “imbalance” in a person’s hormones, a theory that was once proposed as an explanation for the disorder. 6 5

A number of factors may make a person more likely to develop premenstrual syndrome or premenstrual dysphoric disorder. It is thought that these may include: 6 8 11 9 12 13

• Family history of PMS or PMDD
• Personal or family history of mental health conditions, e.g. depression or anxiety
• Stress
• Being overweight
• Being in one’s mid-20s or one’s 30s, which seems to be the average age range of onset; PMDD may worsen with age 14 15 16
• History of early-life abuse

Diagnosis of premenstrual dysphoric disorder can only be made by a medical professional, after careful consideration of the person’s symptoms. A doctor will usually begin by taking the person’s medical history and performing a physical examination. Though there are no specific laboratory tests for PMDD, blood tests may be ordered to rule out other conditions that may be causing symptoms, such as anemia or an underlying thyroid disorder. 3 8

The doctor will ask questions about the symptoms being experienced. To provide detailed information on when they occur and how often, it is recommended that anyone who is concerned that they may have PMDD, keep a daily symptom diary or chart for 2-3 months, including severity ratings of symptoms and dates of menstruation. 3 9 Details can be recorded in a notebook or by using a specialized app designed for people affected by PMDD, several of which exist. The free Ada app can also help track symptoms. Download the app or find out more about how it works.

According to the criteria set out in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), for a PMDD diagnosis to be made, at least five of the following symptoms must be present cyclically during most menstrual cycles over the preceding year. These symptoms need to include at least one of the first four on the list. 8

• Depressed mood, feeling hopeless, negative thoughts about oneself
• Anxiety, tension, feeling “on edge”
• Unstable emotions, e.g. suddenly becoming sad or a heightened sensitivity to rejection
• Lasting anger or irritability, or an increase in fighting with loved ones
• Loss of interest in activities that are normally enjoyed
• Difficulty concentrating
• Lethargy, becoming tired easily or lack of energy
• Appetite changes, eating too much or food cravings
• Sleep disturbances, including sleeping too much or insomnia
• Feeling overwhelmed or out of control
• Physical symptoms, e.g. tender breasts, headaches, body pain, bloating

For a diagnosis of PMDD to be made, the symptoms need to be present most of the time during the week before menstruation and go away within a few days after menstruation begins, being absent in the week after the period.

Additional criteria require that: 8

• Symptoms must be so severe that they significantly interfere with the person’s daily functioning
• Symptoms must not be caused by another disorder, e.g. depression or bipolar disorder
• Symptoms must be documented and rated on a daily basis by the person, for a minimum of two menstrual cycles

In many cases, a person’s symptoms may be related to a different condition. Symptoms of major depression, anxiety, bipolar disorder and other mental health conditions may become worse in the build-up to menstruation, which may lead to them being mistaken for PMS or PMDD. This is called premenstrual exacerbation (PME) of symptoms. 9 17

It is generally possible to tell the difference between PMDD and another disorder by tracking symptoms over a few months. PMDD symptoms are expected to be cyclical and only present for a few days to two weeks before one’s period. However, symptoms of a mood disorder like depression are expected to be also present, to some degree, outside of that pattern. Furthermore, during pregnancy or after menopause, PMDD symptoms will not be present. Differentiating PMDD from other mental health conditions is important, as treatment approaches differ. 9 17

It is possible to have both PMDD and another condition, like depression. 17

There are a number of possible treatments for premenstrual dysphoric disorder. These include antidepressant medications, hormone therapies, lifestyle changes and other remedies. The most appropriate treatment strategy for a particular person will be determined after considering their symptoms, general health, circumstances and preferences.

Medication recommended for the treatment of PMDD includes antidepressants, hormone therapy and painkillers.

In many cases, a doctor will recommend a low dose of an antidepressant for the treatment of PMDD. This will usually take the form of a selective serotonin reuptake inhibitor (SSRI) or selective serotonin and norepinephrine reuptake inhibitor (SNRI), which may increase the levels of serotonin in the brain and provide relief from symptoms of PMDD, particularly mood symptoms. This type of medication does not suppress ovulation. While considered effective for many people, SSRIs may cause unpleasant side-effects in some women and might not be suitable for everyone. 6 5 8 11 9 14

Birth control: Some women may find relief from PMDD symptoms with the use of a combined oral contraceptive pill which contains synthetic forms of estrogen and progesterone, the hormones involved in the menstrual cycle. By preventing ovulation from occurring each month, these hormonal contraceptive pills may help to reduce premenstrual symptoms. However, they may cause unpleasant side-effects and may not provide relief for everyone, even worsening cyclical symptoms in some cases. 3 4 6 5 8 14

Estrogen patch: Another option is an estrogen patch, gel or implant, which also suppresses ovulation. However, this may cause unpleasant side-effects in some women, and those who have not had a hysterectomy will need to take a progesterone medication, too, to lower the risk of developing uterine cancer that may be otherwise associated with this treatment. 6 5 8 11

Good to know: Taking a progesterone-only supplement is not considered an effective treatment for PMDD and should be avoided, unless it forms part of a combined hormone therapy recommended by a licensed doctor. 5 11

Gonadotropin-releasing hormone (GnRH) agonists: These medicines, which are usually administered in the form of an injection, trigger a temporary menopause, providing relief from PMDD symptoms. However, they can cause very unpleasant side-effects and are only recommended in severe cases of PMDD where other treatments have not worked. GnRH medicines typically need to be taken with hormone replacement therapy (HRT) to prevent the development of menopausal symptoms and to reduce the risk of bone weakening and osteoporosis that may occur with long-term use. 6 5 8 11

Benzodiazepines: These anti-anxiety drugs may sometimes be recommended for relief from symptoms of PMDD, particularly anxiety. However, they are highly addictive and should be used with extreme caution, if at all. 9

Nonsteroidal anti-inflammatory drugs (NSAIDs): These and other types of painkillers may be recommended for relief from pain that occurs as part of PMDD. 4 8

Some women may find talk therapy in the form of cognitive behavioral therapy (CBT) helpful in the management of PMDD symptoms. 6 5 14 CBT may be recommended as part of a combined treatment approach or, in some cases, on its own.

Reducing stress: Taking steps to lower one’s stress levels by using relaxation techniques like yoga and meditation, practicing self-care and carefully scheduling work and other commitments, may be helpful. Tracking one’s menstrual cycle using a diary or app may be useful in anticipating the onset of troublesome symptoms of PMDD and planning around them. 2 6 5 14

Diet: It is thought that reducing one’s intake of caffeine, e.g. in coffee and tea, as well as sugar, salt and alcohol in the lead-up to menstruation may help to improve premenstrual symptoms to some extent. Eating complex carbohydrates, e.g. whole grains and starchy vegetables, instead of simple carbohydrates such as white bread and pastries, may also be recommended. In addition, increasing consumption of high-protein foods and having small meals throughout the day, rather than three large meals, may have a positive effect in some women. However, more research is needed on the relationship between diet and premenstrual tension. 10 5 8 11 18

Exercise: Getting regular exercise is often recommended as part of the management of premenstrual symptoms, and many women may find it helpful. However, while moderate exercise is generally considered beneficial in promoting good health, further research is needed to confirm how effective it is in relieving symptoms of PMDD. 2 6 5 8 11 14 18

Stopping using tobacco products: It is recommended that a person quit using tobacco products to help with the treatment of PMDD or PMS. 2

Before taking any supplement or natural remedy for PMDD, it is important to consult a doctor. Some supplements and natural remedies may cause side-effects, or interact or interfere with medications, and may not be suitable for everyone.

Calcium: Taking a calcium supplement in the luteal phase of the menstrual cycle, i.e. the lead-up to menstruation, has been shown to help with many premenstrual symptoms, including low mood, tiredness and bloating. The dose used in studies was 500-1200mg of calcium daily, in the form of tablets containing calcium carbonate, taken from 7-10 days after the start of a period. Further research is needed on the efficacy of calcium supplementation in PMDD specifically. 8 14 18 19

Magnesium: Though the results of studies have been mixed, and further research is needed, it is thought that taking a magnesium supplement may help to relieve some premenstrual symptoms in some women, such as water retention. 8 14 20

Vitamin B6: Also known as pyridoxine, it is thought that vitamin B6 may help to relieve premenstrual symptoms in some women. However, further research is needed. If a supplement is taken, it should not exceed 100 mg/day, as very high doses of vitamin B6 can lead to peripheral neuropathy, damage to nerves in the hands and feet. 10 14 18

Chasteberry: Also known as vitex agnus-castus, it is thought that chasteberry may help to relieve premenstrual symptoms in some women. However, further research is needed. Due to the possibility of hormonal effects, chasteberry should not be taken by: 6 14 18 20 19 21 22 23 24

• Anyone who is trying to fall pregnant or is currently pregnant or breastfeeding
• Anyone who is on hormone-related medication, such as a birth control pill or HRT
• Anyone who has a hormone-sensitive condition, such as breast cancer

Furthermore, as chasteberry may affect the neurotransmitter dopamine, it should be used with caution and only under medical supervision in anyone who is on dopamine-related medication, such as antipsychotic drugs or drugs for Parkinson’s disease.

St. John’s Wort: Also known as hypericum perforatum, St. John’s Wort is a herb that is known to have antidepressant effects and may help to provide relief from premenstrual symptoms in some women. However, further research is needed on its efficacy. St. John’s Wort is known to interact with many drugs, including SSRIs and oral contraceptives. 14 18 20 19 25

Ginkgo biloba: It is thought that ginkgo leaf extract may help to relieve premenstrual symptoms in some women. However, further research is needed. Ginkgo supplements can cause serious side-effects, including increased risk of bleeding. The substance also interacts with many medications. 14 20 19

Evening primrose oil: Though popularly seen as a natural remedy for premenstrual symptoms, particularly breast tenderness, evening primrose oil has not been found to be effective in scientific studies and is not recommended for the treatment of PMDD. 8 14

Bright-light therapy: Involving the use of a special lamp or light box that emits frequencies of light similar to those experienced in bright sunlight, this type of therapy is believed to have potential in the treatment of PMDD, but further research is needed before it can be recommended by medical practitioners. 18

Acupuncture: Some women may report acupuncture as being of benefit in the relief of premenstrual symptoms. However, there is currently insufficient evidence to recommend it. 18

In severe cases of PMDD where other treatments have not been effective or suitable, surgery may be considered. This takes the form of a major procedure in which the ovaries and often also uterus (womb) are removed. Because the surgery results in the onset of menopause, PMDD symptoms can be expected to disappear permanently.

To prevent complications that can arise from early menopause, it is typically necessary to take estrogen in the form of hormone replacement therapy (HRT) after the surgery. Having a hysterectomy prevents a woman from being able to fall pregnant, so it is not considered an option for someone who may want to have children. Before recommending surgery, a doctor will typically suggest inducing a temporary menopause with (GnRH) agonists to see how well the person responds. 10 6 5 18 19

PMDDSevere PMSSevere premenstrual tension (PMT)Premenstrual disorder (PMD)Late luteal phase dysphoric disorder (outdated)

Q: What are the main PMDD symptoms?
A: While they vary from person to person, common symptoms of premenstrual dysphoric disorder that lead a woman to see a doctor include: 6

• Irritability
• Anger
• Anxiety
• Depression
• Tiredness

Q: When are PMDD symptoms the worst?
A: Symptoms tend to be most severe in the week before menstruation, peaking approximately two days before the period begins. 6

Q: Do I have premenstrual dysphoric disorder (PMDD)?
A: If you think that you might have signs of PMDD, try using the Ada app to find out more about your symptoms, and consult with a doctor. Only a licensed medical practitioner can diagnose a person with PMDD.

Q: Are PMDD and PCOS linked?
A: Premenstrual dysphoric disorder and polycystic ovary syndrome are not generally thought to be connected. The two are separate conditions and having one does not mean a person will also experience the other. PCOS is characterized by cysts on the ovaries and can cause irregular or absent menstruation, as well as other symptoms like excess hair growth and weight gain. It may also be associated with an increased risk of depression, anxiety and/or sleep disorders. 26 If you think that you might have signs of PCOS, try using the Ada app to find out more about your symptoms, and consult with a doctor.

Q: Can PMDD cause depression?
A: Premenstrual dysphoric disorder can cause symptoms of depression, which are expected to ease with menstruation each month. If depressive symptoms remain, it is advisable to consult a medical practitioner to rule out major depression and other types of depression, and other health conditions.

Q: Can PMDD make you suicidal?
A: Yes, in some cases PMDD can cause a person to have suicidal thoughts. They may feel overwhelmed and unable to cope, and struggle to see a way forward. However, it is important to remember that effective treatment is available. 27

If you are feeling suicidal, contact a helpline, doctor or emergency support services right away.

Q: Can PMDD last all month?
A: Because PMDD is related to the menstrual cycle, symptoms are not expected to be present all month. If symptoms of PMDD persist after menstruation and seem to be present throughout the menstrual cycle, it is advisable to consult a doctor about the possibility of other conditions being present, for example depression, bipolar disorder or a thyroid disorder.

Q: Does PMDD affect fertility?
A: Premenstrual dysphoric disorder is not thought to affect fertility, and has not been shown to be associated with infertility in a woman. 28

Q: Does PMDD get better after menopause?
A: Yes. Because ovulation and the menstrual cycle cease after menopause, PMDD can be expected to disappear too. This is the case in menopause that occurs naturally with aging, as well as menopause that is induced by medication or the surgical removal of the ovaries in younger women. 10

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