What is Premenstrual Dysphoric Disorder (PMDD)?

Premenstrual dysphoric disorder (PMDD) is a severe form of premenstrual syndrome (PMS). While the physical and emotional PMS symptoms are more commonly known, they are also experienced at varying severity by 80-90% of women or individuals of reproductive age assigned female at birth, whereas about 2-8% of women suffer from PMDD. It should be noted that due to a lack of public awareness on PMDD and inadequate concern among the medical community along with underfunded research on this syndrome, the number of individuals affected could be much higher. 

Photo by Yuris Alhumaydy on Unsplash

Understanding PMDD and its Symptoms:

PMDD is classified in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders as a depressive disorder among women or individuals of reproductive age assigned female at birth. PMDD is not caused by a hormonal imbalance, but can be described as a negative reaction in the brain due to the naturally varying levels of estrogen and progesterone during the luteal phase of the menstrual cycle, which is the phase that begins right after ovulation. The article, “The Etiology of Premenstrual Dysphoric Disorder: 5 Interwoven Pieces” by doctors Edwin Raffi and Marlene Freeman describe the disorder, “of consistent yet intermittent changes in mental health and functionality,” and suggests for individuals to track symptoms for at least two months in order to be properly diagnosed. The emotional symptoms they list include:

• Mood swings (sudden sadness, tearfulness, or heightened sensitivity)

• irritability, anger, or increased interpersonal conflicts

• depressed mood, hopelessness, or self-deprecating thoughts

• anxiety or tension

The behavioral/cognitive symptoms they list are:

• decreased interest in usual activities (eg, work, hobbies, friends, school)

• difficulty concentrating

• lethargy, low energy, easy fatigability

• change in appetite, overeating, food cravings

• hypersomnia or insomnia

• feeling overwhelmed or out of control

• physical symptoms (breast tenderness or swelling, headache, joint or muscle pain, bloating, inflamed gums, weight gain, and more).

Research-Based Causes and Possible Contributors to PMDD:

What is the cause of PMDD? Raffi and Freeman suggest five interwoven variables that influence each other, summarized below:

1. Genetic susceptibility

2. Progesterone and allopregnanolone (ALLO): studies show patients with PMDD have lower levels of ALLO, a naturally occurring neurosteroid made from progesterone that interacts with gamma-aminobutyric acid (GABA) receptors for emotional regulation

3. Estrogen, serotonin, and brain-derived neurotrophic factor (BDNF): Studies on animals with removed ovaries and menopausal women have shown estrogen does induce changes related to serotonin metabolism. The neurotransmitter BDNF is also linked to estrogen, and is expressed in the regions of the brain involved in learning and memory 

4. Putative brain structural and functional differences

5. Trauma: High cortisol levels, histories of trauma, PTSD, and increased levels of proinflammatory markers were all found in some women with PMDD, suggesting a strong correlation between these disorders and PMDD

Recognizing PMDD Symptoms are Important. Here’s Why:

Individuals with PMDD are at increased risk for suicide and suicidal thoughts or self-harm.

If you or an individual you know is in crisis and needs help:

• Call 911 to reach emergency services or go to the nearest emergency hospital

• Call or text 988 to connect with the 988 Suicide & Crisis Lifeline, a 24 hour, confidential support lifeline for anyone who is in emotional distress or is having thoughts of suicide. The lifeline can also be reached via live chat.
  

In addition to centuries of gender bias in medicine, and because women were not required to be in clinical research until 1993, women’s health is severely understudied and underfunded. This means the efficacy of drug treatment, from accurate dosing to potential side effects, are based on research that was performed only on male bodies, and the consequences range from undertreating or even overtreating conditions to complications, which all greatly reduce the quality of life and increase the risk of fatalities. 

Treatment for PMDD:

Prescription medication: serotonergic antidepressants such as 20 mg of fluoxetine have been shown to be effective whether used daily and throughout the full menstrual cycle or only during the luteal phase. Other commonly used drugs and the recommended usage timeline and side effects listed in this article include citalopram, paroxetine, sertraline, clomipramine, and alprazolam. This AAFP article also highlights other treatment options such as hormone therapy.

Lifestyle changes: exercising can help reduce symptoms. Reducing caffeine intake can help with lowering anxiety. Reducing alcohol intake and stopping smoking can help with inflammation that PMDD can cause all over the body. Reducing sodium intake can help with bloating. And of course, meeting your body’s sleeping needs is just as important for all of the previously mentioned symptoms, from irritability to bloating to inflammation.

Nutritional Supplements: vitamins like 1,000 mcg of vitamin B12 and 100 mg of vitamin B6 daily are known to reduce feelings of depression in patients. Calcium is another supplement that can help reduce symptoms of PMDD. It is recommended you speak to your doctor before starting any vitamins or supplements to prevent any interference or absorbency issues with medication or other supplements you might be taking.

Therapy: Therapy is effective not just for your overall mental health but can greatly reduce stresses and worries that can trigger or worsen symptoms of depression that tend to increase in individuals before and during menstruation.

Photo by Hannah Busing on Unsplash

If the symptoms presented here are familiar to you or you think you have PMDD, your struggle is validated and you are not alone. There are steps you can take to improve your quality of life, such as the ones outlined here, but they may vary by individual case and will not look the same for every individual who has PMDD. 

Maybe you’d like to try taking holistic treatments such as exercising, cutting back on unhealthy habits, and taking the appropriate vitamins and supplements first. Or maybe you’d like to learn more from your healthcare provider and seek medication. We only hope this information empowered you and helped lessen the feelings of isolation we often face when struggling with a misdiagnosed or undiagnosed condition. 

Increasing access to education, resources, and research on women’s health issues is a necessary step forward towards closing the gender gap. 

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Sources

Bhatia, Subhash C, and Shashi K Bhatia. “Diagnosis and treatment of premenstrual dysphoric disorder.” American family physician vol. 66,7 (2002): 1239-48.

Hantsoo, Liisa. “What Is PMDD? Premenstrual Dysphoric Disorder.” IAPMD, 14 Jan. 2019, iapmd.org/about-pmdd.

Raffi, Edwin, and Marlene P. Freeman. “Diagnosis, etiology, and treatment of premenstrual dysphoric disorder.” DeckerMed Psychiatry, 2018, https://doi.org/10.2310/psych.13018.

Tiranini, Lara, and Rossella E Nappi. “Recent advances in understanding/management of premenstrual dysphoric disorder/premenstrual syndrome.” Faculty Reviews, vol. 11, 2022, https://doi.org/10.12703/r/11-11. 

US Food and Drug Administration. Guideline for the study and evaluation of gender differences in the clinical evaluation of drugs; notice. Fed Register 1993; 58: 39406.

Ward, M W, and T D Holimon. “Calcium treatment for premenstrual syndrome.” The Annals of pharmacotherapy vol. 33,12 (1999): 1356-8. doi:10.1345/aph.19023

Wyatt, K M et al. “Efficacy of vitamin B-6 in the treatment of premenstrual syndrome: systematic review.” BMJ (Clinical research ed.) vol. 318,7195 (1999): 1375-81. doi:10.1136/bmj.318.7195.1375