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Premenstrual Dysphoric Disorder: Signs, Causes, and Possible Treatment

Premenstrual dysphoric disorder (PMDD) is classified as a severe mood disorder. It can be characterized by intense emotional and physical changes that occur in the week before menstruation begins. It is believed to be an extremely common condition that affects millions of people around the world.

There are some commonalities between PMS and PMDD. In both conditions, symptoms usually start about a week before menses. They typically resolve before menstruation ends. Both conditions can cause physical and affective symptoms, including bloating, cramping, breast tenderness, fatigue, and alterations to sleep.

Despite these similarities, PMDD is not the same as PMS. The American Psychiatric Association states that PMDD also causes intense sadness, anxiety, extreme moodiness, or excessive irritability or anger. While PMS is often uncomfortable and frustrating, PMDD can be debilitating and have a significant effect on a person’s career and personal life.

  • Common symptoms: fatigue, bloating, irritability, depression, sadness, and anxiety
  • Less common/more severe symptoms: hopelessness, feelings of worthlessness, lethargy, persistent and uncontrollable anger or irritability, tension and anxiety, variable moods and tearfulness, difficulty concentrating and sleeping, significant appetite changes, feeling overwhelmed or a lack of control, decreased interest in normal activities

PMDD can be difficult to recognize because it shares symptoms with many other mental health conditions, including depression, anxiety, and bipolar disorder. With PMDD, there should be a complete resolution of symptoms after menstruation. If symptoms do not fully abate, then a care provider may alternatively consider a coexisting mental health condition for diagnosis and treatment.

It is also not uncommon for migraines, chronic fatigue syndrome, pelvic and bladder pain, and irritable bowel syndrome to worsen before or during menses. Your care provider should be able to help you determine whether you are suffering from PMDD, another condition, or multiple at the same time.

Frustratingly, the exact cause of PMDD is not clear. There are a variety of factors at play, including hormones, timing of the condition, and sensitivity to hormone levels.

  • Hormones and neurotransmitters: Body tissues are sensitive to the rise and fall of hormones during the menstrual cycle. The changing levels of estrogen, progesterone, and serotonin all may play a role in the development of PMDD.
  • Timing: PMDD often has underlying mood symptoms like depression and anxiety. While there is no clearly defined relationship between hormones and PMDD, the presence of PMDD symptoms at a specific time in the menstrual cycle suggests there is some sort of hormonal link.
  • Sensitivity: Because not everyone who gets a period develops PMDD, researchers’ educated guess is that some bodies are more sensitive to hormonal fluctuations. This sensitivity may then lead to the development of PMDD.

Though biological causes of PMDD are still uncertain, there are some known risk factors that may contribute to its development. These include a history of past traumatic events (PTE), cigarette smoking, and obesity. The links between each of these risk factors are still unclear.

Currently, there is not a single test that providers use to test for PMDD or PMS. However, don’t let this discourage you from seeking help. If you feel that your premenstrual symptoms aren’t normal, schedule a visit with your health care provider.

At your appointment, your care provider is going to want to take a detailed mental and physical history. They may also want to perform a pelvic exam, especially if you’re due for one. They may ask you to keep a daily journal of both your mood and physical symptoms to bring in to a subsequent visit.

The following are potential criteria for diagnosis of PMDD: 

  • At least five symptoms that occur only during the second half of the menstrual cycle (typically the 5–7 days before menstruation)
  • At least one symptom is mood-related
  • Presence of both physical and behavioral symptoms
  • Symptoms that mostly subside after menstruation

These are some of the potential reportable symptoms:

  • Angry outbursts, anxiety, confusion, depression, irritability, and social withdrawal
  • Bloating, headache, joint or muscle pain, weight gain, breast tenderness and swelling

Typically, treatment will not be suggested or initiated unless you have been exhibiting symptoms for at least 3–6 cycles. 

Without treatment, PMDD is a chronic condition that can significantly impact quality of life. Fortunately, there are a variety of ways you and your care provider can choose to treat your symptoms and regain some control of your life.

Treatments and therapies for PMDD don’t cure the condition. Instead, they minimize symptoms and improve any impairment(s) caused by them:

  • Lifestyle and diet changes: Cutting back on caffeine, alcohol, and smoking is often strongly encouraged. Many patients are encouraged to exercise more, as exercise has been shown to reduce PMS symptoms. Engaging in mindful stress-reducing practices like yoga or meditation may also be encouraged.
  • Cognitive behavioral therapy (CBT): Also known as “talk therapy,” CBT may be helpful for some people with PMDD. Further research in this area is still needed.
  • Nutrition supplements: Talk with your health care provider before taking them. Some people believe that calcium, omega-3 fatty acids, ginkgo biloba, Crocus sativus, or evening primrose oil can help reduce symptoms.
  • Birth control pills: Though there is limited research proving their effectiveness, oral contraceptives are often prescribed to treat both the physical and behavioral symptoms of PMDD and PMS.

Currently, the American College of Obstetricians and Gynecologists (ACOG) recommends that alternative non-medical treatments like supplements, exercise, and lifestyle changes are more appropriate for the treatment of PMS vs. PMDD.

It is normal to experience both emotional and physical discomfort in the days leading up to menstruation. However, these symptoms should not be so bad that they significantly impact your work, your family, or your other relationships. If you find that your premenstrual struggles are consistently affecting your life, start paying attention. Consider starting a daily journal to bring to an appointment with your medical care provider so they can prescribe appropriate treatment — no one should have to live with debilitating PMDD symptoms.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4890701/

https://www.mayoclinic.org/diseases-conditions/premenstrual-syndrome/expert-answers/pmdd/faq-20058315

https://www.uptodate.com/contents/premenstrual-syndrome-pms-and-premenstrual-dysphoric-disorder-pmdd-beyond-the-basics

https://www.aafp.org/afp/2016/0801/p236.html

https://www.health.harvard.edu/womens-health/treating-premenstrual-dysphoric-disorder

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