Premenstrual Dysphoric Disorder (PMDD)

What is premenstrual dysphoric disorder?

PMDD is believed to be an abnormal reaction to the body’s hormonal changes during the menstrual cycle^[1] and might be related to serotonin levels in the brain.^[2] However, the exact cause of PMDD is unknown.

PMDD involves an onset of symptoms one to two weeks before menstruation. These symptoms range widely from sleeplessness, panic attacks, and irritability to cramps, tiredness, and mood swings.^[2]

PMDD has a much broader range of effects that vary from person to person. One patient might experience a poor self-image, bloating, and headaches, while another might have severe acne, breast pain, and swollen extremities.

Symptoms of premenstrual dysphoric disorder

As noted above, the range of PMDD symptoms is quite extensive, and the symptoms might vary widely from one patient to another. Nevertheless, the most common PMDD symptoms can be categorized into seven distinct categories, as listed below:^[1][3]

• Psychological symptoms, such as irritability, nervousness, and depression, are highly common. Other emotional symptoms include moodiness, paranoia, and anxiety. In some cases, confusion, feeling out of control, and emotional sensitivity might also be present. Other possible psychological symptoms include agitation, anger, and crying spells.
• Gastrointestinal symptoms might include cramps, bloating, and constipation. Backache, pelvic heaviness, nausea, and vomiting are also common.
• Fluid retention often occurs with PMDD and includes periodic weight gain, breast fullness, and swelling, especially of the ankles, feet, and hands. Diminished urine output is common as well.
• Neurologic and vascular symptoms include dizziness, fainting, and headache. Muscle spasms, heart palpitations, and numbness or tingling in the arms and legs are also commonplace. In some instances, an increased propensity for bruising might occur.
• Skin problems are common for women with PMDD, including acne, skin inflammation, and itching. PMDD tends to aggravate skin disorders, too, including cold sores.
• Eye problems, such as infections and vision changes, may occur with PMDD.
• Respiratory problems, like allergies and infections, might be exacerbated by PMDD.

Yet other symptoms might occur that don’t fit well into these seven categories. For example, some women experience hot flashes, painful menstruation, and diminished coordination during bouts of PMDD. Moreover, food cravings (and even binge eating), appetite changes, and a diminished sex drive might also occur.^[1]

It’s important to reiterate that these symptoms might be debilitating for some women (which is a primary difference between PMDD and PMS). PMDD might cause significant interference with work, social engagements, and family obligations. 

The outlook for PMDD is quite good. The symptoms noted above may go away with proper self-care or professional treatment or, at the very least, diminish to tolerable levels.

Causes of premenstrual dysphoric disorder

As mentioned earlier, researchers are unsure of the exact cause of PMDD. However, what is better understood are the risk factors that make the development of PMDD more likely.

For example, many women with PMDD have comorbid conditions of general anxiety, depression, or Seasonal Affective Disorder (SAD).^[3] Furthermore, a history of trauma is associated with the development of PMDD^[4], as is a family history of PMDD, mood disorders, thyroid disorders, or substance abuse.^[3]

Other research shows links between cigarette smoking (particularly during adolescence) and the onset of severe PMS or PMDD^[5], as well as a link between obesity and PMDD.^[6] Genetics might also play a role - twin studies seem to support the hypothesis that genes responsible for some serotonergic and estrogen receptors are related to developing severe PMS or PMDD.^[7][8]

Diagnosing premenstrual dysphoric disorder

While there is no specific test that doctors can use to diagnose PMDD, there are many instruments they can utilize to assist in making an informed diagnosis. These might include:^[4]

• The Premenstrual Symptom Screening Tool (PSST) asks patients to rate their symptoms' severity using a 19-item questionnaire.
• The Daily Record of Severity of Problems (DRSP) groups symptoms and impairments into 11 distinct categories, each of which is rated on a six-point scale from “not at all” to “extreme.”
• The Calendar of Premenstrual Experiences (COPE) categorizes 22 common symptoms into four categories: fluid retention, mood, appetite, and cognitive/autonomic symptoms 

Additionally, a physician will likely perform a physical examination - including a pelvic exam and a thyroid test - as well as a psychiatric evaluation.^[3] These tests eliminate possible alternative causes for the reported symptoms rather than confirming PMDD. 

In many cases, patients are asked to maintain a symptom diary to track symptoms, when they occur, and how severe they are. Doing so can help medical professionals make a more informed diagnosis. 

Furthermore, doctors can rely on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), for guidance when determining a diagnosis. The DSM-5 classifies PMDD with depressive disorders. The diagnostic criteria are as follows:^[4] 

Criterion A (at least five of the following, including at least one of the first four listed):

• Markedly depressed mood, self-deprecating thoughts, or feelings of hopelessness
• Marked tension or anxiety, as well as feelings of being on edge or keyed up
• Marked affective lability
• Marked irritability or anger that is persistent, or frequent interpersonal conflicts
• Decreased interest in usual activities, including hobbies, time with loved ones, school, or work
• Subjective sense of difficulty in concentrating
• Lethargy, fatigue, or marked lack of energy
• Marked change in appetite, such as overeating or having cravings for specific foods
• Insomnia or hypersomnia
• A subjective sense of being out of control or feeling overwhelmed
• Other physical symptoms, such as weight gain, headaches, breast tenderness or swelling, joint or muscle pain, or bloating

Criterion B

• Symptoms significantly interfere with functioning in the social, scholastic, occupational, or sexual realms.

Criterion C

• Symptoms are related to the menstrual cycle and must not better represent the symptoms of another disorder (e.g., dysthymic disorder, panic disorder, major depressive disorder, or a personality disorder). However, PMDD symptoms might present in addition to the symptoms of another disorder.

Criterion D

• Daily ratings confirm the criteria in sections A, B, and C for two or more consecutive symptomatic menstrual cycles. But, a PMDD diagnosis can be provisionally made without this confirmation.

Prevention of premenstrual dysphoric disorder

There are currently no preventative measures for PMDD since the precise cause of the disorder isn’t yet fully understood. Some strategies can help manage PMDD symptoms, though.

For example, self-care, such as eating a healthy diet, avoiding stress, and exercising regularly, can help reduce some PMDD symptoms. Taking appropriate vitamins (e.g., calcium, magnesium, and vitamin B6), abstaining from caffeine and alcohol, and drug therapies (discussed in the next section) can help patients manage their symptoms as well.^[1][3]

Treatment for premenstrual dysphoric disorder

One of the simplest and most effective treatments for PMDD is making healthy lifestyle changes. For example, reducing stress through relaxation techniques and eating a well-balanced diet can help relieve some PMDD symptoms.

For example, cutting back on foods high in sugar or salt might help mitigate some symptoms.^[2] Adding regular exercise to the daily routine and participating in enjoyable activities can also help reduce symptoms.

There are common pharmacological treatments as well. In particular, antidepressants, birth control pills, and non-prescription pain relievers have proven efficacious in treating PMDD symptoms:^[2]

• Selective Serotonin Reuptake Inhibitors (SSRIs) are antidepressants that increase serotonin levels in the brain. Currently, three SSRIs have approval from the Food and Drug Administration (FDA) to treat this disorder, including fluoxetine, sertraline, and paroxetine.
• Birth control pills containing Ethinyl estradiol and drospirenone have FDA approval to treat PMDD symptoms.
• Pain relievers and anti-inflammatories like ibuprofen, aspirin, and naproxen can help relieve physiological symptoms of PMDD, like joint pain, backache, headache, cramps, and breast tenderness. 

Cognitive-behavioral therapy (CBT) is yet another option for treating PMDD. Limited studies have shown that CBT is as effective for treating PMDD symptoms as a daily 20mg dose of fluoxetine.^[9] 

Less commonly, doctors might prescribe hormonal therapy to suppress ovulation. This course of treatment might cause a greater likelihood of osteoporosis, medical menopause, and hot flashes.^[4]

Likewise, danazol, a synthetic partial androgen agonist/antagonist and gonadotropin inhibitor that can prevent ovulation, has shown promise in treating PMDD symptoms. However, danazol can cause teratogenicity (factors that can negatively affect the normal intrauterine development of a fetus) and hirsutism (excessive hair growth on the face, back, and chest).^[4]

Surgery is yet another course of treatment. While research is fairly limited, hysterectomies and bilateral salpingo-oophorectomies have both shown promise for reducing PMDD symptoms.^[9]  

Surgery is typically reserved for women who have tried the above strategies without success. It might also be an option for women whose symptoms are tolerable with drug therapies but who experience significant adverse effects from their medications.

Self-care for premenstrual dysphoric disorder

Self-care strategies for PMDD are similar to those you can use as preventative measures, such as eating a balanced diet, getting plenty of rest, and getting regular exercise.

Self-care also involves understanding what’s going on with your body and knowing when it’s time to seek help. A symptom diary can help you track your symptoms and might shed light on when symptoms might occur and how severe they might be. As noted earlier, a diary can also be extremely informative for your doctor as they seek to diagnose your condition.

Talking about your experience with your partner and other loved ones can also help with self-care. Doing so enables you to explain how you’re feeling and why while also opening the door for your loved ones to provide the necessary support. 

As explained above, some of the symptoms of PMDD can be minimized and well managed with over-the-counter drugs, like taking an anti-inflammatory to reduce cramps. However, it’s important that you follow the recommended usage guidelines for any over-the-counter medicines.

Additionally, if your symptoms are severe enough to warrant a prescription from your doctor or healthcare provider, ensure you take the medication according to your doctor’s guidance. If your symptoms become severe to the point of being unbearable, call your doctor immediately or call 911 for help.

Frequently asked questions about PMDD

How common is PMDD?

Research indicates that about five percent of women of child-bearing age have PMDD^[2], though some estimates are as high as eight percent.^[10] Onset usually occurs during a woman’s 20s, though, in some cases, it might develop during a woman’s teenage years. 

PMDD vs PMS - What’s the difference?

The primary difference between PMDD and PMS is that PMDD involves a severe mood disturbance that often interferes with a woman’s ability to function normally. While PMS might involve similar symptoms, they are typically far less severe. Moreover, PMDD is much less common than PMS, which occurs in up to 80 percent of women during their child-bearing years.^[10]