What Is PMDD (Premenstrual Dysphoric Syndrome)?

Premenstrual dysphoric disorder (PMDD) is a more severe form of premenstrual syndrome (PMS). Along with common PMS symptoms, including bloating, headaches, and breast tenderness, people with PMDD can experience anxiety, mood swings, depression, and even suicidal thinking in the week or two before menstruation begins.

Symptoms continue into the beginning days of a period and are significant enough to disrupt a person's ability to function in everyday life. Learning more about the causes, symptoms, and ways of treating PMDD can help you handle the emotional turmoil that comes with the condition. 

Most people experience at least one sign of PMS during their menstrual cycle, but recent studies say that for 2.5% to 10% of people who menstruate, their symptoms will escalate to disabling levels.

A little under the weather
Cropped shot of a young woman lying down on her bed and suffering from period pains at home.

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What Is PMDD?

Premenstrual dysphoric disorder is a severe and chronic psychiatric condition characterized by typical PMS symptoms plus drastic mental health decline during the week or two leading up to menstruation. Its psychological and physiological symptoms can impair work ability, relationships, and everyday activities, ranging from eating to sleeping to exercising. Lifestyle modifications and certain drug therapies can help lessen the impact of PMDD symptoms and improve quality of life.

Premenstrual dysphoric disorder

Premenstrual dysphoric disorder is an acute form of PMS affecting people of childbearing years who menstruate. Experts say symptoms like anxiety and depression may be associated with changes in serotonin (neurotransmitter associated with happiness) and estrogen (sex hormone) levels during the menstrual cycle.

Symptoms

Physical and psychological changes associated with premenstrual dysphoric disorder are markedly different than those experienced throughout the rest of the menstrual cycle.

Physical

Physical symptoms of premenstrual dysphoric disorder can impact the gastrointestinal, neurological and vascular, and respiratory systems, including: 

  • Cramps
  • Constipation
  • Nausea
  • Vomiting
  • Pelvic heaviness or pressure
  • Backache
  • Acne
  • Skin inflammation with itching
  • Dizziness
  • Fainting
  • Numbness, prickling, tingling, or heightened sensitivity of arms and/or legs
  • Easy bruising
  • Heart palpitations
  • Muscle spasms
  • Fluid retention
  • Vision problems

Psychological

PMDD symptoms includes the expected mood shift and irritability of PMS, but people with premenstrual dysphoric disorder experience more intense forms of these symptoms and additional mental health problems that can interfere with work, social, and personal activities. 

Experts have shown that PMDD is strongly and independently associated with non-fatal suicidal behavior and suggest that clinicians assess and be vigilant of suicidality in women with PMDD.

The psychological symptoms of PMDD include:

  • Irritability
  • Nervousness
  • Lack of control
  • Agitation
  • Anger
  • Insomnia
  • Difficulty concentrating
  • Depression
  • Severe fatigue
  • Anxiety
  • Confusion
  • Forgetfulness
  • Poor self-image
  • Paranoia
  • Emotional sensitivity
  • Crying spells
  • Moodiness
  • Trouble sleeping

When to Seek Help

If you are having suicidal thoughts, contact the National Suicide Prevention Lifeline at 1-800-273-8255 for support and assistance from a trained counselor. If you or a loved one are in immediate danger, call 911. For more mental health resources, see our National Helpline Database.

Diagnosis

Your doctor will perform a physical exam and take your mental health history to rule out any other psychological disorder that could be causing similar symptoms, including bipolar depression, borderline personality disorder, and panic disorder.

Your doctor will also order appropriate lab tests to rule out underlying physical conditions like hypothyroidism (an underactive thyroid gland) or hyperthyroidism (an overactive thyroid gland). Dysfunction in the thyroid has been consistently linked to mood disorders.

Your self-reported symptoms will then be compared with the DSM-5 criteria for PMDD.

A diagnosis of premenstrual dysphoric disorder requires that:

  • Most of your periods for the past year have had at least five symptoms
  • Symptoms are present in the final week before menstruation
  • Symptoms start to improve within a few days after menstruation begins and become minimal or absent in the week after menstruation

Keeping a daily log of symptoms that you can bring to your doctor’s appointment is a good way to help you remember key items to address and get the most effective treatment for PMDD possible.

Causes

There is no known cause of PMDD, but researchers can point to an abnormal response to the cyclically fluctuating levels of serotonin and estrogen as one likely factor contributing to PMDD. Serotonin in particular is relevant in epidemiology and treatment.

A family history of PMDD, PMS, or postpartum depression and a personal history of mood disorders like depression and anxiety are notable risk factors. Smoking is also a known risk factors.

Any menstruating person can develop PMDD, but those who have a family history of mental illness or mood disorder are known to be more likely, although the exact cause is not clear.

Treatment

Home Remedies

The following lifestyle modifications should be attempted before trying prescription medications:

  • Stress management strategies, including meditation and deep breathing or stretching techniques
  • Maintaining healthy sleep habits 
  • Utilizing light therapy for mood management
  • Decreasing sugar, salt, caffeine, and alcohol intake (they are considered symptom aggravators) 
  • Increasing complex carbs to increase serotonin-precursor tryptophan 
  • Increasing physical activity like swimming, dancing, walking, or lifting weights

Medication

Nonsteroidal anti-inflammatory drugs (NSAIDs) such as acetylsalicylic acid (a key ingredient in medications like Aspirin) and ibuprofen are typically well tolerated and can be used to reduce the pain and headaches associated with menstruation. Diuretics, or water pills, can be used to relieve bloating associated with fluid retention. 

The benefits of antidepressants, specifically selective serotonin reuptake inhibitors (SSRIs), are well researched, and these medications continue to show significant benefits for mood issues associated with PMDD. You may only need to take SSRIs during the second half of your cycle, but keep in mind they do require three months to take effect. FDA-approved medications for PMDD include fluoxetine (Prozac and Sarafem), sertraline (Zoloft), and paroxetine (Paxil). Other common choices include venlafaxine (Effexor) and escitalopram (Lexapro).

Oral contraceptives, namely the estrogen-progestin combination birth control called Yaz (each tablet contains 20 mcg ethinyl estradiol and 3 mg drospirenone) has been approved by the FDA in the treatment of PMDD. Progesterone treatment alone has been proven ineffective.

Gonadotropin-releasing hormone (GnRH) agonists like leuprolide acetate or goserelin acetate are expensive medications that cause ovaries to temporarily stop making estrogen and progesterone (inducing a temporary menopause). This treatment depletes estrogen, so hormonal replacement therapies are also necessary. Due to its cost and complexity, this is an effective but last resort option.

Nutritional Supplements

While many claims have been made about the potential of herbal medicine in the treatment of PMDD, only one fruit extract (Chaste tree or Vitex agnus-castus) has been proven to control PMS-associated mood swings and irritability.

However, other vitamins and minerals have been shown to support the reduction of symptoms and/or improve prognosis, including:

  • Vitamin B6, up to 100 mg per day, for mild PMS and depression. More than 100 mg can cause peripheral neuropathy
  • Vitamin E, up to 600 IU per day. Antioxidant helps with reducing affective and physical symptoms 
  • Calcium carbonate, 1,200 to 1,600 mg per day, can reduce core PMS symptoms almost by half 
  • St. John’s Wort, consult on dosage, well-recognized as a natural option for reducing symptoms of depression. This supplement has many contraindications

Are Nutritional Supplements Safe?

Nutritional supplements are not approved by the FDA, nor do they require third-party testing for accuracy or efficacy of health claims. Natural remedies can interact with prescription medications or cause serious side effects, so always consult your doctor to choose what’s right for you.

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  1. Office on Women's Health. Premenstrual dysphoric disorder (PMDD).

  2. Fatemi M, Allahdadian M, Bahadorani M. Comparison of serum level of some trace elements and vitamin D between patients with premenstrual syndrome and normal controls: A cross-sectional study. Int J Reprod Biomed. 2019 Sep;17(9):647-652. doi: 10.18502/ijrm.v17i9.5100x

  3. Cleveland Clinic. Premenstrual Dysphoric Disorder (PMDD).

  4. John Hopkins Medicine. Premenstrual Dysphoric Disorder (PMDD).

  5. Pilver CE, Libby DJ, Hoff RA. Premenstrual dysphoric disorder as a correlate of suicidal ideation, plans, and attempts among a nationally representative sampleSoc Psychiatry Psychiatr Epidemiol. 2013;48(3):437-446. doi:10.1007/s00127-012-0548-z.x

  6. Gudipally PR, Sharma GK. Premenstrual Syndrome. 2020 Jul 21. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan–.

  7. Reid RL. Table 1, Diagnostic Criteria for Premenstrual Dysphoric Disorder (PMDD) - Endotext - NCBI Bookshelf. National Center for Biotechnology Information.

  8. National Center for Biotechnology Information. Premenstrual syndrome: Treatment for PMS.

  9. UpToDate. Patient education: Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) (Beyond the Basics).

  10. Schellenberg R. Treatment for the premenstrual syndrome with agnus castus fruit extract: prospective, randomised, placebo controlled study. BMJ. 2001;322(7279):134-137. doi:10.1136/bmj.322.7279.134.x

  11. Bhatia SC, Bhatia SK. Diagnosis and treatment of premenstrual dysphoric disorder. Am Fam Physician. 2002 Oct 1;66(7):1239-48.