What Is PMDD (Premenstrual Dysphoric Syndrome)?

Premenstrual dysphoric disorder (PMDD) is a severe and chronic psychiatric condition characterized by typical premenstrual syndrome (PMS) symptoms plus drastic mental health decline during the week or two leading up to menstruation. PMDD is a more severe form of 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.

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. 

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, 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 include 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
• The sense of a lack of control
• Agitation
• Anger
• Insomnia
• Difficulty concentrating
• Depression
• Mood swings
• Severe fatigue
• Anxiety
• Forgetfulness
• Poor self-image
• Emotional sensitivity
• Self-deprecating thoughts
• Crying spells
• Moodiness
• Trouble sleeping
• Sleeping too much
• Sensitivity to rejection

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 major depressive disorder and anxiety are notable risk factors. Smoking is also a known risk factor.

Diagnosis

Your healthcare provider will perform a physical exam and take your mental health history to rule out any other psychiatric disorder that could be causing similar symptoms, including bipolar disorder, major depressive disorder, borderline personality disorder, and panic disorder.

Your healthcare provider 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

Treatment

Home Remedies

The following lifestyle modifications may 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, which may increase serotonin-precursor tryptophan 
• Increasing physical activity like swimming, dancing, walking, or lifting weights

Medication

Nonsteroidal anti-inflammatory drugs (NSAIDs) such as 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.

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) have 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 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 shown some benefit in controlling PMS-associated mood swings and irritability, however the evidence is not conclusive.

Certain other vitamins and minerals have some evidence 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. The antioxidant may help with reducing affective and physical symptoms. 
• Calcium carbonate, 1,200 to 1,600 mg per day, was found in one study to 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 and interactions.