Breaking the cycle: a guide to understanding and managing premenstrual dysphoric disorder (PMDD)
Thursday 23 March 2023
If you’re someone who gets their period, you might be familiar with the symptoms of premenstrual syndrome (PMS). This is a common condition experienced by about 75% of women in the days leading up to their period.
Some symptoms of PMS include mood changes, fluid retention, tiredness and headaches.
For many, PMS symptoms are mild and are managed with lifestyle changes and natural or over the counter medications.
For 3 to 8% of women, these symptoms can be much more severe and debilitating. This is a condition known as premenstrual dysphoric disorder (PMDD).
PMDD can significantly affect a person’s mental health, and those with it may feel alone and unsure of how to get help.
So, let’s shine some light on PMDD.
What is PMDD?
PMDD is a severe form of PMS that causes emotional and psychological distress. It can be so serious that it can impact a person’s daily life. Those with PMDD find normal activities such as work or school, exercising, or self-care difficult. It sometimes triggers thoughts of suicide and self-harm.
Although it's related to the menstrual cycle, PMDD isn't believed to be caused by a hormonal imbalance. Researchers think PMDD may be triggered by the hormonal changes in the part of the menstrual cycle between ovulation and menstruation (luteal phase).
After ovulation, follicle stimulating hormone (FSH) and luteinising hormone (LH) drop. Progesterone and oestrogen start to rise, and this contributes to PMDD symptoms. These symptoms can last for one to two weeks. The oestrogen and progesterone levels drop when the body is ready for another period.
Studies show that those with PMDD are very sensitive to these hormonal changes. For some, this could be due to a serotonin deficiency. Serotonin is the brain hormone that controls your mood and makes you feel happy.
Anyone can develop PMDD, but it is most likely genetic. Another risk factor could be a personal or family history of mood disorders. Smoking is also a possible risk factor, but there’s not enough evidence to support this.
Research suggests that 83% of Australians with PMDD had experienced trauma early in life. Early trauma experiences such as physical, sexual or emotional abuse and/or neglect are more common among PMDD sufferers than the general Australian population.
Women who experience gender dysphoria are also at increased risk for PMDD.
PMDD has been recognised as a psychological condition since 2013 and is the only type of premenstrual disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
Signs and symptoms
PMDD can sometimes be misdiagnosed as some PMDD symptoms mimic other conditions. It can be confused with bipolar disorder, thyroid conditions, personality disorders or depression. With PMDD, symptoms overlapping with these disorders occur only on the days between ovulation and the end of a period.
Like PMS, the symptoms of PMDD usually appear around a week or two before a period. They will then settle down a few days after the period starts.
Some of the specific symptoms someone with PMDD might have include:
- extreme or sudden mood changes and emotional sensitivity
- irritability or anger
- depressed mood -- feeling hopeless, worthless, or guilty
- anxiety, tension, or feeling ‘on edge’
- little or no interest in usual activities (work, school, friends or hobbies)
- difficulty concentrating or focusing (brain fog)
- tiredness, low energy or excessive sleepiness
- appetite changes, food cravings, overeating, or binge eating
- insomnia (trouble falling or staying asleep)
- feeling overwhelmed or out of control
- physical symptoms -- breast tenderness or swelling, joint or muscle pain, bloating or weight gain, acne, headaches.
So, what does PMDD feel like? It can be different from person to person.
Some report feeling very sensitive to everything around them. Everything they feel can be extreme, from lights to sounds, even thoughts and actions.
Others experience severe depression and panic, self-doubt or rejection sensitivity. Some feel like they’re not good enough and are unworthy of love. They can struggle with relationships and friendships.
A PMDD diagnosis can only be made if someone has at least five symptoms for two or more menstrual cycles. One or more of the symptoms must be emotional or mood related (one of the first four symptoms listed in bold above).
If you think you have PMDD, the best way to understand what's happening is to keep a detailed diary of the symptoms and when they occur. The easiest way to keep track is to download a cycle tracker app on your mobile device. You can show this record to your healthcare provider.
Management and treatment options
There are many ways that PMDD can be managed. This management depends on the severity of symptoms and how much they impact a person’s everyday life.
It’s best to discuss the various treatment options with your healthcare provider. Together you can figure out what will suit your lifestyle and situation.
One option that may help ease symptoms are SSRIs (selective serotonin reuptake inhibitors). These antidepressants can improve symptoms by boosting brain chemicals. SSRIs are usually prescribed only for the luteal phase of the menstrual cycle when symptoms are present.
The combined oral contraceptive pill may also have positive results. It stops ovulation and stabilises the hormonal changes during the menstrual cycle. Some find that this reduces PMDD symptoms.
In some cases, when nothing else has worked, the surgical removal of the ovaries (bilateral oophorectomy) may be considered. Sometimes the uterus can be removed (hysterectomy) at the same time.
If both ovaries are surgically removed, hormone replacement therapy (oestrogen and progesterone) is necessary. This reduces menopausal symptoms that come with the fast drop in hormones.
There are a few other helpful options that don’t involve medication or surgery:
Exercise and physical activity
Exercise increases the level of serotonin in the brain. But not just any exercise. The most effective type of physical activity you can do to help PMDD is aerobic exercise.
Aerobic exercise is any type of cardiovascular conditioning, or “cardio”. It can include activities like brisk walking, swimming, running, or cycling. You must do at least 30 minutes of aerobic exercise to get the serotonin 'high'.
Aerobic exercise differs from anaerobic exercise (like HIIT, weightlifting, pilates and other forms of strength training). Anaerobic exercise isn’t as beneficial for those with PMDD as it doesn’t increase serotonin much. This type of exercise is shorter and more intense than aerobic activity. In fact, cortisol (the stress hormone) increases after anaerobic exercise.
Reduce stress levels
Research has shown that stress may make symptoms of PMDD worse for some people. It can lead to ‘increased rumination and self-focused attention’. Rumination involves repetitive thought patterns. These happen when people try to process their emotions but become 'stuck' in negative thought patterns. They will often replay painful memories without progressing through to resolution. Rumination is common in people with unresolved trauma histories.
Some of the following stress reducing activities can help to ease PMDD symptoms if used as part of a daily routine.
- Exposure to bright light is one method that can help feelings of depression in those with PMDD. Light therapy or light exposure can help to balance serotonin in the brain. Opening your blinds and curtains when you wake up can lift your mood. So let that light in every day!
- Yoga is an excellent way to calm the mind and body. It can improve your general health and help to decrease anxiety and depression. Yoga increases serotonin which makes the body more relaxed.
- Controlled breathing and meditation both help to reduce depressive symptoms. There are many apps available that can guide you in controlled breathing techniques. All you need is a quiet, comfortable spot with no interruptions. Basic breathing exercises involve breathing in and out deeply and slowly for several minutes. This slows the heart rate and focuses the mind.
Accessing a mental health clinician can help to deal with past trauma. This may be a significant contributing factor to distress associated with PMDD. This trauma can stem from early life experiences such as physical, sexual or emotional abuse and/or neglect.
Some with PMDD say their symptoms settle after changing their diet.
These foods help to balance blood glucose levels, lowering cravings and increasing mood and energy:
- fruit and vegetables
- good quality proteins (including meat, but especially fish)
- healthy fats (including avocado, nuts and olive oil)
- complex carbohydrates (like legumes, whole grains and quinoa).
Some foods to avoid in the luteal phase of the menstrual cycle are bread, pasta and refined sugar. They are simple carbohydrates that will increase blood glucose levels too quickly. Eating these foods will also lead to fatigue and low mood.
Reduce caffeine and alcohol
Many of those with PMDD have said that cutting back on or quitting caffeine has been the best choice they ever made.
Caffeine intake (especially if it’s more than 400mg per day) can increase the body’s cortisol (the stress hormone). It can also affect sleep patterns and increase heart rate and blood pressure. This can negatively influence your mood and increase feelings of anxiety. To help your PMDD symptoms, try reducing the caffeine you drink or cutting it out altogether.
Reducing or stopping the consumption of alcohol may also help settle the symptoms of PMDD. Drinking alcohol can boost your serotonin at first, giving that euphoric feeling. Serotonin levels will then drop, which can worsen feelings of anxiety and depression. If you already have low serotonin due to PMDD, excessive alcohol intake can make symptoms worse.
Take vitamins and herbal supplements
Many people with PMDD report positive experiences with taking vitamins and herbal supplements for symptoms. These supplements help to support (not replace) a healthy, balanced diet.
Supplements that can help relieve PMDD symptoms include:
- magnesium glycinate or magnesium citrate
- vitamin B6
- zinc picolinate
- chaste tree or chasteberry (vitex agnus-castus).
Any supplements you take will potentially have side effects. They may also not mix well with certain medications or affect you differently if you have a medical condition.
It’s always important to speak to your doctor before taking anything to ensure it’s right for you. Your doctor might suggest a blood test before supplementing, so the correct dosages can be recommended.
Many people with PMDD symptoms feel alone, frightened, and unsure if what they are going through is normal. If you've read this and think you may have symptoms, make an appointment to see your healthcare provider. You can also call Lifeline on 13 11 14 for immediate support.
- International Association for Premenstrual Disorders (IAPMD)
- Premenstrual Dysphoric Disorder (PMDD) | Johns Hopkins Medicine
- Is Premenstrual Dysphoric Disorder (PMDD) Real? | Psychology Today
- Premenstrual syndrome (PMS) | Better Health Channel
- Premenstrual syndrome (PMS) | Jean Hailes
- The prevalence of early life trauma in PMDD I Psychiatry Research