All about Premenstrual Dysphoria Disorder (PMDD)

Premenstrual dysphoria disorder, or PMDD, affects between 5% and 6% of women of childbearing age, which means there are around 824,000 women in the UK affected by the condition. PMDD is a hormone-based mood disorder caused by abnormal reactions in the brain to hormone changes. In this article, we’ll explore PMDD, its causes and treatments.

What is premenstrual dysphoria disorder?

PMDD is essentially an extreme form of PMS (premenstrual syndrome). It leads to a variety of symptoms each month during the luteal phase of the menstrual cycle. This is the time after ovulation but before the period begins. The luteal phase lasts around two weeks on average but it can be shorter or longer. 

Women with PMDD experience symptoms between a few days during the luteal phase or every day. Though lots of women experience PMS symptoms, with PMDD these are much worse and seriously impact upon your life. PMDD can make work and relationships difficult to manage. It can also lead to suicidal thoughts. 

Often, people refer to PMDD as an endocrine disorder since it is related to hormones. However, people who have PMDD experience a range of physical symptoms as well as ones on their mental health like anxiety, depression and suicidal feelings. For this reason, it is categorised as a mental health problem in diagnostic manuals. 

A person’s experience of PMDD can be mild, moderate or severe. There are also believed to be subtypes of PMDD, depending on when and how severe the symptoms are. 

What causes premenstrual dysphoria disorder?

Though there is still a lot that is unknown when it comes to premenstrual dysphoria disorder, NIH (National Institutes of Health) researchers discovered in 2016 that people who have PMDD are more sensitive to oestrogen and progesterone. This is a biological response at the cellular level, which is interesting. 

It is also believed that serotonin, a neurotransmitter in the brain, also plays a role. Serotonin is involved in the regulation of mood and it contributes to the feeling of wellbeing. The levels of serotonin in the body fluctuate during the menstrual cycle, which some women are more sensitive to. 

There are several possible contributing factors to the condition too. These include:

• A person’s genetics. It is likely that certain genetic variations make a person more prone to developing PMDD.
• Smoking: Some people believe that smoking nicotine impacts upon your hormone sensitivity.
• Stress and trauma: In some cases, it’s believed that traumatic or stressful events like physical or emotional abuse can cause PMDD or worsen its symptoms.

What are the risk factors for premenstrual dysphoria disorder?

Any female can get premenstrual dysphoria disorder but there are also risk factors that can increase the chances of getting the condition. These include:

• Genetics: Women who have a family history of PMDD or PMS are more likely to have the condition themselves.
• Biological factors: Women who have experience of other mood disorders like postnatal depression or depression.
• Cigarette smoking.
• Stress: Women who experience high levels of stress are more susceptible to PMDD. This is because stressful situations can impact the body’s ability to cope with hormonal changes.
• Significant life events or trauma: Traumatic experiences can contribute to the development or worsening of PMDD.
• Age and reproductive factors: PMDD occurs in women of reproductive age. Symptoms are more likely to begin in the late teens or early twenties. The symptoms can be exacerbated following reproductive events like pregnancy, childbirth and menopause.

What are the signs and symptoms of premenstrual dysphoria disorder?

The symptoms of premenstrual dysphoria disorder appear in the last two weeks of the menstrual cycle and they can be so severe that they disrupt your daily life. Women who suffer from PMDD find work, home and relationships difficult to navigate during these episodes. There is a marked difference between this time compared to the beginning of their cycles. 

These are the most frequently observed symptoms of premenstrual dysphoria disorder:

Phycological symptoms

• Agitation
• Anger
• Anxiety
• Crying spells
• Confusion
• Depression
• Difficulty in concentrating
• Emotional sensitivity
• Forgetfulness
• Irritability
• Insomnia
• Lack of control
• Moodiness
• Nervousness
• Poor self-image
• Paranoia
• Severe fatigue
• Trouble sleeping
• Suicidal feelings: 72% of people with PMDD report suicidal feelings, 49% have planned suicide attempts and 34% have made suicide attempts. This is compared to 3% of the general population.

Gastrointestinal symptoms

• Abdominal cramping
• Backache
• Bloating
• Constipation
• Nausea
• Vomiting
• Pelvic pressure or heaviness

Skin problems

• Acne
• Aggravation of existing skin problems like cold sores
• Skin inflammation and itching

Fluid retention

• Breast pain and fullness
• Weight gain
• Swelling of the extremities
• Diminished output of urine

Respiratory issues

• Infections
• Allergies

Vascular and neurological symptoms

• Dizziness
• Headaches
• Fainting
• Tingling, numbness, prickling, etc.
• Easily bruising
• Muscle spasms
• Heart palpitations

Other symptoms

• Vision changes
• Eye infections
• Decreased sex drive
• Changes in appetite
• Decreased coordination
• Food cravings
• Hot flushes

Since PMDD is linked to the menstrual cycle, women who are pregnant do not experience symptoms. However, once they begin ovulating again after pregnancy, the symptoms will usually return.

Living with premenstrual dysphoria disorder

Living with PMDD isn’t easy and many women find it a challenge to manage their symptoms. It’s important to seek an official diagnosis with a healthcare professional like a gynaecologist or mental health specialist so that you can get a treatment plan. 

You can ease the symptoms of PMDD by making changes to your lifestyle.

Nutrition, exercise and sleep

Eating well and getting exercise regularly can help you reduce your symptoms and manage them better. Sleep is also important for keeping everything balanced.

If you haven’t already, consult with a healthcare professional, preferably a gynaecologist or mental health provider, for a proper diagnosis and personalised treatment plan.

Managing stress

Using stress-reducing techniques like yoga, meditation, mindfulness and deep breathing can help people manage PMDD symptoms.

Cognitive Behavioural Therapy (CBT)

This helps women recognise any negative thought patterns that exacerbate their condition. It can help them to manage the behaviours associated with PMDD.

Social support

Finding a support system is crucial. This can help you recognise, manage and cope with the symptoms of PMDD and the challenges they bring.

How is premenstrual dysphoria disorder diagnosed?

Keeping a symptom diary can be a good first step to take to a GP if you think you have PMDD. It is likely that the GP will refer you to a specialist. However, PMDD is symptom-based and there is no official diagnostic test that will confirm either way that the condition is present. As the disorder has mental health symptoms, it might be necessary to rule out other conditions like anxiety, depression and personality disorders, for example. 

For a diagnosis to be given, you’ll usually have to have five key symptoms during most menstrual cycles for at least 12 months. 

On average, individuals wait around 12 years to get an accurate PMDD diagnosis and they usually see around six healthcare providers before they are diagnosed. This is because it is difficult to separate the symptoms from other conditions. 

There are studies ongoing to see if there is a greater incidence of PMDD in people with Autism Spectrum Disorder and ADHD.

How is premenstrual dysphoria disorder treated?

This is a chronic condition that requires treatment. There are a range of methods to treat the symptoms and these depend on individual cases.

Here are some of the ways in which PMDD can be treated and improved:

Lifestyle changes

Changes to your diet can help promote overall health and wellbeing and balance hormones. This might mean an increase in carbohydrates and protein and a decrease in alcohol, caffeine, salt and sugar. Other lifestyle changes like taking regular exercise and practising stress management techniques like yoga or mindfulness can help. 

The advantages of this treatment are that it is accessible to all and non-invasive. This will also have positive effects on your overall health. The disadvantages of this are that it requires sustained effort and time before you’ll see any results. What’s more, the symptoms of PMDD can make it difficult to want to make these changes.

Nutritional supplements

Taking supplements like calcium, magnesium and vitamin B6 are thought to alleviate symptoms of PMDD by addressing potential nutritional deficiencies. The advantages of taking these are that they’re non-pharmacological and easily accessible. They also have positive effects on your general health.

Anti-inflammatory medications

Some doctors recommend nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen to reduce inflammation and alleviate any pain associated with PMDD. This, however, won’t have any impact on emotional symptoms.

SSRIs (Selective Serotonin Reuptake Inhibitors)

These are a type of antidepressant that increases circulating serotonin levels to regulate mood and provide emotional stability. These are effective in addressing the emotional symptoms of PMDD and are widely prescribed for the condition. Specific medications prescribed for this include sertraline, fluoxetine and paroxetine. 

They do, however, come with potential side effects and it can take a while to find a medication and dose that works for each individual.

The contraceptive pill

Birth control pills that contain ethinyl oestradiol and drospirenone regulate hormonal fluctuations and help to alleviate symptoms of PMDD. However, their effectiveness can vary and they might not be suitable for everyone.

Hysterectomy

In severe cases of PMDD, a hysterectomy (removal of the uterus) may be considered. This is often coupled with the removal of the ovaries to eliminate hormonal fluctuations but this essentially starts the menopause. The disadvantages of this, of course, are that it is irreversible and has associated risks and long-term consequences.

Considerations for treatment

The choice of treatment will depend on the severity of the symptoms, individual response and personal preferences. The approach to treatment should be individualised and might include a combination of therapies. There should also be regular monitoring by health professionals to evaluate the effectiveness of the chosen treatments and adjust as needed.

What is the difference between PMS and PMDD?

Both conditions are related to the menstrual cycle and both involve different emotional and physical symptoms. 

The difference between the two is largely in the severity and prevalence. Around 90% of women experience premenstrual syndrome (PMS) and the symptoms aren’t severe. PMDD is much less common but its symptoms are much worse.

What’s more, PMS doesn’t impair day-to-day functioning unlike PMDD and doesn’t require treatment by specialists.

Similar conditions to PMDD

There are lots of conditions that have overlapping symptoms or associations with hormonal fluctuations. Here are some conditions that can have similarities with PMDD.

PME – Premenstrual exacerbation of underlying mental health conditions

Women who have mental health conditions like anxiety disorders or depression find that their symptoms are worse during the premenstrual phase of their cycle. Though this isn’t the same as PMDD, it can lead to emotional distress.

Endometriosis

Endometriosis is a condition that affects women of reproductive age. It occurs when the lining of the uterus grows in other places. It can cause pain, bloating and mood changes which are exacerbated during the premenstrual phase.

Polycystic ovary syndrome (PCOS)

Polycystic Ovary Syndrome is a hormonal disorder that leads to irregular menstrual cycles, ovarian cysts and elevated androgen levels. Women who have PCOS can experience emotional symptoms and mood changes.

Premenstrual magnification of physical symptoms

Some women experience an amplification of physical symptoms like migraines during their premenstrual phase. Though this wouldn’t meet the criteria for a diagnosis of PMDD, the symptoms can still be distressing.

Final thoughts on premenstrual dysphoria disorder

Navigating PMDD and its treatment options can be a challenge. The condition itself has a profound impact on women, often going undiagnosed for many years. Treatments and management of the condition must be individualised and monitored. Understanding the advantages and drawbacks of each treatment will allow patients to make informed decisions alongside healthcare professionals. Lifestyle changes, nutritional supplements, anti-inflammatory medications, SSRIs, contraceptive pills, and, in extreme cases, a hysterectomy, each play a role in managing PMDD symptoms. With PMDD, the boundaries between physical and mental health converge and so the pursuit of effective treatment requires perseverance and collaboration.