Premenstrual Dysphoric Disorder

Definition

Premenstrual dysphoric disorder (PMDD) is a condition related to the menstrual cycle. It has many symptoms that affect both the mind and body in the weeks leading up to the menstrual period. It’s like premenstrual syndrome (PMS), but the symptoms of PMDD are much worse. 

The effects on the mood are so intense that it meets the criteria for a mental health disorder. Most people notice some physical and emotional changes before their period. But the severe symptoms of PMDD affect fewer than 10% of people.

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Causes

Experts don’t fully understand the exact cause of PMDD. It may be that the brain has an abnormal response to the hormonal changes of the menstrual cycle. Studies have also shown a strong connection between PMDD and serotonin. Serotonin is a chemical substance that helps the brain regulate pain, mood, and sleep. Changing levels of serotonin may contribute to the symptoms of PMDD as well.

There are certain factors that can increase your risk of developing PMDD. These risk factors include:

• Family history of PMS or PMDD

• Personal or family history of any type of depression, including postpartum depression 

• Personal or family history of any mood disorder, such as anxiety 

• Alcohol or substance abuse

• Stress

• History of trauma

• Tobacco use

• Obesity

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Symptoms of PMDD

Symptoms of PMDD can vary from person to person. They affect both physical and mental health and can start 1 to 2 weeks before your period.

Physical symptoms

The physical symptoms of PMDD can include: 

• Changes in appetite, food cravings, or binge eating

• Cramps

• Breast tenderness

• Bloating

• Headaches

• Weight gain

• Joint or muscle pain

Mental health symptoms

The mental health symptoms of PMDD can include:

• Lasting irritability or anger

• Depressed mood with feelings of sadness or despair, or even thoughts of suicide

• Feelings of tension or anxiety 

• Panic attacks

• Mood swings 

• Decreased interest in usual activities

• Trouble thinking or focusing

• Tiredness or low energy

• Excessive sleeping, or not being able to sleep (insomnia)

• Sense of being overwhelmed, or feeling out of control

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Diagnosis

There’s no specific laboratory or imaging test for PMDD. Your healthcare provider will likely take a full history, do an exam, and get bloodwork from you. This is to make sure there’s nothing else causing your symptoms. 

The diagnosis of PMDD is a clinical one. This means a healthcare provider bases the diagnosis on your symptoms alone. That’s why it’s important to keep a calendar or diary of your symptoms. To be considered PMDD, your symptoms must meet the following requirements:

• You have at least five symptoms the week before your period, and the symptoms get better after your period begins. 

• The symptoms interfere with work, school, social activities, or relationships. 

• The symptoms are not from another illness.

• The symptoms occur for at least two cycles in a row. 

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Treatments

Management of PMDD focuses on both the physical and mental symptoms. You can work with your healthcare provider to figure out the best treatment plan for you. 

While medications can help treat PMDD (more below), there are many non-medication approaches you can try. Some of the lifestyle changes and complementary treatments include:

Vitamins and supplements

For some, vitamins and supplements may provide symptom relief. These include:

• Calcium: improves fatigue and mood and reduces appetite changes

• Vitamin B6: benefits depression and mood

• Vitamin E: helps breast fullness and mood changes

• Chaste tree berry: reduces breast tenderness, headache, and water retention

• Evening primrose oil: decreases breast tenderness

Exercise 

Studies show that aerobic exercise for 30 minutes a day improves symptoms. Exercise helps PMDD because of the release of endorphins after vigorous activity. The endorphins can improve mood and energy levels and reduce premenstrual symptoms. Common aerobic exercises that may help PMDD include:

• Walking

• Running

• Cycling

• Swimming

• Biking

Dietary changes 

Making minor changes in your diet can go a long way to reducing PMDD symptoms. Here are some things in your diet that you may want to avoid:

• Simple carbohydrates: Simple carbohydrates cause blood sugar spikes, which can make you tired and moody. Complex carbohydrates, like whole grains, are high in fiber and help stabilize blood sugar. 

• Salt: Avoiding added salt and salty snacks can help reduce the common PMDD issue of water retention. Seasoning food with fresh herbs and spices may be a good substitute for salt. 

• Caffeine: Decreasing caffeine can help to prevent insomnia and restlessness.

• Alcohol: Limiting alcohol can improve your sleep and help to manage mood swings. 

Stress reduction

Reducing stress may help to improve the symptoms of PMDD. Some strategies to reduce stress include:

• Cognitive behavior therapy (CBT): CBT helps to identify negative thoughts and strategies to cope. This can help with both physical and mental symptoms of PMDD.

• Yoga: A regular practice of deep breathing and yoga helps to reduce symptoms. 

• Mindfulness: Mindfulness techniques are effective in improving PMDD symptoms.

Acupuncture 

Acupuncture dates back to ancient Chinese medicine. It’s the practice of placing very thin needles into specific sites to stimulate these areas. These sites are thought to correlate with certain symptoms. Acupuncture sites may be helpful to control:

• Cramps

• Bloating

• Pelvic and back pain

• Headaches

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Medications

There are different medications for PMDD. Your specific symptoms and your body’s response can help to determine the best approach. Some of the more common medications for the treatment of PMDD are:

Selective serotonin reuptake inhibitors (SSRIs) 

SSRIs increase the amount of serotonin available in the body. These medications keep the body from breaking down serotonin. This leads to more available serotonin that can help your mood, sleep, and emotions. 

Common SSRIs for PMDD symptoms include:

• Fluoxetine (Sarafem)

• Sertraline (Zoloft)

• Paroxetine (Paxil)

• Citalopram (Celexa)

There are multiple ways to take SSRIs for PMDD:

• Continuous dosing: you take it daily throughout the month

• Intermittent dosing: you take it after day 14 of your cycle through the start of your period

• Semi-intermittent dosing: you take it daily and increase the dose after day 14 of your cycle

• Symptom-onset dosing: you take it when your symptoms start and for a few days after your period starts

Continuous dosing may be useful for people who have other mood or anxiety disorders. It may also be an easier dosing schedule for those with irregular cycles or who forget to take their pills.

Intermittent dosing may be useful for people with a regular cycle and no symptoms in the first 2 weeks. This can also be helpful for people concerned about the side effects of SSRIs.

Based on your medical history, your provider will decide which SSRI and dosing schedule to try.

Combination oral contraceptives pills

Combination oral contraceptives (OCPs) contain both estrogen and progestin hormones. Taking these hormones prevents the natural changes in your body’s hormone levels. Most OCPs are likely to help with symptoms of PMDD. Studies show that OCPs that have drospirenone work best for PMDD. 

This treatment is useful for people who can’t tolerate SSRIs. It’s also a good option for those interested in the added benefit of birth control.

Gonadotropin-releasing hormone agonists 

Gonadotropin-releasing hormone (GnRH) agonists work to induce a medical menopause. Menopause is when estrogen levels normally decline and menstrual cycles no longer occur. The GnRH agonists mimic this by interrupting a hormone pathway. This stops estrogen production and will stop monthly menstrual cycles. This treatment works to prevent PMDD symptoms by preventing the menstrual cycle altogether. 

GnRH agonists can come in the form of nasal sprays or injections. Common GnRH agonists include:

• Leuprolide 

• Nafarelin

Treatment with GnRH agonists is effective, but its side effects make it less popular than other options. The side effects can mimic natural menopause. While taking this medication, you may experience:

• Hot flashes

• Vaginal dryness

• Decreased libido

• Fatigue

• Bone density loss 

GnRH agonists are most common among people who can’t tolerate SSRI or OCP therapy.

Surgical management

In rare cases, surgical management may be an option. A complete hysterectomy (removal of the uterus and ovaries) stops the menstrual cycle and improves PMDD symptoms. This is often a last-resort option for people who can’t tolerate other treatments and who don’t plan to become pregnant in the future.

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Written by Nicole E. Cieri-Hutcherson, PharmD, BCPS, NCMP