What Is Premenstrual Dysphoric Disorder

Overview

Premenstrual syndrome (PMS) refers to a set of physical and behavioral symptoms that occur regularly during the second half of the menstrual cycle. These symptoms, which include mood changes and physical discomfort, tend to happen before menstruation and gradually subside afterward in women of reproductive age.⁴ Although most females experience only mild discomfort, which does not interfere with their personal, social, or professional lives. The nomenclature for premenstrual disorders has evolved over the years, they were first referred to as "menses moodiness" in the eighteenth century, then as "premenstrual tension" in the early nineteenth century, and ultimately as "premenstrual syndrome" in the fifties. Premenstrual syndrome (PMS) refers to the subset of women who suffer symptoms that are severe enough to interfere with everyday functioning and activities, even though some discomfort before menstruation is quite usual. Premenstrual dysphoric disorder (PMDD), also referred to as late luteal dysphoric disorder (LLDD), is the most severe form of premenstrual syndrome (PMS), having the greatest impact on women's functioning and perceived quality of life often prompting them to seek treatment.⁴ It is estimated that mild PMS is common, affecting up to 75 percent of women with regular menstrual cycles, while 5-8% in the UK have PMDD.⁸

PMDD is an intensified form of premenstrual syndrome (PMS) that occurs during the week or two before your period begins, as hormone levels decrease after ovulation.^1,3 It is a chronic medical condition that affects women of reproductive age, but the good news is that various treatments and self-care approaches can effectively manage symptoms for most women⁶

Unfortunately, the term PMS has become widely used in popular culture (I'm PMSing") due to the growing public awareness of unpleasant premenstrual experiences. It is important to distinguish between typical premenstrual symptoms and PMDD, which is marked by severe distress, interferes with daily tasks, and disrupts interpersonal relationships.⁷

Causes of premenstrual dysphoric disorder

The cause of PMDD is currently unknown, but it could be a reaction to normal hormone changes that occur during the menstrual cycle.¹ Symptoms may be triggered by decreasing levels of estrogen and progesterone hormones before menstruation and after ovulation.² Hormone fluctuations throughout the menstrual cycle can affect tissues in the body, potentially causing a serotonin deficiency.⁶ Serotonin is a natural substance found in the brain and intestines that affects mood and physical symptoms by narrowing blood vessels.¹ However, it's unclear why some women develop PMS or PMDD while others do not. Based on multiple studies women who develop PMDD may be more sensitive to normal hormone changes, which makes them more likely to experience mood, behavioral, and somatic symptoms. This explanation is based on multiple studies.^4,6 

Studies indicate that there are alternate reasons behind PMDD, along with factors that can escalate its severity. These possible causes include genetics, as certain genetic variations may lead to heightened hormone sensitivity; smoking, which can impact hormone sensitivity; and trauma and stress, as some research has indicated a link between PMDD and past traumatic events like emotional or physical abuse. Furthermore, stress can exacerbate the symptoms of PMDD.¹⁰

Signs and symptoms of premenstrual dysphoric disorder

PMDD symptoms are comparable to PMS but are much stronger and have a greater negative impact on your daily life.⁵ The duration of PMDD symptoms can range from a few days up to two weeks, depending on the individual. Typically, symptoms become more intense six days before menstruation and are at their most severe two days before the onset of menses for women experiencing these symptoms.⁴

Symptoms can include:^4,5,6

Physical symptoms:

• Tenderness of breasts
• Pain at muscles or joints
• Bloating or gaining weight
• Headaches

Behavioral symptoms:

• Fatigue, lack of energy
• Low interest in usual activities
• Lack of concentration
• Binge eating or cravings
• Hypersomnia or insomnia
• Feeling of being overburdened or out of control

Mental and emotional symptoms:

• Feeling depressed, hopeless, worthless in some cases, even suicidal
• fluctuating moods with frequent tears
• Increased irritability or anger, frequent conflicts with family or coworkers
• Increased anxiety or edginess

Management and treatment for premenstrual dysphoric disorder

Women with premenstrual dysphoric disorder (PMDD) are recommended to use conservative treatments in addition to prescription medication.6

• Conservative Methods

These methods include regular exercise, relaxation techniques such as meditation, yoga, breathing techniques, self-hypnosis, or biofeedback, and dietary modifications like increased intake of complex carbohydrates or proteins for increased serotonin levels, and supplementation with calcium and vitamin B6.⁴ These therapies have been shown to relieve symptoms in some women with fewer or no side effects.⁶

• Pharmacological methods
  • Psychotropic agents: refer to medications that affect the mind, emotions, and behavior
  • Serotonin Reuptake Inhibitors (SRIs): They are used to manage severe mood and somatic symptoms of premenstrual dysphoric disorder (PMDD) from mid-cycle to menses. However, some women may experience sexual side effects with SRIs, such as difficulty having an orgasm, in which case using a lower dose or trying another medication in the same drug class is recommended⁶
  • Benzodiazepines (BZDs): BZDs have been found to be effective in treating severe anxiety and premenstrual insomnia in women. However, it's important to note that there is a risk of dependence associated with BZDs, especially in cases where there has been prior substance abuse, so careful monitoring is necessary⁴

• Suppression of ovulation
  • Hormonal therapies (GnRH agonist): To alleviate very severe PMS and PMDD symptoms, clinicians may use hormonal therapies such as GnRH agonists. These therapies halt estrogen and progesterone production in the ovaries, which temporarily induces menopause and reduces physical symptoms like bloating and irritability. However, these medications also result in low levels of estrogen that can lead to severe hot flashes and bone loss over time. For this reason, women are additionally treated with low doses of estrogen and progesterone to prevent hot flashes and bone loss. Although this treatment is highly effective, it is complicated and expensive and is typically only used if other treatments have been unsuccessful⁶
  • Danazol, which inhibits ovulation, is an efficacious treatment for PMDD, but it can cause hirsutism and teratogenicity and is therefore not the preferred initial agent⁴
  • Oral contraceptive pills (OCPs): Although they are commonly used in clinical practice, there is not strong evidence to support their efficacy in treating PMDD. Some women may find relief from their PMS or PMDD symptoms when taking a birth control pill, while others may find that it exacerbates their symptoms and should seek alternative treatments⁶

Diagnosis

Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) cannot be diagnosed with a single test. Diagnosis is made by the symptoms’ onset with respect to the menstrual cycle and exclusion of other medical conditions.

If you suspect that you might have PMDD, the first step would be to visit your doctor. Your doctor may require you to keep a detailed record of your symptoms on a daily basis for at least two full menstrual cycles to determine if there is a pattern in their occurrence.^6,11 They may also ask about your medical history, including any previous mental health issues, and your lifestyle habits like smoking, drinking, or weight will be evaluated. In addition, they may conduct a physical examination and blood tests to rule out any other medical problems.¹¹

Thus, for a physician diagnose PMDD, at least 5 out of the following 11 symptoms should be present, including 1 of the first 4 listed:⁴

1. Feeling extremely sad or hopeless about yourself, or having negative thoughts about yourself
2. Feeling anxious or tense, like you're always on edge or keyed up
3. Having strong and quickly-changing emotions, especially from happy to sad or vice versa
4. Feeling angry or irritable frequently, or having more conflicts with others than usual
5. Losing interest in activities you usually enjoy, such as work, school, friends, or hobbies
6. Finding it hard to concentrate or focus on tasks, even when they're important
7. Feeling very tired or lacking energy, even when you haven't done much
8. Eating more or less than usual, or craving specific foods during your period
9. Having trouble sleeping or sleeping too much
10. Feeling overwhelmed or out of control with your emotions or life circumstances
11. Experiencing physical symptoms like breast tenderness or swelling, headaches, joint or muscle pain, bloating, or weight gain

Additionally, these symptoms must be severe enough to interfere significantly with social, occupational, sexual, or scholastic functioning.

The symptoms must also be related to the menstrual cycle and not just an exacerbation of another disorder, such as depression, anxiety, bipolar disorder, and perimenopause. Therefore, they should be occurring during the luteal phase of the menstrual cycle, typically in the five to seven days leading up to the period. It is important to note that these symptoms should not be present between days 4 and 12 of a 28-day menstrual cycle in women with PMS or PMDD.⁶

Blood tests are not necessary for diagnosis, but may be recommended to rule out other medical conditions that have similar symptoms. For instance, anemia can cause fatigue and thyroid function tests can detect hypothyroidism or hyperthyroidism.⁶

Furthermore, these criteria must be confirmed by daily ratings during at least two consecutive symptomatic menstrual cycles.⁴

Risk factors

Events that have caused trauma in the past and existing anxiety disorders can increase the likelihood of developing PMDD, but it's unclear how this happens and further research is necessary.⁴

Smoking cigarettes is strongly linked to moderate-to-severe cases of PMS, with both current and former smokers having an increased risk compared to non-smokers. The risk of PMDD is also higher for women who begin smoking during adolescence. ⁴  

Obesity is another risk factor for PMS, with a significant increase in risk seen for each 1 kg/m2 increase in BMI, especially for women with a BMI of 27.5 or higher. ⁴  

Anxiety or depression.²

PMS.²

Family history of PMS, PMDD or mood disorders. There is evidence that genetics are risk factors in the development of PMS/PMDD, with recent research suggesting involvement of the gene that codes for the serotonergic 5HT1A receptor and allelic variants of the estrogen receptor alpha gene (ESR1). These genetic factors are currently speculative risk factors.^2,4

Complications

If PMDD is left untreated, it can result in depression and possibly suicide, particularly in severe cases. The condition can lead to significant emotional suffering and have adverse impacts on both personal relationships and professional pursuits.²

FAQs

How can I prevent premenstrual dysphoric disorder?

Here are some tips that may help you to prevent PMDD or control it better:⁵

• Maintain a regular exercise routine
• Consume a healthy and well-balanced diet. Eating frequent small meals every few hours may be more beneficial than having three larger meals
• Ensure that you get sufficient rest, aiming for 7 to 8 hours of sleep each night
• Try stress-reducing activities such as yoga or meditation to alleviate tension
• Avoid smoking and excessive consumption of alcohol
• Take pain relievers like ibuprofen or paracetamol to alleviate discomfort
• Keep track of your symptoms by maintaining a diary for at least two to three menstrual cycles, which can be brought to a GP appointment

How common is premenstrual dysphoric disorder

It is estimated that 5-8% of women in the UK have PMDD.⁸

When should I see a doctor

You should seek help from your doctor when the actions you have taken to assist with the situation have proven ineffective, and your symptoms are significantly impacting your day-to-day activities.⁵

Summary

Premenstrual Syndrome is a set of symptoms that people assigned female at birth experience weeks before their period. These symptoms include: 

• Mood Swings 
• Feeling upset, anxious or irritable
• Tiredness
• Bloating and stomach issues
• Headaches