Your complete guide to preparing for a GP appointment: gynecology edition
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Severe premenstrual symptoms? You might have PMDD
Written by
Eleni Stefanou
Medically reviewed by
Dr Georgina Leslie, Clinical Lead at Bloomful
Updated on
6 Sep 2023
PMDD stands for ‘premenstrual dysphoric disorder’ and is a more severe version of PMS (short for 'premenstrual syndrome').
PMDD sets off a host of emotional and physical symptoms a few days or weeks before your period and can make your normal routine seem like an impossible mountain to climb. For some women, symptoms can last for weeks while for others they can clear after a few days.
What is the difference between PMS and PMDD?
It can be difficult to distinguish between the two because of their similar symptom profiles.
It might help to think of PMS as a series of mild to moderate symptoms associated with the arrival of your period, whereas PMDD is considered to be a severe mood disorder.
To diagnose PMDD, healthcare providers will refer to symptoms listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM). They will also factor the timing of your symptoms into their assessment (more on this below). (1)
Physical symptoms
Fatigue and lack of energy
Sleeping too much or too little
Changes in appetite including cravings
Bloating
Breast tenderness or swelling
Pain in muscles and joints
Headaches
Changes to your vision
Increased fluid retention (swollen hands and ankles)
Peeing less than usual
Digestive issues (constipation, nausea or cramps)
Backache
Feeling dizzy
Heart palpitations
Decreased coordination
Hot flashes
Mood symptoms
Feeling hopeless and sad
Persistent irritability
Feeling anxious or tense
Fluctuations in mood
Losing interest in daily activities
Withdrawing from social situations
Feeling overwhelmed
Difficulty concentrating
Feeling confused
Forgetting things more than usual
Diminished sex drive
Crying more than usual
Suicidal thoughts
Paranoia
If you are having suicidal thoughts, there are organisations that can help. In the UK and Ireland, Samaritans can be contacted on 116 123, or emailed at jo@samaritans.org. In the US, the National Suicide Prevention Lifeline is 988 (you can also text HOME to 741741 to connect with a crisis-informed counsellor). In Australia, you can call 13 11 14. Live somewhere else? Find your closest helpline at befrienders.org.
According to the DSM, you have PMDD if you experience five or more symptoms during the luteal phase of your cycle. This is the time between ovulation and your first bleed day. If your cycle lasts 28 days, PMDD symptoms will usually appear during the two weeks before your period. These symptoms have to occur for at least two months (or two menstrual cycles) for a PMDD diagnosis to be confirmed.
A doctor will also look to see if your symptoms disappear or lessen once your period starts. If they persist, other conditions that may be causing your symptoms should be investigated and ruled out.
It’s worth noting that PMDD was only recently recognised as a disorder. This means that some GPs may be unfamiliar with the symptoms and may even tell you that it’s normal to feel this way before your period (it’s not!). If you’re worried that your symptoms won’t be taken seriously, read our guide on how to advocate for yourself in healthcare settings.
Because of its impact on mood, PMDD can be mistaken for conditions that share similar symptoms, including depression, anxiety, and bipolar disorder. If you suspect your symptoms are connected to your menstrual cycle, it’s important to demonstrate this to your doctor. You can share a symptoms diary that shows when your symptoms appeared in your cycle and when they started to improve.
Things get more complicated if you have an existing mental health condition that worsens between ovulation and your first bleed day. This is known as premenstrual exacerbation (PME). In this case, it’s important to track your symptoms and examine them with a healthcare professional who can assess the timings and help you come up with a personalised care plan.
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While the exact cause is currently unknown, people with PMDD are thought to be sensitive to the normal hormone fluctuations that occur during a person’s menstrual cycle. Symptoms appear during the luteal phase, which is when the hormone progesterone starts to rise. (2) However, the link to progesterone is only one piece of the puzzle and more research needs to be done to understand its relationship to PMDD.
While research also points to there being a genetic link, further studies need to unpack and support this theory. (3)
PMDD shows up differently for each person. Not everyone will experience the same set of symptoms or in the same severity. This means there isn’t a one-size-fits-all approach to treating the condition. Often, a combination of interventions will be needed to improve symptoms.
Lifestyle changes
The first step in managing PMDD involves the familiar staples of:
Good sleep
Stress reduction
Regular exercise
Healthy diet
It can be challenging to incorporate these practices into your schedule, especially when your body is experiencing big monthly changes. However, even a minor adjustment, such as reducing screen time before bed or moving your body to release tension, can have far-reaching effects. For example, a good night’s sleep aids in regulating cortisol, which in turn can help manage stress levels.
SSRIs
Selective serotonin reuptake inhibitors are used to treat anxiety and depression and have been shown to reduce both mood and physical symptoms in some women suffering from PMDD (5). While SSRIs can make a difference for some people, they don’t work for everyone (6) and can cause side effects, including nausea, weight gain, and lowered libido. If your symptoms don’t improve or side effects persist, you can speak to your doctor about trying a different SSRI.
Hormonal birth control
Contraception can help by preventing ovulation and, consequently, the hormone fluctuations that are closely linked with PMDD.
Research has shown that a contraceptive pill containing drospirenone (a synthetic form of the hormone progesterone) significantly reduced PMDD symptoms in women who took it for 3-4 months. (4) In the UK, the brand name for this pill is Eloine. In the US, it’s Yaz.
When it comes to birth control, it’s important to note that:
• It doesn’t work for everyone and in some cases can make mental health symptoms worse. If your symptoms remain the same or worsen after a few months of trial, speak to your healthcare provider about stopping or trying a different kind of birth control. If your symptoms become severe, speak to your doctor ASAP.
• If you are currently on a form of birth control that doesn’t contain drospirenone and are still impacted by PMDD, it’s worth speaking to a healthcare provider about changing to something that does contain drospirenone and seeing if your symptoms improve.
• You might benefit from taking pills continuously and avoiding the short break or sugar pill days in their pack. This interval triggers a hormone change that may impact you if you're sensitive to hormone fluctuations.
GnRH medications
Gonadotropin-releasing hormone medications are usually used as a second-line option when other treatments have been unsuccessful. These medications, known as GnRH agonists and antagonists, impact a hormone called GnRH, which is involved in regulating menstruation (5).
GnRH medications work by reducing the function of the ovaries, leading to a decrease in estrogen and progesterone. While these medications can help with PMDD symptoms, they come with various risks that affect multiple body systems, even once you stop medication. It is therefore important to discuss these implications with your healthcare provider. (5)
Cognitive-behavioural therapy (CBT)
CBT is a form of psychotherapy that can help you cope with the emotional and mental impact of PMDD. By working one-to-one with a therapist or in a group setting, you are given tools to help you notice and reevaluate thoughts and behaviours. Developing these skills can make it easier to bounce back from life’s inevitable curveballs and help you deal with difficult emotions including sadness, anxiety, and irritability.
CBT is usually prescribed alongside medication to address both mental and physical symptoms of PMDD (this is known as a pharmacotherapy-psychotherapy combination treatment). This method has had mixed success outcomes as its effectiveness largely depends on the severity and type of PMDD symptoms you are experiencing. (5)
1. Find an empathetic doctor
PMDD is a complex condition that can fly under the medical radar. It’s important to work with someone who won’t jump to conclusions and is willing to partner with you to find the right treatment, however long that process might take.
2. Keep a symptoms diary
Track your physical, mental, and emotional symptoms alongside your menstrual cycle. This will help you and your doctor identify patterns that may point to PMDD. Tracking symptoms can also help you anticipate when things are likely to become more challenging so you can take action and soften the impact.
3. Find your community
Tap into the knowledge and support of a PMDD group. There are thousands of women who are going through a similar journey and would love to help you through yours.
4. Adopt a ‘trial and error’ approach
Finding the combination of interventions that is most fitting for you will take time. If something doesn’t work, see it as a stepping stone as you navigate a map that will eventually lead to a happier, healthier you.
References
(1). Understanding and treating PMS/PMDD. (Published: 2003 Authors: Bosarge, Penelope M)
(2). Premenstrual Dysphoric Disorder: Epidemiology and Treatment. (Published: 2015 Authors: Liisa Hantsoo & C. Neill Epperson)
(3). Towards understanding the biology of premenstrual dysphoric disorder: From genes to GABA. (Published: 2023 Authors: Liisa Hantsoo, Jennifer L. Payne)
(4). The efficiency of oral contraception containing drospirenone in treating symptoms of premenstrual syndrome or premenstrual dysphoric disorder in gyneacology practice. (Published: 2010 Author: Svojanovská K)
(5). Treatment of premenstrual dysphoric disorder (PMDD): advances and challenges. (Published: 2021 Author: L. Hantsoo, J. Riddle)
(6). Selective serotonin reuptake inhibitors and initial oral contraceptives for the treatment of PMDD: effective but not enough. (Published: 2008 Author: Uriel Halbreich)
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