What is PME?
Premenstrual Exacerbation (PME) refers to the premenstrual exacerbation/worsening of the symptoms of another disorder, such as major depressive disorder or generalized anxiety disorder.
Premenstrual Dysphoric Disorder (PMDD) and Premenstrual Exacerbation (PME) are difficult to distinguish from each other.
PMDD is characterized by experiencing severe mood and physical symptoms usually starting about one to two weeks before the start of one’s period each cycle (during the premenstrual, or luteal phase) with symptoms subsiding within a few days of starting one’s period. PME refers to the premenstrual exacerbation/worsening of the symptoms of another disorder, such as major depressive disorder or generalized anxiety disorder in the luteal or menstrual phases of the cycle. (The luteal phase is the time between ovulation and menstruation).
Unsure if you may have PMDD or PME? Try our self screen:
Both PME and PMDD are described as “Core Premenstrual Disorders” by an International Group of Experts. However, the larger amount of research conducted on PMDD has led to PMDD becoming an official diagnosis in the DSM-5 as of 2013, whereas the research on PME is still lagging behind, and it remains a phenomenon studied in research but not yet diagnosed and treated clinically (similar to PMDD prior to 2013!).
Which conditions can be exacerbated premenstrually?
Major depressive disorder
Persistent depressive disorder (dysthymia)
Suicidality
Schizophrenia
Anxiety disorders
Alcoholism
Eating disorders
And more
At IAPMD we focus predominantly on the exacerbation of psychiatric disorders.
Why do PME and PMDD to be distinguished from each other?
Scientists need to differentiate these conditions to better understand their unique causes which may be different from each other. This is also important because about half of those who seek treatment for PMS or PMDD actually have PME or another psychiatric disorder, like depression, and not PMDD. Correct diagnosis is needed for all, so that all may receive effective treatment for their experience of symptoms.
We also want to make it clear that we understand why some people would be resistant or upset by the idea that they have PME rather than PMDD. Many patients report feeling dismissed by the idea of having PME rather than PMDD since this means that their problem is not yet an official diagnosis.
This is understandable, although do remember that PMDD wasn’t an official diagnosis either until 2013, and it is important to fight to make sure that the experiences of real patients are reflected in our diagnostic systems. Due to mental health stigma, some patients feel as though their symptoms must be ‘less biological’ if they are labeled “PME of depression” rather than “PMDD”.
The downside to having this additional category is that it adds increasing possible confusion for patients and providers. Additionally, some patients say that they feel as though they need to have PMDD (rather than PME) to be taken seriously and receive treatment. Nevertheless, here is why we think it’s worth it to separate them:
Ability to support and advocate for those whose symptoms don’t show the prototypical PMDD pattern: Since those with PME do not meet diagnostic criteria for PMDD, we need a new category for them that allows us to provide them with education, support, and advocacy without changing our fundamental understanding of PMDD as a luteal phase disorder.
Development of new treatment options.
Advocating for research on the role of the cycle in PME of various disorders. By highlighting that the symptoms of various chronic disorders show fluctuating severity across the cycle, we can raise awareness of these issues in many different clinical and research areas that would otherwise ignore the impacts of the menstrual cycle.
In the end, everyone deserves validation, support, and a compassionate and knowledgeable group of providers to help them find the right treatment for them. We acknowledge both PMDD and PME as core premenstrual disorders because we believe that this acknowledgment of diverse symptom presentations will improve the lives of those living with PMDs.
We must have a label or category for those individuals (who live with PME) if we are going to predict who responds to which treatment, and demand the development of new treatments that are effective for PME (currently there are no evidence-based treatments).
If you are unsure if you have PMDD or PME you can try our self-screen here.
How can we differentiate PMDD and PME?
Researchers suggest that we can differentiate PMDD and premenstrual exacerbation of another disorder by going ‘symptom by symptom’ with daily ratings (tracking) of the severity of each symptom. To do this, they explain that “symptoms of the ongoing disorder that worsen premenstrually should not be counted as symptoms of PMDD, but should instead be considered evidence for [PME]… of the current disorder. For example, depressed mood that increases premenstrually in a woman with [major depression] is considered to be evidence for [PME] of the woman’s major depression, rather than considered as a possible symptom of PMDD.”
You can see how this gets tricky. Depressed mood is a symptom of both PMDD and major depression. So, is depressed mood severe premenstrually because of PMDD or premenstrually exacerbated major depression? Also, could the cyclic depressed mood of PMDD have caused the now co-occurring major depression? However, despite the theoretical controversy, this method is often effective in diagnosing PMDD and PME respectively, although it is conservative and could lack some sensitivity (i.e. with this method, it is difficult to receive diagnoses of both major depression and PMDD because the conditions share some of the same symptoms).
So is it PMDD or PME?
PMDD – symptoms arise premenstrually, subside within a few days of starting one’s period, and are not present in the week post-period.
PME – symptoms are present throughout the entire cycle, but become more severe in the premenstrual phase.
PMDD and PME – some symptoms are present throughout the entire cycle and worsen in the premenstrual phase. Some additional symptoms arise only in the premenstrual phase and subside around the time of one’s period.
How are treatments for PMDD and PME different?
Selective serotonin reuptake inhibitors (SSRIs; type of antidepressant) are considered a first-line clinically effective treatment for PMDD. Often physicians may prescribe an SSRI to be taken only in the luteal/premenstrual phase for patients with PMDD and this treatment is often effective. However, for PME, SSRIs should be prescribed to be taken throughout the entire cycle to treat the underlying disorder. Then, if symptoms persist in the premenstrual phase, physicians may prescribe an increased dose to be taken only in this phase.
Several RCTs (randomized controlled trials) indicate that those with PME of depression don’t seem to respond well to some of our best treatments for PMDD, including drospirenone-containing oral contraceptive pills, GnRH agonists, or Sepranolone. So far, no studies have demonstrated the effectiveness of any treatment for PME of depression, although of course any treatment that improves the underlying depression may be expected to have a positive impact on the person’s overall symptoms.
In addition, some of the later lines of treatment for PMDD (including chemical menopause and surgical menopause) are often effective for PMDD, but do not effectively treat the underlying disorder when it comes to PME. This is another reason why correct diagnosis is extremely important. Before drastic measures are taken, those experiencing premenstrual symptoms should carefully track these symptoms prospectively and be open to the possibility of a diagnosis of either PMDD or PME of another condition.
What’s the bottom line?
If you experience symptoms only in the premenstrual phase, it is most likely PMDD. If you experience symptoms throughout your entire cycle, but they are more severe in the premenstrual phase, it is most likely PME of another condition. PMDD and PME may also co-exist.
All this being said, it’s important to note that while this is based on the clinical diagnostic criteria for PMDD and other conditions, you have every right to own your unique experience. You know your body. You know when you feel good and you know when you don’t. Your experience of PMDD, PME, or another condition could be somewhat different from the ‘textbook definition,’ and that is always deserving of compassion, understanding, and effective treatments.
