What is PMDD?

Premenstrual Dysphoric Disorder (PMDD) is a cyclical, hormone-based mood disorder with symptoms arising during the premenstrual, or luteal phase of the menstrual cycle and subsiding within a few days of menstruation. It affects an estimated 5.5% of women and AFAB individuals of reproductive age. While PMDD is directly connected to the menstrual cycle, it is not a hormone imbalance. PMDD is a severe negative reaction in the brain to the natural rise and fall of estrogen and progesterone.

Those with PMDD are at increased risk for suicide and suicidal behavior. Many people with PMDD, though not all, have a history of sexual trauma or depression. There is no blood or saliva test to diagnose PMDD although these tests can rule out other underlying disorders. The only way to diagnose PMDD is by tracking symptoms daily for at least two menstrual cycles.

AFAB = assigned female at birth

Symptoms of PMDD

  • Mood/emotional changes (e.g. mood swings, feeling suddenly sad or tearful, or increased sensitivity to rejection)
  • Irritability, anger, or increased interpersonal conflict
  • Depressed mood, feelings of hopelessness, feeling worthless or guilty
  • Anxiety, tension, or feelings of being keyed up or on edge
  • Decreased interest in usual activities (e.g., work, school, friends, hobbies)
  • Difficulty concentrating, focusing, or thinking; brain fog
  • Tiredness or low-energy
  • Changes in appetite, food cravings, overeating, or binge eating
  • Hypersomnia (excessive sleepiness) or insomnia (trouble falling or staying asleep)
  • Feeling overwhelmed or out of control
  • Physical symptoms such as breast tenderness or swelling, joint or muscle pain, bloating or weight gain

A diagnosis of PMDD requires the presence of at least five of these symptoms, one of which must be a "core emotional symptom" (one of the first four symptoms listed in bold). 4,5

Just finding out about PMDD and not sure where to start? Check out our handy ‘beginners guide’ here:

Causes of PMDD

PMDD is believed to be heritable as shown in studies on families and twins.6 It is a suspected hormone sensitivity disorder in the brain. Studies suggest that, among women and AFAB individuals with PMDD, brain circuits involved in emotional response may activate differently compared to those without PMDD.7 This could be due to atypical brain reactions to luteal phase changes in allopregnanolone (ALLO; a main progesterone metabolite) in those with PMDD versus those without. While increased ALLO usually makes people feel calmer, ALLO has an abnormal, opposite effect in PMDD— it causes agitation, anxiety, and negative mood changes. It is possible that women with PMDD have developed a tolerance to the calming effect and emotional regulation of ALLO.8,9

In 2017, researchers at the National Institutes of Health (NIH) found that women with PMDD are more sensitive to changes in the sex hormones estrogen and progesterone, and they found that this might be due to a molecular mechanism in their genes. Researchers compared white blood cells in women with PMDD and those without, and confirmed that women with PMDD had differences in the genes that process sex hormones.4

There are many ongoing areas of research into the causes of PMDD; ultimately, it may be that PMDD results from a combination of these factors.


Further Reading - The Etiology of Premenstrual Dysphoric Disorder: 5 Interwoven Pieces by MGH Center For Women's Mental Health

PMS & PMDD

The term premenstrual syndrome (PMS) has a long history both clinical and colloquial. PMS is often used in the general population and popular culture in a way to explain or dismiss a woman's volatile mood, depression, anger, or behavior. Clinically, PMS is a collection of emotional and/or physical symptoms including bloating, breast tenderness, increased hunger, weepiness, and irritability. A woman or AFAB individual with PMS will have fewer, and usually less severe, premenstrual symptoms than a woman with PMDD.11 PMS is more common than PMDD, and as many as 80% of women experience some form of PMS in the second half of their menstrual cycle. Women may experience mild, moderate, or severe symptoms of PMS

PMS may interfere with a woman's quality of life, interpersonal relationships, or ability to attend work or school, according to the American College of Obstetricians and Gynecologists. However, PMS symptoms are generally more easily managed than PMDD and do not require prescription medication including antidepressants. PMS is also not classified as a mental illness in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), while PMDD is.

PMDD is characterized by a cluster of mood symptoms that recur in the luteal phase of most menstrual cycles over the course of a year. An estimated 2-8% of women meet the criteria for PMDD. PMDD may be mild, moderate, or severe. PMDD is the only form of premenstrual disorder currently classified in the DSM-V. While PMS and PMDD are often used interchangeably in mainstream media and popular culture, the etiology, diagnosis, and treatment widely differ. It is important to use the correct terminology when discussing PMDD so that awareness, education, and treatment may be correctly achieved.

 

The Personal Impact of PMDD

PMDD can cause severe emotional, professional, and personal harm to those who have it. Sufferers of PMDD report damaging and impulsive behaviors that may include suddenly leaving a job or a relationship. Others report sudden and increased thoughts about suicide and self-harm. PMDD can feel like a "half-life". PMDD can feel like "one week of hell and three weeks of cleaning up".  As women today have an estimated 450 periods during their lifetime, PMDD is a long term diagnosis. Providing sufferers with compassion and understanding is the first step in improving patient outcomes. The free tools, resources, information, and support provided by IAPMD can help you in this journey.

 
 

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Citations

  1. Pagano, M.D., T. (Ed.). (2014, June 28). Sexual Health: Your Guide to Premenstrual Dysphoric Disorder. Retrieved April 23, 2015, from http://www.webmd.com/women/pms/premenstrual-dysphoric-disorder?page=2  

  2. Gallenberg, M.D., M. (2012, December 14). What's the difference between premenstrual dysphoric disorder and premenstrual syndrome? Retrieved April 20, 2104, from http://www.mayoclinic.org/diseases-conditions/premenstrual-syndrome/expert-answers/pmdd/faq-20058315

  3. Goldberg, M.D., J. (Ed.). (2014, September 7). Depression, Thyroid Conditions, and Hormones. Retrieved April 23, 2015, from http://www.webmd.com/depression/guide/depression-the-thyroid-and-hormones

  4. "Sex Hormone-Sensitive Gene Complex Linked To Premenstrual Mood Disorder". 2017. Medicalxpress.Com. Accessed January 4 2017. http://medicalxpress.com/news/2017-01-sex-hormone-sensitive-gene-complex-linked.html

  5. Diagnostic and Statistical Manual of Mental Disorders (5th ed.), (2013), American Psychiatric Association. Washington, DC.

  6. PMDD Research — UNC Center for Women's Mood Disorders. (2016).Med.unc.edu. Retrieved 17 March 2016, from https://www.med.unc.edu/psych/wmd/research/pmdd

  7. Huo L, Straub RE, Roca C, et al. Risk for premenstrual dysphoric disorder is associated with genetic variation in ESR1, the estrogen receptor alpha gene. Biol Psychiatry. 2007;62(8):925-933.

  8. Comasco E, Hahn A, Ganger S, et al. Emotional fronto-cingulate cortex activation and brain derived neurotrophic factor polymorphism in premenstrual dysphoric disorder. Hum Brain Mapp. 2014;35(9):4450-4458.

  9. Girdler SS, Straneva PA, Light KC, et al. Allopregnanolone levels and reactivity to mental stress in premenstrual dysphoric disorder. Biol Psychiatry. 2001;49(9):788-797.

  10. Hantsoo L, Epperson CN. Premenstrual Dysphoric Disorder: Epidemiology and Treatment. Current psychiatry reports. 2015;17(11):87. doi:10.1007/s11920-015-0628-3.

  11. Menstruation and Menstrual Suppression Survey Fact Sheet. (2018). Arhp.org. Retrieved 22 August 2018, from http://www.arhp.org/publications-and-resources/studies-and-surveys/menstruation-and-menstrual-suppression-survey/fact-sheet


Reviewed January 14, 2019 by Dr. Liisa Hantsoo