Premenstrual dysphoric disorder (PMDD) is a severe form of premenstrual syndrome (PMS). Many women experience abdominal pain or a headache, are tense, sad and irritable or feel bloated and uncomfortable in the days leading up to their period. The medical term for this is “premenstrual syndrome”, also known as “premenstrual tension” (PMT).
PMS symptoms are usually not very severe and most women cope well with them. But some women have such severe PMS that they are unable to go about their everyday lives during that time. If that is the case, various treatment options are available. Like PMS, premenstrual dysphoric disorder follows a predictable, cyclic pattern. Symptoms begin in the late luteal phase of the menstrual cycle (after ovulation) and end shortly after menstruation begins.
PMDD is a severe, sometimes disabling extension of premenstrual syndrome. Although regular PMS and PMDD both have physical and emotional symptoms, PMDD causes extreme mood shifts that can disrupt your work and damage your relationships. PMDD occurs in 2% to 10% of menstruating women.
Women with family history of premenstrual syndrome or PMDD are at greater risk for developing PMDD, as there appears to be a strong genetic component. PMDD symptoms may be severe enough to interfere with a woman’s daily life. Women with depression may have worse symptoms during the second half of their cycle and may need changes in their medication.
Some women with PMDD have suicidal thoughts. Suicide in women with depression is more likely to occur during the second half of their menstrual cycle.
What are the symptoms?
In both PMDD and PMS, symptoms usually begin seven to 10 days before your period starts and continue for the first few days during the time that you have your period. Both PMDD and PMS may cause the same symptoms like bloating, breast tenderness, fatigue and changes in sleep and eating habits. In PMDD, however, the symptoms are severe.
The symptoms can include any of the following:
- Mood swings.
- Depressed mood or feelings of hopelessness.
- Marked anger, increased interpersonal conflicts.
- Tension and anxiety.
- Decreased interest in usual activities.
- Difficulty concentrating.
- Fatigue or increased tiredness.
- Change in appetite, food cravings or binge eating.
- Feeling out of control or overwhelmed.
- Sleep problems.
- Physical problems, such as bloating, breast tenderness, swelling, headaches, joint or muscle pain.
- Increased craving for carbohydrates.
What causes PMDD?
As with PMS, the exact cause of PMDD is not known. Most researchers, however, believe PMDD is brought about by the hormonal changes related to the menstrual cycle.
Recent studies have shown a connection between PMDD and low levels of serotonin, a chemical in the brain that helps transmit nerve signals. Certain brain cells that use serotonin as a messenger are involved in controlling mood, attention, sleep, and pain. Therefore, chronic changes in serotonin levels can lead to PMDD symptoms.
Underlying depression and anxiety are common in both PMS and PMDD, so it’s possible that the hormonal changes that trigger a menstrual period worsen the symptoms of mood disorders. If you have any of the PMDD symptoms listed, you should see your doctor.
The following risk factors may also play a role:
- Alcohol or substance abuse.
- Thyroid disorders
- Being overweight.
- Having a mother with a history of the disorder.
- Lack of exercise.
How is PMDD diagnosed?
No physical examination or lab tests can diagnose PMDD. A complete history, physical examination (including a pelvic exam), thyroid testing and psychiatric evaluation should be done to rule out other conditions. Before a doctor makes a diagnosis of PMDD, he or she will rule out other emotional problems, such as depression, anxiety or panic disorder, as the cause of the symptoms.
In addition, underlying medical or gynaecological conditions, such as endometriosis, fibroids, menopause and hormonal problems that could account for symptoms also must be ruled out. PMDD is diagnosed when at least five of the listed symptoms (including at least one of the first four) occur for most of the time during the seven days before menstruation and go away within a few days of the start of the menstrual period.
If these symptoms are present every day and do not improve with menstruation, they are unlikely due to PMDD.
How Is PMDD treated?
Treatment is directed at preventing or minimizing symptoms. Many of the same strategies used to treat PMS may also be helpful in relieving symptoms of PMDD. The four main forms of treatment include:
Good nutrition: Many health experts recommend that women with PMDD limit their intake of salt, caffeine, refined sugar, and alcohol. Supplements, such as calcium, vitamin B6, vitamin E and magnesium may be recommended. Some studies have suggested consuming 1 200mg of dietary and supplemental calcium daily to reduce symptoms of PMS and PMDD in some women. Please speak to your doctor before taking any of these supplements.
Lifestyle changes: Regular aerobic exercise such as walking or swimming appears to improve premenstrual symptoms. It’s unclear whether it can treat PMDD, although exercise is generally recommended as it has additional benefits. Cutting back caffeine, avoiding alcohol and stopping smoking may ease symptoms, too. Getting enough sleep and using relaxation techniques, such as mindfulness, meditation and yoga, also may help. Avoid stressful and emotional triggers, such as arguments, whenever possible.
Medications: Several antidepressants may be used to treat PMDD. Selective serotonin reuptake inhibitors, such as fluoxetine (Prozac, Sarafem, others) and sertraline (Zoloft), may reduce symptoms such as emotional symptoms, fatigue, food cravings and sleep problems. Other antidepressants have also been effective in relieving symptoms of PMDD.
These medicines can be taken continuously or intermittently (only during the 14-day premenstrual period). Taking them intermittently may decrease the side effects of these drugs. Some over-the-counter pain relievers such as aspirin, ibuprofen (Motrin), and naproxen (Aleve) may help some symptoms such as headache, breast tenderness, backache, and cramping.
Diuretics, or water pills, can help with fluid retention and bloating. Hormones can be used to treat PMDD. Ovulation can be stopped, either using medication or surgically (as a last resort). Medicines used to stop ovulation include birth control pills. The second hormonal approach to treat PMDD is the use of progesterone or oestrogen to relieve symptoms. It’s unclear whether this approach is effective. Another approach involves taking birth control pills with no pill-free interval or with a shortened pill-free interval. v
Counselling: Therapy to help women with PMDD develop effective coping strategies may help some with PMDD. Relaxation therapy, meditation, reflexology and yoga may also help, but these approaches have not been widely studied. Cognitive behavioural therapy (CBT) may be used either with, or instead of, antidepressants. During CBT, you will have about 10 visits with a mental health professional over several weeks.