Experts share everything you need to know about diagnosing and treating premenstrual dysphoric disorder (PMDD).
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If you menstruate, you're likely well-versed in premenstrual syndrome (PMS). PMS is a combination of emotional and physical symptoms that occur in the days after ovulation (the luteal phase), before the menstrual period (the beginning of the follicular phase). If a woman is not pregnant following ovulation, estrogen and progesterone levels drop drastically, resulting in physical symptoms such as swollen breasts and cramping, and emotional symptoms that include irritability, moodiness, and lethargy. For many people, these symptoms are annoying but manageable and usually begin to abate once their period begins.
For others, PMS is more extreme, leading to severe anxiety, depression, and even suicidal thoughts. The physical symptoms one typically experiences with PMS, including cramping, bloating, breast tenderness, and muscle pain, are often more pronounced. These extreme cases are identified as premenstrual dysphoric disorder, or PMDD, and affect about 3 to 8 percent of women of childbearing age.
What Causes PMDD
Dysphoric: It comes from the Greek words "dys," meaning ill or abnormal, and "phoric," meaning to bear or carry. So why do some women carry these abnormal symptoms? As you might have guessed, genetics play a part—a 30 to 80 percent heritability range, to be exact. Brain structure is connected, too. According to Liisa Hantsoo, Ph.D., an assistant professor of psychiatry at the University of Pennsylvania, who studies the role of hormones and measures stress response in PMDD patients, women with PMDD are more sensitive to stress at different points in their cycle, which is modulated by hormones (including cortisol, the stress hormone) and brain chemistry. Hantsoo's research demonstrates that PMDD patients respond to stress during their cycle in a "physiologically different way" than women who do not have PMDD.
How PMDD Is Diagnosed
The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5) defines PMDD as a depressive disorder. If you meet at least five of the 11 defined symptoms throughout two tracked menstrual cycles, you'll be diagnosed with PMDD.
While PMDD and major depressive disorder share similar characteristics, PMDD symptoms occur between the luteal and follicular phases of the menstrual cycle, while major depressive disorder is characterized by an episode (or multiple episodes) of a severely depressed mood for two weeks or longer. Biologically, stress response and pain sensitivity are measured differently in PMDD versus other mood disorders and are specifically tied to the menstrual cycle, rather than affecting a person's mental state on a daily basis.
If you think you may be experiencing PMDD, the first step is getting in tune with your body. "For both PMDD and PMS, tracking the symptoms across at least two menstrual cycles is the gold standard. It can help you become more familiar with your symptom pattern and can help you identify factors that make your symptoms better or worse," Hantsoo notes. She recommends the use of a tool called the Daily Record of Severity of Problems, which is an online scoring sheet that can be printed and used to manually track symptoms throughout multiple cycles.
How to Treat PMDD
Hantsoo notes that therapy—particularly cognitive behavioral therapy (CBT)—is a good place to start. CBT is a goal-oriented form of therapy, focusing on the thoughts, feelings, and beliefs that a person holds, and how to apply problem-solving strategies to help manage responses to those cognitive processes. Hantsoo notes that CBT techniques that are used for anxiety or depression can be applied to PMDD patients, depending on their particular symptoms.
"If a woman with PMDD tries CBT and isn't getting sufficient symptom relief, medication is the most effective option," Hantsoo says. The American College of Obstetricians and Gynecologists (ACOG) recommends the use of a selective serotonin reuptake inhibitor (SSRI). SSRIs can be taken daily, just as one would manage major depressive disorder or anxiety, or during the luteal phase of the cycle only. A primary care physician or gynecologist can help determine if a patient meets the criteria for a PMDD diagnosis and suggest initial management tactics, including referral to a therapist and/or psychiatrist. "It's important to find health care providers that you feel comfortable with and who will listen and work with you," Hantsoo adds.
Despite the fact that PMDD affects estrogen and progesterone levels, Hantsoo notes that hormonal treatments (such as oral contraceptives, which suppress ovulation) tend to have mixed results for PMDD patients. According to research published in JAMA Psychiatry, some patients report that oral contraceptives exacerbate their PMDD symptoms, while others find that an ethinyl estradiol and drospirenone-based pill (such as Yaz) or continuous levonorgestrel and ethinyl estradiol (such as Lybrel) are effective.
How Exercise, Nutrition, and Natural Remedies Can Help PMDD
In addition to psychotherapy and pharmacologic management, there are other effective strategies for treating PMDD symptoms. According to the Journal of the Institute of Obstetrics and Gynaecology, aerobic exercise has been proven to help improve PMS symptoms, including fatigue and concentration, though it has not been well studied for PMDD. Yoga has also been shown to help with symptoms of anxiety and depression throughout the menstrual cycle. Hantsoo agrees that while exercise may help, it's likely better suited for mild PMS versus severe PMDD, and notes that much of the research out there is correlational—there are very few high-quality studies that show exercise can help relieve symptoms, and results will vary from woman to woman.
There are also more alternative forms of treating PMDD symptoms. Kelly McCarthy, a clinical herbalist, notes that "herbs can fill in the gaps where the prescriptions aren't enough, or can help ameliorate some side effects those prescriptions can have." Specifically, McCarthy recommends the use of "nervines, which calm and support the nervous system; adaptogens, which support our adrenal glands and help us be less affected by stress and long-term mental health struggles like anxiety and depression; and blood movers, which can stimulate the flow of blood, life force, and menstruation."
When determining what herbal remedies to recommend, McCarthy takes the "whole picture" of a patient into account, including "diet, stress levels, sleep quality, and liver function." She has noticed that herbal remedies and teas can help normalize the frequency and duration of one's cycle, reduce cramping and spotting, and improve symptoms of anxiety and depression. McCarthy recommends trying one to two herbs daily for two months, and using the herb prior to the onset of any PMDD symptoms. "Some of my favorite calming and uplifting teas are lemon balm, chamomile, tulsi, and lavender."
McCarthy also notes the importance of balanced nutrition. "Having a diet focused on vegetables, high fiber, and good-quality fats can make a big difference." Hantsoo adds that the ACOG's recommendation of reducing alcohol and caffeine intake, consuming calcium-rich foods (which studies show can help PMS symptoms), and favoring complex carbohydrates over simple carbohydrates is also a smart approach diet-wise. (Although, easier said than done if you're experiencing premenstrual cravings!) And again, Hantsoo notes that nutritional interventions for both PMS and PMDD are an area in need of more extensive study.
And don't forget self-care: McCarthy stresses the value of recognizing what your body needs and listening to those needs.
Hantsoo echoes this advice and says understanding your diagnosis can be empowering. "Have honest conversations with loved ones about your symptoms, and how symptoms can manifest in your relationships; let them know how they can support you when you are feeling symptomatic."
Where Do I Start?
It can take time to find what PMDD management strategies work best for you. If your premenstrual symptoms feel abnormal or unbearable, set up an appointment with your primary care physician to discuss your options. Most importantly, know that you're not alone. The National Suicide Prevention Lifeline is available 24 hours every day at 1-800-273-8255. For additional PMDD resources, check out the Gia Allemand Foundation and the ACOG website.