Premenstrual dysphoric disorder, or PMDD for short, is essentially a supercharged version of premenstrual syndrome (PMS). The “disorder” term is important: For the women who have it, it can mean life-interrupting severe psychological and physical symptoms during their luteal phase, right before their period starts.
While PMS affects more than 85% of women <link to previous PMS article on Marea>, 3 to 5% of women have symptoms so intense it qualifies as PMDD. So how do you know if you have PMS or the more rare PMDD? The biggest difference between the two conditions is how miserable that time of the month makes you.
PMS is no picnic, but it shouldn’t be impossible to cope with. If you find you’re having to call out of your regular commitments (school, work, etc.), or rain-check weekend outings when you’re about to start your period, you could be suffering from PMDD.
The symptoms of PMDD shouldn’t be ignored—and there are specific criteria for diagnosis and several treatment options. Here’s how to know if the PMS symptoms you’re dealing with are on the spectrum…or if you’re suffering from PMDD.
Symptoms You Shouldn’t Ignore
PMDD basically turns PMS symptoms up to 11. That means major mood changes, irritability, and anxiety, in addition to crippling fatigue and headaches. Here are the most common complaints, as outlined by the American College of Obstetrics and Gynecology (ACOG):
Psychological symptoms of PMDD:
- Angry outbursts
- Social withdrawal
Physical symptoms of PMDD:
- Abdominal bloating
- Breast tenderness or swelling
- Joint or muscle pain
- Swelling of extremities
- Weight gain
The key factor in all of these symptoms is that they get worse right before your period, then mostly resolve a few days after menstruation. If they seem to last for the entire month, you may be dealing with premenstrual exacerbation—an entirely different condition in which existing mental health issues (such as major depressive disorder or bipolar disorder) are exacerbated by your period.
Diagnostic criteria for PMDD includes having at least five of the above symptoms in the five days before you get your period, with symptoms generally relieved within four days of the onset of your period. Depression is the most commonly reported symptom. Symptoms should be severe enough to interfere with your social life, work, or schooling.
However, some of these symptoms could be related to other mental health conditions, such as depression or a panic disorder, or other gynecological issues, such as endometriosis or fibroids.
Your physician will work to rule these and other conditions out before giving you a diagnosis of PMDD, if that may be the case.
What to Do If You Think You Have PMDD
If you think your PMS symptoms are interfering with your life, keep a log of what you’re experiencing and talk to your OB/Gyn. Your doctor will want to see at least two months’ worth of symptom tracking.
There’s also a handy quiz to take a quick self-assessment, but this shouldn’t serve as a true medical diagnosis.
Causes of PMDD
This probably doesn’t come as a surprise given big Science’s lack of research on women, but the exact cause of PMDD is largely unknown. Some studies have shown that women with PMDD have lower levels of the neurotransmitter serotonin, which is involved in regulating mood and sleep.
Some suspect that the main cause of PMDD is related to a histamine intolerance or an abnormally sensitive response to allopregnanolone, a metabolite (derivative) of progesterone, one of the main hormones involved in the menstrual cycle. This sensitivity could be genetic, but it could also be related to other factors such as stress, being overweight, or having a history of trauma or abuse.
Another study found that patients with PMS/PMDD had lower levels of magnesium throughout the course of their menstrual cycle.
Here's where we stand. We believe in the functional medicine approach. Every physician is different, just like every body is different and some will use SSRI's or oral contraceptives as first line of treatment.
We believe that you should always start with things you can control in your life, things that don't require a prescription or solution with additional side effects. Here's a quick checklist of where we like to start.
- Are you supporting yourself with nutritious foods, eating enough and supplementing where necessary?
- Are you currently getting enough sleep?
- Are your mindfully managing stress?
- Getting regular exercise?
- Supporting your gut health?
If you're not answering yes to all of these then we believe there is room for symptom improvement by working toward being able to answer yes to all of these.
For most physicians, the first line of treatment is usually selective serotonin reuptake inhibitors (SSRIs), with good results. In clinical trials, 60 to 70% of women with PMDD usually see an improvement in their symptoms, compared to 30% on placebo. SSRIs tend to help those who have more mood symptoms than physical symptoms, however.
Some patients with PMDD have seen good results using SSRIs solely during the luteal phase (luteal phase dosing) as opposed to taking them continuously throughout the month. This has the added benefit of reducing side effects such as sexual dysfunction, among others. It’s important to note that people with bipolar disorder are not usually a good candidate for SSRI therapy. Talk to your doc about a course of action that works for you.
Oral contraceptives are the second-line treatment for many, as the progestin (synthetic progesterone) included in these drugs doesn’t convert to allopregnanolone, eliminating that issue of sensitivity for some.
Magnesium, calcium, and B6 supplementation has shown to be helpful, as these nutrients (all found in Marea) help in the production of GABA (a neurotransmitter) and assist with the body’s response to progesterone, as well.
Other alternatives that may prove helpful are a low-histamine diet, cognitive behavioral therapy, and exercise.
Side note: Be your own health advocate. Before starting any new pharmaceutical or supplement regimen, be sure to do your own research using reputable sources and speak to your physician and healthcare team about any potential side effects or drug interactions. We believe in empowering yourself with knowledge to make the best possible decision. Be curious and ask questions—no one knows your body better than you do.
Can PMDD Be Treated with Self-Care?
While self-care is an important part of any healthy lifestyle, symptoms of PMDD are so severe that they often require medical intervention *in addition to* proper self-care, including rest, physical activity, and a balanced diet. However, PMDD shouldn’t be managed with self-care alone. Talk to your doctor if you find that you’re unable to cope with your PMS symptoms.
Fathizadeh N, Ebrahimi E, Valiani M, Tavakoli N, Yar MH. Evaluating the effect of magnesium and magnesium plus vitamin B6 supplement on the severity of premenstrual syndrome. Iran J Nurs Midwifery Res. 2010;15(Suppl 1):401–405.
Hofmeister S, Bodden S. Premenstrual syndrome and premenstrual dysphoric disorder. American Family Physician. 2016;94(3):236-240.
Yoder EA. Premenstrual Dysphoric Disorder. Presentation at the 86th Annual Conference of the American College of Osteopathic Obstetricians and Gynecologists. 2019. (PDF).
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