Premenstrual Dysphoric Disorder (PMDD): Symptoms, Causes, & Treatments

What Is PMDD?

Many women experience physical, emotional, and behavioral symptoms prior to menstruation.² However, a portion of women experience symptoms that are severe enough to affect their lives. These women suffer from premenstrual dysphoric disorder.

Women with PMDD often find that their symptoms interfere with their ability to function in many areas, such as their work, school, and relationships, as well as how they feel about themselves. Approximately 3% to 8% percent of women of childbearing age experience PMDD.²

PMDD Vs. PMS

Around 90% of women experience premenstrual syndrome (PMS).³ Like PMDD, PMS involves physical and emotional symptoms that occur one to two weeks before menstruation when levels of hormones like estrogen and progesterone decrease. PMS typically lasts until menstruation is over and hormone levels rise again.

To be diagnosed with PMS, women must report at least one physical or mood symptom in the week before menstruation for at least three menstrual cycles. Common PMS symptoms include bloating, headaches, weight gain, sadness, anxiety, and irritability.

The difference between PMS and PMDD is the amount and severity of symptoms.⁴ Women with PMS may experience one or a few symptoms, but these symptoms do not typically interfere with their functioning. Women with PMDD experience a greater number of symptoms that do affect their functioning in several areas of their lives.

Symptoms of PMDD

Premenstrual dysphoric disorder is a type of depressive disorder that causes symptoms that are severe enough to interfere with a woman’s life.² The symptoms of PMDD are both emotional and physical and are directly related to a woman’s menstrual cycle. They usually begin around one to two weeks before menstruation and gradually resolve after menstruation is over.¹

The symptoms of PMDD may include:⁵

• Depression, feelings of hopelessness, and/or negative thoughts and feelings toward one’s self
• Anxiety disorders, tension, or feeling “on edge”
• Significant mood changes, such as suddenly feeling sad
• Anger, irritability, and/or an increase in conflicts with others
• Decreased interest in activities or hobbies
• Difficulty concentrating
• Low energy, lethargy, or feeling easily fatigued
• Appetite changes, overeating, and/or food cravings
• An increase or decrease in sleep
• Feeling overwhelmed or out of control
• Physical symptoms such as bloating, breast tenderness, headaches, or muscle pain

To be diagnosed with PMDD, you must experience at least five of the 11 symptoms listed above and at least one of the first four symptoms listed.⁵ Unlike other mental health disorders, the symptoms of PMDD are directly related to a woman’s menstrual cycle.

What Causes PMDD?

Premenstrual dysphoric disorder is caused by the hormonal changes that occur during a woman’s menstrual cycle. Women with PMDD are believed to be more sensitive to these hormonal changes, which increases their risk of experiencing physical and emotional symptoms.²

There are several different theories on how hormones and neurotransmitters play a role in PMDD.² Some researchers believe that certain women may be more sensitive to changes in levels of sex steroids like progesterone. Progesterone levels decrease in the late luteal phase, which is the time between ovulation and menstruation.

The decrease in progesterone affects gamma-aminobutyric acid (GABA), which is a neurotransmitter linked to anxiety and mood. Serotonin levels also fluctuate throughout the menstrual cycle.¹ Women with PMDD may be more sensitive to changes in serotonin, thus leading to mood symptoms.

There is some evidence to suggest that genetics may play a role.² Studies of twins have found that the genes involved with serotonin and estrogen may explain why some women develop PMDD.

Risk Factors of PMDD

Certain risk factors can also increase the likelihood of developing PMDD, including history of trauma, stress, and having a pre-existing anxiety condition.^{2, 6}  While these risk factors do not necessarily cause PMDD, women with these factors have a higher likelihood of experiencing the condition.

Risk factors for developing PMDD include:

• History of psychological trauma
• Stress
• Having a pre-existing anxiety disorder
• Smoking cigarettes
• Obesity

How Is PMDD Diagnosed?

PMDD may be diagnosed by a medical or mental health professional, such as a physician, OBGYN, psychiatrist, or therapist. To diagnose PMDD, a medical professional may conduct a physical exam and ask you about your health history and symptoms.¹

Instead of conducting a physical exam, a mental health professional will ask you about your mental health history and symptoms. Your healthcare provider may also ask you to track your symptoms on a calendar or diary to better understand their pattern.

Medical and mental health professionals may also use screening tools or assessments to gather information about your symptoms. There are several different screening tools used for this purpose, such as the Premenstrual Symptom Screening Tool (PSST).² Once your healthcare provider diagnoses you with PMDD, they will talk to you about your different treatment options.

Treatment of PMDD

There are several different ways to approach treating premenstrual dysphoric disorder, including oral contraceptives, psychiatric medication, and therapy. Additionally, making certain lifestyle changes, such as altering your diet, can also help improve some of the symptoms of PMDD. Many women benefit from utilizing one or more of these forms of treatment.

Here are forms of PMDD treatment:

Medication

Medications are one option for treating PMDD.⁷ Certain psychiatric medications and oral contraceptives can help alleviate the physical and emotional symptoms associated with PMDD. Women typically seek medication if their symptoms are moderate to severe and/or other forms of treatment, like individual therapy, haven’t been effective. Medications are often combined with therapy to improve effectiveness.

Selective serotonin reuptake inhibitors (SSRIs) have shown to be effective in decreasing symptoms of PMS and PMDD.^{2, 7} They work by altering levels of serotonin in the brain. Studies have found that taking SSRIs continuously or only during the luteal phase (i.e., the time between ovulation and menstruation) can help reduce symptoms. Higher doses can also be effective in alleviating some of the physical symptoms.

Selective serotonin-norepinephrine reuptake inhibitors (SNRIs) like venlafaxine can also help decrease mood symptoms. These types of medications alter levels of both serotonin and norepinephrine in the brain. For more information about psychiatric medications, you can talk to a physician or psychiatric provider.

Oral contraceptives (i.e., birth control pills) can also help improve symptoms of PMDD.^{5, 7} The Food and Drug Administration (FDA) has approved birth control pills that contain drospirenone and ethinyl estradiol as effective treatments for PMDD.¹ Taking oral contraceptives can help manage physical symptoms like bloating, headaches, weight gain, swelling, and breast soreness and reduce heavy menstrual bleeding. If you’re interested, speak with your OBGYN.

Therapy

Therapy is another approach to treating PMDD.⁶ Therapy can be provided by a psychologist, social worker, therapist, or counselor individually or in a group setting. It can also be offered face-to-face or through telehealth, which involves speaking with a therapist either over the phone or through a video platform.

Here are forms of therapy for PMDD:

• Cognitive behavioral therapy (CBT): this is a specific type of talk therapy that is effective for treating PMDD.⁷ This form of therapy focuses on changing unhealthy thoughts and teaching skills to deal with anxiety, depression, and stress. Studies on CBT for women with PMDD have found that it can help improve a woman’s ability to deal with the physical and emotional symptoms of PMS and PMDD).
• Mindfulness-based cognitive therapy (MBCBT): this is a type of cognitive behavioral therapy that focuses on increasing awareness and acceptance of negative thoughts, feelings, and sensations.⁸ It incorporates mindfulness-based techniques, like yoga, meditation, deep breathing, and guided imagery into treatment. Rather than resisting the physical and emotional symptoms of PMDD, MBCBT encourages women to accept these sensations and experiences without judgment. MBCBT has shown to be effective in decreasing depression and anxiety in women who suffer from PMS.

Lifestyle Changes

Making certain lifestyle changes can help improve PMDD symptoms. Exercising, eating a healthy diet, and getting adequate sleep may improve depression and reduce the physical symptoms associated with PMS.^{1, 3} Aim to eat a diet that consists of fruits, vegetables, complex carbohydrates, and protein. It is also recommended to avoid salt, caffeine, and sugar two weeks before menstruation.

Studies show that smoking tobacco can worsen symptoms of PMS.³ You should avoid smoking altogether and speak with a healthcare provider if you are interested in quitting.

How to Get Help for PMDD

If you think that you might have premenstrual dysphoric disorder, start by speaking with your OBGYN or healthcare provider about your symptoms. They will be able to assess whether you might be suffering from PMDD. If you are diagnosed with PMDD, they can talk to you about your different treatment options and provide medical treatment.

If you’d like to try therapy to treat your PMDD, ask your healthcare provider for a list of referrals of local therapists that specialize in working with premenstrual disorders. You can also contact your health insurance company, use an online therapist directory, or ask family and friends for recommendations. Look for a mental health professional like a psychologist, social worker, therapist, or counselor that has experience treating women with PMDD.

Psychiatric medication may also be an option for treating your PMDD. To locate a medication provider, you can ask for referrals or recommendations for a psychiatrist or psychiatric nurse practitioner that works with PMDD. You can also contact your health insurance company or search online.

If you are seeing more than one specialist to treat your PMDD, such as an OBGYN, therapist, and psychiatrist, you can consent to have them speak with one another and work together as a treatment team. This allows them to coordinate care, which can help enhance your treatment.

How to Get Help for a Loved One

If you think that someone you know may be dealing with PMDD, start by bringing up your concerns. It is important to be caring and non-judgmental when speaking with them. Also avoid talking about it when the person is irritable or you are experiencing conflict with one another. Instead, bring up your concerns when you’re both calm and you have a private place to talk.

If your loved one is open to hearing your concerns, share some possible treatment options. Explain to them that they can start by talking with their OBGYN or healthcare provider or making an appointment with a therapist or psychiatric provider. Offer to help them search for referrals, call or email providers, or even go with them to their first appointment.

If your loved one is not ready to get help, avoid pressuring them to do so. This will only increase their resistance to future help. Instead, let them know that you are here to help if they change their minds in the future.

6 Ways to Manage PMDD Symptoms

Living with premenstrual dysphoric disorder can be physically and emotionally taxing. In addition to getting treatment, you can also benefit from taking steps to understand your symptoms, relieve stress, maintain good health, and modify your activity at certain points of your menstrual cycle.

Here are six ways to manage PMDD symptoms:

1. Track Your Symptoms

Many women benefit from tracking their periods and PMS symptoms. After a few months of keeping track, you will have a better idea of when your symptoms tend to start and finish. You can track your symptoms by writing them down on a calendar or using an online program or app.

You can also keep track of certain lifestyle factors that may impact your symptoms, such as how much sugar or caffeine you consume, whether you exercised that day, and how much you slept. This allows you to see how these different behaviors affect your PMDD symptoms and can give you insight into habits to work on changing.

2. Release Stress

Stress management is an important tool for coping with PMDD.¹ Too much stress can cause depression, anxiety, and irritability. There are countless ways to release stress. Some women may benefit from physical activity, like running, walking, going to the gym, or playing sports. Other women may find creative outlets, like writing, painting, or sculpting, to be beneficial.

Mindfulness practices, like meditation, yoga, and deep breathing, can also help relieve stress and alleviate symptoms of PMDD.⁹ If you are new to mindfulness, you can take a class or find a guided practice online. Just a few minutes a day can provide benefits.

3. Exercise

Exercising your body on a regular basis can help alleviate PMDD and make it easier to cope with the physical and emotional symptoms that arise during menstruation.¹⁰ Aim for at least two and a half hours a week of moderate physical activity, like yoga, pilates, or power-walking, or at least 75 minutes of vigorous activity, such as jogging or other forms of cardio exercise.¹¹

In addition to helping you cope with PMDD, exercise can help lower your blood pressure and cholesterol and decrease your risk of developing certain cancers, type 2 diabetes, heart disease, and stroke.

4. See a Nutritionist

Eating a healthy diet and getting adequate nutrients can help you manage your symptoms of PMDD. Some women find that eating more complex carbohydrates and protein and avoiding caffeine, salt, and sugar helps reduce the severity of symptoms.^{1, 3/a>}

Some research studies also suggest that calcium, vitamin B6, magnesium, and omega-3 and omega-6 supplements can be helpful. If you think your diet may be affecting your PMDD, consider seeing a nutritionist or dietician for more guidance on how to adjust your eating habits.

5. Plan Ahead

Knowing your symptoms can help you plan ahead for what to expect during the different points of your menstrual cycle. It can be helpful to refer to your calendar or tracking system to see when your symptoms are most severe. On these days you may benefit from eating a clean diet, avoiding alcohol, sugar, and caffeine, exercising, and getting at least eight hours of sleep per night.

During your hardest days, you will also want to manage your expectations for yourself and avoid putting too much on your plate.

6. Join a PMDD Support Group

If you suffer from PMDD, you may feel misunderstood. Connecting with other women who also experience this condition can help you to feel less alone. Joining a PMDD support group is one way to connect. To find a group, you can conduct a search online or ask your healthcare provider for referrals.

PMDD Tests & Self-Assessment Tools

When you see a professional for treatment, they may use one or more screening tools to help determine whether you have PMDD.

Here are screening tools that professionals can use to diagnose PMDD:²

• The Premenstrual Symptom Screening Tool (PSST) is a 19-item questionnaire that asks about the severity of different PMDD symptoms
• The Calendar of Premenstrual Experiences (COPE) asks you to log 22 different symptoms of PMDD for each day of your cycle. Your provider can then see what symptoms arise at different points in time.
• The Daily Record of Severity of Problems (DRSP) allows you to rate 21 different symptoms of PMDD from 1 (not at all) to 6 (extreme)

In addition to screening tools, professionals may also rely on clinical judgment when evaluating you for PMDD. Clinical judgment is when a professional uses their knowledge and experience to arrive at a diagnosis. Your provider may use an assessment tool, clinical judgment, or both when diagnosing you with PMDD.

Self-Assessments

If you suspect you may have PMDD, you can take a self-assessment quiz online. The International Association for Premenstrual Disorders (IAPMD) offers a free screening tool to help you determine if you are suffering from PMS or PMDD. The quiz is based on a screening tool used by the University of Pennsylvania Health System’s Premenstrual Syndrome Program to help screen participants for research studies.

The purpose of the assessment is to help you clarify whether you might be experiencing a premenstrual condition like PMDD. It is not intended to replace a professional’s opinion. You should still speak with your healthcare provider about your symptoms.

PMDD Statistics

Premenstrual syndrome affects the majority of women at some point between puberty and menopause. Though premenstrual dysphoric disorder affects a smaller number of women, the symptoms of PMDD can be severe and significantly affect a woman’s quality of life.

Consider the following statistics related to PMD:

• Around 90% of women of childbearing age experience symptoms of PMS like bloating, cramping, irritability, and fatigue.³
• Over 60% of women report bloating and swelling and 70 percent experience breast-related symptoms like pain and tenderness. Around 22% report severe breast discomfort.⁷
• Around 3-8% of women of childbearing age experience PMDD.¹
• On average, women with PMDD experience 6.4 days of severe symptoms during each menstrual cycle.²
• Throughout the lifetime, women with PMDD may experience 8 years’ worth of severe symptoms.²

Final Thoughts On PMDD

PMDD can be difficult to deal with, but you’re not on your own. Getting help from loved ones and a therapist can make a big difference in how you feel.