What Is Premenstrual Dysphoric Disorder (PMDD)
If you’re a woman of childbearing age, there’s a pretty good chance you experience at least one of the symptoms of premenstrual syndrome during the week or two before your period starts from time to time (according to the NHS, most women have PMS at some point (i)).
Some women, however, have much more severe – indeed sometimes disabling – PMS symptoms, known as premenstrual dysphoric disorder (PMDD). This is thought to affect between two and five per cent of premenopausal women (ii), and like PMS it causes a range of emotional and physical symptoms each month.
These symptoms can vary from one woman to the next. One of the manuals used by many doctors as a diagnosis tool – the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (or DSM-5) (iii) – sets out the following symptoms as criteria for diagnosing PMDD:
Marked lability (for example mood swings or suddenly feeling sad or tearful)
Marked irritability or anger
Markedly depressed mood
Marked anxiety and tension
Decreased interest in usual activities
Difficulty in concentration
Lethargy and marked lack of energy
Marked change in appetite (such as overeating or specific food cravings)
Hypersomnia (excessive sleepiness) or insomnia
Feeling overwhelmed or out of control
Physical symptoms such as breast tenderness or swelling, joint or muscle pain, headaches, weight gain and bloating
If you’re affected by at least one of the first four symptoms, plus four or more others, you may be diagnosed with PMDD. According to DSM-5 symptoms of PMDD are also severe enough to interfere with work, school, your usual social activities or your relationships, and are not linked with any other disorder such as major depressive disorder, persistent depressive disorder (dysthymia), panic disorder or personality disorder, or any other underlying medical disorder.
The above symptoms aren’t comprehensive, however, and according to the mental health charity Mind, some people with PMDD also find one of their monthly symptoms is having thoughts about suicide (iv).
What causes PMDD?
PMDD is defined as an endocrine disorder, which means it’s related to your hormones – though at the moment nobody really knows exactly what causes it. However, it’s thought the symptoms may be caused by an increased sensitivity to reproductive hormones, which leads to changes in the brain chemicals and neurologic pathways that control mood and the sense of wellbeing.
Some scientists have discovered an over-expression of a particular gene complex – called ESC/E(Z) – may cause an abnormal sensitivity to the hormones oestrogen and progesterone in women with PMDD, which suggests PMDD symptoms may have a biological basis (v).
Researchers have also found evidence that normal changes in hormone levels – not just the hormones themselves – may trigger PMDD symptoms in those affected (vi). This could explain why PMDD symptoms only happen during the luteal stage of the menstrual cycle. This is the stage lasting 12 - 14 days that starts just after ovulation (when your ovaries release an egg) and ends just before your period starts, during which levels of oestrogen and progesterone are particularly high (in other words the second half of the menstrual cycle).
Meanwhile, there are some risk factors that may make you more likely to be affected by PMDD (vii), including:
A family history of PMS or PMDD
Being overweight or obese
Having a past history of trauma or sexual abuse
According to Mind, some women find getting a diagnosis of PMDD can be difficult, arguably because even health professionals don’t know a lot about it, and because it’s not always obvious that the symptoms are linked to the menstrual cycle.
Here are a few things you could do if you’re not sure whether your symptoms are PMDD related, or if you’re not getting the help you need from your GP, as suggested by Mind (viii):
Keep a detailed record of your symptoms – try noting your symptoms in a diary or download a mood chart from the internet. The longer you do this, the better prepared you’ll be to describe your symptoms to your GP.
Download a copy of the PMDD treatment guidelines from the National Institute for Health and Care Excellence (NICE) and take them with you to your GP appointment (in these guidelines, PMDD is referred to as ‘severe PMS). The National Association for Premenstrual Syndrome also has guidelines for PMDD treatment (it’s called ‘severe PMS’ here too).
Ask to see a GP at your local surgery who specialises in mental health or gynaecology.
Consider finding an advocate – someone who can come to appointments with you and help make sure you’re listened to (find out more about advocacy here).
How is PMDD treated?
If you’re diagnosed with PMDD there are several treatments you may be offered, including the following:
The combined oral contraceptive – the pill – may be an option, especially for women who also need contraception. This may help reduce PMDD symptoms by controlling or preventing your periods, depending on whether you take it cyclically (that is, three weeks out of every four) or continuously. But they don’t work for everyone with PMDD, plus they may also cause side effects. If you’re offered the pill, your GP may want you to try it for just three months initially, to see if it helps.
Painkillers or anti-inflammatory drugs
If you have physical symptoms such as headache or other general aches and pains, your GP may recommend a simple painkiller such as paracetamol or an anti-inflammatory painkiller such as ibuprofen. You can buy these over the counter at pharmacies and many other shops, but it’s a good idea to talk to your GP before you try them.
Cognitive behavioural therapy (CBT)
According to NICE guidelines, women who need help with the psychological symptoms of PMDD may benefit from a referral for CBT (ix). CBT is a talking therapy that aims to help you change the way you think and behave as a way of managing your problems and is commonly used to treat mental health issues such as anxiety and depression. CBT is one of several talking therapies offered within the NHS-based Improving Access to Psychological Therapies (IAPT) programme.
Antidepressant drugs called selective serotonin reuptake inhibitors (SSRIs) are also used to treat PMDD, with studies showing they may be effective when taken every day or just during the second half of the menstrual cycle (x). According to NICE, SSRIs are included in the management of PMDD because there’s increasing evidence that the hormone serotonin may be important in the development of PMS (ix).
If your GP thinks a SSRI treatment may help you, you’d normally be offered an initial trial of three months’ treatment, and if effective, your treatment could last for six months to a year. However, SSRIs can cause several side effects, so they may not be suitable for everyone. Your GP may also offer you antidepressants to treat feelings of depression associated with PMDD.
If none of the above treatments controls your symptoms satisfactorily, your GP may refer you to a clinic with a specialist interest in PMS or a general gynaecology clinic. You may also be asked to consider having a hysterectomy – an operation to remove your uterus – or a bilateral oophorectomy (which removes the uterus, ovaries and fallopian tubes) if your PMDD is very severe and all other treatments have failed to make a difference to your symptoms.
How to care for yourself
If you’re diagnosed with PMDD your GP may give you lifestyle advice that, according to NICE, should include the following:
Have regular, frequent (2 - 3 hourly), small and balanced meals that are rich in complex carbohydrates (whole grains, beans, vegetables, whole wheat pasta, brown rice etc)
Take regular exercise (aim for 150 minutes of moderate-intensity exercise each week)
Have plenty of sleep
Try to reduce stress (using relaxation techniques such as meditation, mindfulness or yoga may help you look after your wellbeing when you’re under pressure)
Give up smoking (if appropriate)
Cut back on alcohol – aim for no more than 14 units of alcohol a week, spreading your units evenly over three or four days
Other diet and lifestyle changes you could make include
The mental health charity Mind also has lots of advice on reducing the impact PMDD has on your life, including the following:
Talk to someone you trust
Having someone listening to you and taking your problems seriously can be a huge help and make you feel better, even if you find sharing details about sensitive things such as your menstrual cycle difficult at first. Try talking to a friend or a family member, or even your GP. Contact with others can also help make you feel less isolated.
Get specialist support
Having contact with an organisation that specialises in support and advice for PMDD can be useful. Here in the UK, you can get in touch with the National Association for Premenstrual Syndrome – or try the US-based International Association for Premenstrual Disorders, which provides links to a number of Facebook groups you could join. You could also join the Elefriends community – a Mind organisation designed to help people with experience of a range of mental health problems.
Know your cycle
Having prior warning of when your symptoms might start can be helpful – if could, for instance, let you put off any stressful events or tasks for another time, and plan relaxing activities that you know would improve your mood. Keeping a record of your symptoms and when during your cycle they happen can help you do this.
Make a self-care box
According to Mind, some people find it helpful to fill a box with things that usually cheer them up and help them relax, such as a favourite book or film and a notebook and pen for keeping a record of your thoughts or to write notes of encouragement to yourself. Why is this useful? Because when your PMDD symptoms have started, it may be difficult to think about things that could help.
Tackle sleep difficulties
Not getting the sleep you need means you may not have the energy to cope with difficult feelings and experiences. If you’re struggling to sleep well, read our guide to sleep and insomnia for tips.
Having regular, frequent meals that are healthy and balanced can help keep your blood sugar stable, which in turn can make a big difference to your mood and energy levels. Aim to have at least five portions of fruit and vegetables every day and try to limit your intake of fatty and sugary foods.
Exercise may be the last thing on your mind when you have PMDD symptoms. But according to Mind exercise can help reduce the symptoms of depression (xi) – plus being physically active may help you to relax.
Spend time in natural surroundings
Being outside in green spaces can help you feel more in touch with your surroundings, says Mind.
Natural support for PMDD
It’s essential to take care of yourself if you’re affected by PMDD or PMS symptoms, which may include taking one or more nutritional supplements such as the following:
A form of inositol – a water-soluble vitamin-like substance – myo-inositol has been researched as a natural treatment for treatments such as polycystic ovarian syndrome (PCOS) and insulin resistance. It has also been looked at by Italian experts for its possible effects on PMDD symptoms (xii). In this trial, women with PMDD were given either a placebo or a myo-inositol supplement, and after the trial period was over those taking the myo-inositol reported significant improvements in their symptoms compared with the women taking the placebo.
High-strength fish oils
The omega-3 fatty acids found in oily fish may be best known for their heart health benefits, but some experts believe they may also combat PMS symptoms. One study, published in the journal Complementary Therapy Medicine, found volunteers who took omega-3 fatty acid supplements for 45 days reported significantly lower levels of depression, anxiety, lack of concentration, headache and breast tenderness than those taking a placebo (xiii). Add more omega-3 fatty acids to your diet by having one or no more than two portions of oily fish each week (salmon, trout, pilchards, sardines, mackerel, herring etc), or look for a good-quality fish oil supplement.
Many natural health practitioners recommend magnesium supplements for PMS symptoms as they’re thought to help with symptoms of irritability, depression, anxiety, tension, bloating, tiredness and headaches. A review of studies looking at dietary supplements and herbal remedies for PMS found two studies of magnesium showed a positive effect (xiv), while other researchers have found magnesium may improve PMS-related mood changes (xv). Foods rich in magnesium include green leafy vegetables, nuts, seeds, beans, avocados, tofu, whole grains, bananas and raw cacao powder.
There is some evidence that taking vitamin B6 may be useful for relieving premenstrual symptoms and premenstrual depression, with one review published in the British Medical Journal suggesting doses of up to 100mg a day may be beneficial (xvi). However, many experts advise caution with a dose this high, as it’s believed taking too much vitamin B6 could cause nerve damage (xvii). The NHS suggests taking doses of 10 - 200mg of vitamin B6 a day for short periods may not cause any harm, though there’s not enough evidence to say how long these doses could be taken for safely (xviii).
Please note: never take high doses of vitamin B6 for anything longer than short periods without seeking medical advice.
You can also get vitamin B6 from foods such as turkey, chicken, pork, fish, avocado, whole grains, eggs, soya beans and bread.
Known as the sunshine vitamin because of the way the body manufactures it when skin is exposed to sunlight, vitamin D has been found in lower levels in women affected by PMS, with researchers writing in the journal JAMA Internal Medicine suggesting a high intake, along with calcium, may reduce PMS risk (xix). Elsewhere scientists have suggested high-dose vitamin D supplements may have positive effects on the physical and psychological symptoms of PMS in adolescents (xx).
In the UK, the Department of Health recommends that everyone should consider taking a daily 10 microgram supplement of vitamin D during the autumn and winter months, when the sun isn’t strong enough for the body to make its own supply and because it’s difficult to get enough vitamin D from food alone (xxi). Some people are also advised to take vitamin D throughout the year if they have very little or no sun exposure.
St John’s wort
This popular herb is used for the relief of slightly low mood and mild anxiety, based on traditional use only. One study also found it to be statistically superior to placebo in improving the most common physical and behavioural symptoms of PMS after volunteers took it daily for two menstrual cycles (xxii).
However, if you’re using hormone-based contraception or taking regular prescription medications including some antidepressant medicines, speak to your GP before taking St John’s wort, as it may interfere with the way certain contraceptives and medicines work.
An alternative to St John’s wort is 5-hydroxytryptophan – or 5-HTP – a natural compound made in the body from the amino acid tryptophan. 5-HTP may be helpful for PMS-related low mood, with a couple of small-scale studies suggesting it may be as effective at treating depression as some antidepressants (xxiii). Synthetic 5-HTP supplements are available, but to find this compound in its natural form look for products made from the seeds of an African shrub called Griffonia simplicifolia.
Premenstrual dysphoric disorder can have a major impact on your everyday life, but these steps may help to make it a little easier to manage. To discover more articles on a range of other common health conditions, visit our health library.
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Christine Morgan has been a freelance health and wellbeing journalist for almost 20 years, having written for numerous publications including the Daily Mirror, S Magazine, Top Sante, Healthy, Woman & Home, Zest, Allergy, Healthy Times and Pregnancy & Birth; she has also edited several titles such as Women’ Health, Shine’s Real Health & Beauty and All About Health.