What is Premenstrual Dysphoric Disorder?


If you experience emotional or physical changes in the days leading up to your period, you are not alone (1). In fact, up to 90% of women report experiencing at least one of these symptoms (2). For some women, these symptoms can be severe and impact their day-to-day life (3,4). If this applies to you, you may be interested to learn more about premenstrual dysphoric disorder (PMDD). In this blog post, we’re going to talk about:


Before we get started, missINFORMED would like to note that Kyra is not a medical professional and this blog post is not a substitute for medical advice. The purpose of this blog post is to help the missINFORMED community get a better overall understanding of PMDD, and to share information that may help guide discussions about PMDD with healthcare professionals. Every menstruator is unique, and it is important to work with healthcare professionals to care for your unique needs! There is no ‘one size fits all’ approach to PMDD.


missINFORMED would also like to take this opportunity to recognize that not all people who menstruate are women and not all women menstruate. The term ‘women’ is used whenever cited literature only studied cisgender women, or did not specify gender, leading us to believe only cisgender women were included based on historical representations. In all other instances, the term ‘menstruator’ is used.


What is PMDD?

You have probably heard about premenstrual syndrome (PMS) before, which is a very common experience for many menstruators around the start of their period. PMDD can be thought of as ‘severe PMS’ because they share a lot of the same symptoms (4). Those living with PMDD typically experience severe irritability, depression, anxiety, pain, and/or changes to eating behaviours 1-2 weeks before their period (3, 4) (scroll down for full symptoms list). Symptoms are usually most severe 3-4 days before the period starts and can last for up to three days after it ends (5). Additionally, symptoms will not be present in menstruators who do not have ovaries, are menopausal, pregnant, breastfeeding, or in other situations where periods have stopped (6,7). PMDD is classified as a depressive disorder under the DSM-5 (8). The DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) is a guide that contains descriptions and symptoms of mental disorders used to aid healthcare practitioners in diagnosis (15). This handbook is periodically reviewed and updated to accommodate new research so that diagnoses can be consistent and reliable. Using DSM-5 criteria, it is predicted that 1-2% of women suffer from PMDD (6). However, it is estimated that up to 20% of women experience significant symptoms prior to their period (9).


How is PMDD diagnosed?

Diagnosis for PMDD is achieved by using mood and experience tracking tools to help identify trends (5). This is done to rule out the possibility that patients have another underlying issue that is simply heightened by changes in the menstrual cycle. Tracking symptoms has the added benefit of helping menstruators learn more about when symptoms occur and what factors may make them better or worse.


To be diagnosed under the DSM-5, patients must have at least five of the following symptoms, with at least one being mood-related (8). These symptoms must cause significant distress and/or interference with typical day-to-day activities:


  • Depressed mood, feelings of hopelessness, and self-deprecating thoughts

  • Anxiety, tension, and feeling ‘on-edge’

  • Mood swings

  • Irritability, anger or increased conflict

  • Loss of interest in normal activities

  • Difficulty concentrating

  • Feeling lethargic, lack of energy

  • Changes in appetite, including overeating or intense specific cravings

  • Hypersomnia (oversleeping) or insomnia (inability to sleep)

  • Feeling overwhelmed

  • Physical symptoms such as:

  • Breast tenderness/swelling

  • Joint/muscle pain

  • Bloating

  • Weight gain

These symptoms must be present during the majority of menstrual cycles, start to improve within a few days after a period, and go away in the week after. You can learn more about tracking PMDD and PMS symptoms here



Why does PMDD happen?

Studies have shown that women with PMDD have estrogen and progesterone levels within the normal range (6). Check out this piece to learn more about how these hormones work in the menstrual cycle (bonus: its bachelor themed!). So you’re probably wondering - if their hormone levels are the same, why are their symptoms so much more severe? Research is still ongoing, but it is thought that menstruators who suffer from PMDD have a higher sensitivity to normal hormonal changes during the menstrual cycle (6). Basically, although the same amounts of hormones are circulating in the body, they produce stronger effects in some individuals. Both estrogen and progesterone have effects on the nervous system that may account for this.


When progesterone is produced by the ovaries it gets converted into allopregnalone (ALLO). ALLO has an anti-anxiety effect, and it is thought that when progesterone (and therefore ALLO) levels drop prior to the onset of your period, this causes ‘withdrawal’ in menstruators with PMDD. Rodent models have supported this idea, as it has been shown that decreasing progesterone leads to depressive and anti-social behaviours. Depressive and anxiety-like symptoms were also found in mice that had low ALLO in the hippocampus, prefrontal cortex, and amygdala in the brain. However, blocking the conversion of progesterone to ALLO prior to withdrawal reduces these symptoms, suggesting that ALLO is primarily responsible for the ‘withdrawal’ effect (10).


Estrogen has also been shown to have powerful effects on mood, appetite, sleep, and behaviour (6). Estrogen is known to regulate the activity of serotonin and norepinephrine in the body, both of which are associated with positive feelings. In animal studies, increasing estrogen levels have been shown to increase serotonin transport in the brain. There is also evidence that women with PMDD have reduced serotonin levels when estrogen levels drop prior to a period. The link between estrogen and serotonin may provide another explanation for the depressive symptoms women with PMDD experience.


What does PMDD treatment look like?*

*This information is not to be taken as health advice. Trained healthcare professionals may recommend different treatments tailored to your specific symptoms. The purpose of this section is to inform on what PMDD treatment MAY look like, but it is in no way a replacement for speaking with your healthcare provider.


The goal of PMDD treatment is typically to either ‘correct’ chemical imbalances in the brain, or to eliminate hormonal fluctuations entirely (9). Antidepressants are the current gold standard for PMDD treatment (4, 5, 6). Specifically, selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs) are used. When antidepressants are used for the management of other psychiatric disorders, it typically takes a few weeks to see improvement, but PMDD patients may see improvement within a day or two (5). It has been shown that taking SSRIs during the second half of the menstrual cycle or taking them continuously reduces symptoms of PMDD (16). This is most likely because SSRIs are able to increase the formation of steroid hormones, such as progesterone, in the body. SSRIs have also been shown to kickstart progesterone transformation into ALLO within minutes of taking them, which may help with ALLO withdrawal. This feature makes it possible to take antidepressants intermittently to control mood swings, but continuous doses may be required to control depressive and anxious symptoms.


Combined oral contraceptives (COC) contain both estrogen and progesterone and have been shown to improve PMDD symptoms by reducing hormonal fluctuations. Typically, these pills are taken in a 21-day cycle with a 7-day break during your period. However, when managing PMDD symptoms, greater improvement has been shown with a 24-day cycle and a 4-day break, which makes hormone levels more stable (7). Compared with a placebo, this regimen has been shown to improve emotional and physical symptoms (11). However, this should be taken with a grain of salt, as more recent studies have suggested that there is a large placebo effect when taking COCs for the management of PMDD (12).

In more severe cases of PMDD, treatment is focused on ‘shutting off’ hormone production by the ovaries to avoid hormonal fluctuations throughout the menstrual cycle. This can be done chemically using GnRH (gonadotropin releasing hormone) agonists and inhibitors, or surgically with oophrectomy as a last resort. GnRH is a hormone that is produced in the brain, and its presence causes the ovaries to produce estrogen and progesterone (13). GnRH agonists ‘mimic’ the body's natural GnRH, but do not result in the production of estrogen and progesterone. Instead, high levels of the GnRH agonist ‘tricks’ the brain into thinking it has already produced enough, and it stops natural production. Once natural GnRH stops being produced, there is nothing in the body to trigger estrogen and progesterone production in the ovaries, causing those levels to drop too. GnRH inhibitors, on the other hand, act directly in the brain to stop natural GnRH from being produced. The use of GnRH agonists and inhibitors is commonly called ‘chemical menopause’ because of their ability to shut off hormone production in the ovaries, and they can be used as a ‘trial-run’ to determine if a full oophrectomy is right for you (5).


An oophrectomy is a last resort for PMDD treatment. An oophrectomy involves the removal of the ovaries, and was first performed for treatment of PMDD in 1872! In studies on women who have received oophrectomy for management of severe pre-menstrual symptoms, 96% were satisfied with the results of the surgery for symptomatic relief (14). However, this is not a ‘perfect treatment’ and can result in bowel and bladder problems, bleeding, and leads to permanent early menopause. Though all menstruators will eventually come face to face with menopause at some point, it is important to make sure you are ready for this change before you seek surgery. The estrogen deprivation that happens during menopause causes symptoms such as genital atrophy, skin ageing, changes to metabolism and body fat storage, and even osteoporosis (17). These symptoms can be reduced by supplementing estrogen after the surgery, but it is important to recognize how stressful this can be on your body when you are deciding (14). Additionally, if you wish to try to become pregnant, this treatment will not be a good fit for you.


Other options that may help PMDD symptoms include cognitive behavioural therapy, yoga, aerobic exercise, and dietary supplementation for calcium, omega-3 fatty acids, and vitamin B6. However, there is not enough research to say whether or not these strategies actually help (5).


References

  1. Wittchen H-U, Becker E, Lieb R, Krause P. Prevalence, incidence and stability of premenstrual dysphoric disorder in the community. Psychological Medicine. 2002 Jan;32(1):119–32.

  2. Campagne DM, Campagne G. The premenstrual syndrome revisited. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2007 Jan 1;130(1):4–17.

  3. Kaiser G, Janda C, Kleinstäuber M, Weise C. Clusters of premenstrual symptoms in women with PMDD: Appearance, stability and association with impairment. Journal of Psychosomatic Research. 2018 Dec 1;115:38–43.

  4. Premenstrual dysphoric disorder (PMDD) | Office on Women’s Health [Internet]. [cited 2021 Oct 4]. Available from: https://www.womenshealth.gov/menstrual-cycle/premenstrual-syndrome/premenstrual-dysphoric-disorder-pmdd

  5. Hantsoo L, Epperson CN. Premenstrual Dysphoric Disorder: Epidemiology and Treatment. Curr Psychiatry Rep. 2015 Sep 16;17(11):87.

  6. Reid RL, Soares CN. Premenstrual Dysphoric Disorder: Contemporary Diagnosis and Management. Journal of Obstetrics and Gynaecology Canada. 2018 Feb 1;40(2):215–23.

  7. Lete I, Lapuente O. Contraceptive options for women with premenstrual dysphoric disorder: current insights and a narrative review. Open Access J Contracept. 2016 Aug 25;7:117–25.

  8. Administration SA and MHS. Table 3.24, DSM-IV to DSM-5 Premenstrual Dysphoric Disorder Comparison [Internet]. Substance Abuse and Mental Health Services Administration (US); 2016 [cited 2021 Oct 4]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519704/table/ch3.t24/

  9. Pearlstein T, Steiner M. Premenstrual dysphoric disorder: burden of illness and treatment update. J Psychiatry Neurosci. 2008 Jul;33(4):291–301.

  10. Nelson M, Pinna G. S-norfluoxetine microinfused into the basolateral amygdala increases allopregnanolone levels and reduces aggression in socially isolated mice. Neuropharmacology. 2011 Jun;60(7–8):1154–9

  11. Efficacy of a new low-dose oral contraceptive with drospirenone in premenstrual dysphoric disorder. Yonkers KA, Brown C, Pearlstein TB, Foegh M, Sampson-Landers C, Rapkin A. Obstet Gynecol. 2005 Sep; 106(3):492-501

  12. Lopez LM, Kaptein AA, Helmerhorst FM. Oral contraceptives containing drospirenone for premenstrual syndrome. Cochrane Database Syst Rev. 2012 Feb 15;(2):CD006586.

  13. Magon N. Gonadotropin releasing hormone agonists: Expanding vistas. Indian J Endocrinol Metab. 2011;15(4):261–7.

  14. Cronje WH, Vashisht A, Studd JWW. Hysterectomy and bilateral oophorectomy for severe premenstrual syndrome. Human Reproduction. 2004 Sep 1;19(9):2152–5.

  15. DSM-5 FAQ [Internet]. [cited 2021 Oct 19]. Available from: https://www.psychiatry.org/psychiatrists/practice/dsm/feedback-and-questions/frequently-asked-questions

  16. Marjoribanks J, Brown J, O’Brien PMS, Wyatt K. Selective serotonin reuptake inhibitors for premenstrual syndrome. Cochrane Database Syst Rev. 2013 Jun 7;2013(6):CD001396.

  17. Monteleone P, Mascagni G, Giannini A, Genazzani AR, Simoncini T. Symptoms of menopause — global prevalence, physiology and implications. Nat Rev Endocrinol. 2018 Apr;14(4):199–215.


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