Throughout history, the medical field has had a complicated and often contradictory relationship with reproductive mental health. While accounts of symptoms related to the menstrual cycle date back to ancient times, their existence was often met with irrational skepticism. Mood fluctuations were frequently attributed to a wandering uterus or the toxic and healing properties of menstrual blood, leading to superstitions, stereotypes, and mockery (Rubinow, 2021). Unless the ailment was experienced by everyone who menstruated, it was commonly dismissed as a non-issue or mere hysteria (Rubinow, 2021). Although the medical community has made significant strides in recognizing the clinical significance of mood and the menstrual cycle, knowledge regarding the range and severity of symptoms people experience leading up to their periods remains limited. This article seeks to differentiate between the more commonly experienced premenstrual syndrome (PMS) and the more severe symptoms indicative of Premenstrual Dysphoric Disorder (PMDD).
Premenstrual Syndrome (PMS)
Premenstrual Syndrome (PMS), a medical condition that affects up to 80% of menstruating individuals, is often misrepresented in popular culture as a woman’s erratic or moody behavior (IAPMD, 2019). PMS is a set of physical and emotional symptoms that occur before menstruation and typically end once periods start. Common symptoms include mood changes such as feeling sad, angry or anxious, as well as physical symptoms such as breast pain, bloating, headache, and cramps. It’s important to note that although many people experience PMS, it is not considered a formal psychiatric diagnosis (Hunter et al., 2021).
Premenstrual Dysphoric Disorder (PMDD)
Premenstrual Dysphoric Disorder (PMDD) is a mood disorder that occurs during the luteal phase of the menstrual cycle, affecting around 3-8% of menstruating individuals of reproductive age (Chan et al., 2023). PMDD was not formally classified and added to the the Diagnostic and Statistical Manual of Mental Disorders until 2013. Unlike other menstrual disorders, PMDD is not caused by a hormonal imbalance, but rather by a severe adverse reaction in the brain to the natural fluctuations of estrogen and progesterone (Hunter et al., 2021). Symptoms are prevalent during the luteal phase, which lasts about 14 days following ovulation and ends with the onset of menstrual bleeding (IAPMD, 2019). Typically, the symptoms subside within a few days of menstruation.
Symptoms of PMDD include:
- Mood/emotional changes (e.g. mood swings, feeling suddenly sad or tearful, or increased sensitivity to rejection)
- Irritability, anger, or increased interpersonal conflict
- Depressed mood, feelings of hopelessness, feeling worthless or guilty
- Anxiety, tension, or feelings of being keyed up or on edge
- Decreased interest in usual activities (e.g., work, school, friends, hobbies)
- Difficulty concentrating, focusing, or thinking; brain fog
- Tiredness or low-energy
- Changes in appetite, food cravings, overeating, or binge eating
- Hypersomnia (excessive sleepiness) or insomnia (trouble falling or staying asleep)
- Feeling overwhelmed or out of control
- Physical symptoms such as breast tenderness or swelling, joint or muscle pain, bloating or weight gain
Impact on Social and Emotional Well-being
Severe premenstrual symptoms and PMDD cause significant emotional and personal distress for those affected. In a 2022 survey, 34 percent of people with PMDD reported a past suicide attempt; over half reported self-harm (Eisenlohr-Moul et al., 2022), According to Osborn et al. (2020), people with PMDD commonly face obstacles such as problems with concentration and keeping up with the demands of academia, which can lead to the discontinuation of higher education. Moreover, the unpredictable psychological symptoms associated with PMDD can make it challenging to fulfill work obligations. PMDD can also have adverse effects on personal relationships, such as feelings of rejection from those around them or self-imposed isolation from loved ones as a means of protecting them. On top of the distress brought on by psychological and physiological symptoms, individuals with PMDD report pervasive shame as a result of external and internalized stigma. People also report invalidating or dismissive interactions with health providers who lack the awareness to provide affirming care (Osborn et al., 2020).
Diagnosis
Accurate diagnosis of PMDD is the first step toward providing effective treatment. The International Association of Premenstrual Disorders (2019) suggests that “more than half of those who seek treatment for PMS or PMDD actually have PME.” Premenstrual symptoms may manifest as a premenstrual exacerbation (PME), which worsens the symptoms of a pre-existing psychiatric disorder, such as major depressive disorder, generalized anxiety disorder, bipolar disorder, or schizophrenia. As such, distinguishing between PME and PMDD is crucial since effective treatment may vary depending on the disorder. Individuals with PME experience a luteal-phase amplification of their typical emotional or behavioral symptoms (Hunter et al., 2021). Symptoms of PMDD, however, only emerge during the premenstrual phase, subside a few days after menstruation begins, and are absent in the week post-period (IAPMD, 2019).
Chan et al. (2023) reports that it takes an average of 20 years for menstruators to receive an accurate diagnosis and treatment for PMDD. This is due to the medical community’s lack of familiarity with PMDD. Osborn et al. 2020 found that many people with PMDD often recognize the connection between their menstrual cycles and fluctuating symptoms before receiving a formal diagnosis. IAPMD (2019) has created a printable symptom tracker to help individuals monitor their symptoms. There is also an app called ME v PMDD that allows for specific PMDD symptom tracking. To diagnose PMDD, it is necessary to monitor symptoms daily for at least two menstrual cycles. A PMDD diagnosis requires the presence of at least five symptoms, one of which must be a “core emotional symptom” (one of the first four symptoms listed above) (APA, 2013).
Treatment
The effects of PMDD can vary in intensity, making it difficult to find a universal treatment. However, understanding the root causes of their symptoms can be immensely empowering for those who experience PMDD, as their suffering is validated in this knowledge. Furthermore, people with PMDD report improved relationships from being able to educate their loved ones about the disorder. Treatment options considered for PMDD include:
Psychotherapy: Psychotherapy can provide individuals with a safe and non-judgmental space to explore their experiences with PMDD. With the help of a therapist, individuals can develop self-compassion and a deeper understanding of PMDD through psychoeducation, learn coping skills for emotional regulation, identify triggers, and improve their relationships. Some therapeutic approaches that have proven effective in treating PMDD include Dialectical Behavioral Therapy (DBT), Emotion-Focused Therapy (EFT), Cognitive Behavioral Therapy (CBT), Mindfulness-Based Cognitive Therapy (MBCT), Acceptance and Commitment Therapy (ACT), and Interpersonal Therapy (IPT) (Shareh et al., 2022).
Lifestyle adjustments: To help minimize the symptoms of PMDD, IAPMD (2019) states it is essential to adjust one’s lifestyle as the first line of defense. This includes getting enough sleep, exercise, and maintaining a healthy diet that contains adequate proteins, complex carbohydrates, fruits, and vegetables. This serves as the foundation for any treatment plan. Although it may be challenging to maintain a healthy diet and regular exercise during the luteal phase, prioritizing stress reduction and adequate sleep to cope with the cycle is paramount.
Medication: SSRIs (selective serotonin reuptake inhibitors) such as fluoxetine (Prozac), sertraline (Zoloft), and others have been shown to be effective in reducing PMDD symptoms (Hantsoo & Riddle, 2021). Birth control pills, hormonal patches, or hormonal IUDs may help regulate hormonal fluctuations and reduce symptoms. Gonadotropin-releasing hormone agonists (GnRH agonists) may also be considered in some cases (Hunter et al., 2021).
Surgical Menopause (THBSO): Hysterectomy with oophorectomy is a treatment option that should only be considered as a last resort for women who suffer from severe PMDD and have not responded to standard, non-invasive treatment methods (IAPMD, 2019).
A holistic treatment approach addresses not only the physical symptoms but also the emotional and social aspects of PMDD. A personalized and holistic treatment approach may include a combination of psychotherapy, medication, and lifestyle changes. Alternative interventions such as yoga/meditation, acupuncture, and herbal remedies may also be incorporated (Jang et al., 2014). To ensure that individuals with PMDD receive timely and appropriate care, it is crucial to coordinate between healthcare providers such as gynecologists, psychiatrists, therapists, and others. This helps to reduce the gaps in treatment and provides integrated care that considers the diverse factors contributing to PMDD.
PMDD is a complicated condition that can affect various aspects of a person’s life. At Wildflower, we strive toward a more compassionate and supportive approach to reproductive mental health. While PMS is a common experience for many, PMDD is a more severe condition that can cause substantial distress. Unfortunately, the lack of comprehensive knowledge surrounding these conditions perpetuates the stigma and shame for those who suffer. It is time to move towards creating a greater understanding and ensuring that those affected receive the necessary support and care. Accurate diagnosis of PMDD is crucial for effective treatment and management of symptoms. By raising awareness and promoting empathy, we can advocate for better treatment options.
References
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Chan, K., Rubtsova, A. A., & Clark, C. J. (2023). Exploring diagnosis and treatment of premenstrual dysphoric disorder in the U.S. healthcare system: a qualitative investigation. BMC Women’s Health, 23(1), 272–272. https://doi.org/10.1186/s12905-023-02334-y
Eisenlohr-Moul, T., Divine, M., Schmalenberger, K. et al. Prevalence of lifetime self-injurious thoughts and behaviors in a global sample of 599 patients reporting prospectively confirmed diagnosis with premenstrual dysphoric disorder. BMC Psychiatry 22, 199 (2022). https://doi.org/10.1186/s12888-022-03851-0
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