Kate Organ, Our PMS & PMDD Specialist, explains the under acknowledged but often debilitating hormone related mood disorders PMS & PMDD.
I first recognised the important role of female reproductive hormones in mental health nearly 15 years ago while working in female psychiatric wards as a Specialist Mental Health Pharmacist. I often listened to women suggesting their hormones were directly influencing their depression, anxiety, or even bipolar disorder during psychiatric assessments.
It has only recently been acknowledged that there is a complex relationship between our hormones, neurotransmitters, and brain function, which can cause mood disorders.
What is PMDD?
Premenstrual dysphoric disorder (PMDD) is a cyclical hormone-related mood disorder with symptoms arising during the luteal or premenstrual phase of the menstrual cycle and subsiding within a few days of the period starting. Symptoms can worsen over time or be triggered by reproductive events such as puberty, pregnancy, perimenopause, or when stopping contraceptives or other hormone-related treatments.
Around 6% of women will meet the diagnostic criteria for PMDD, while only 10% of these will seek a diagnosis and treatment. Symptoms are triggered by hormonal fluctuations within the menstrual cycle, making PMDD a brain hormone sensitivity disorder. Some women experience PMDD from the onset of menstruation, while others are triggered later in life after pregnancy or during perimenopause when severe PMS symptoms are recognised.
What Causes PMDD?
The full picture is not yet clear. However, we do know that women with PMDD have altered serotonin function in the brain and abnormal responses to the progesterone metabolite, allopregnanolone. Women with PMDD are more sensitive to changes in the reproductive hormones oestrogen and progesterone. Some women are sensitive to both hormones, while others may be sensitive to only one.
When to Get Help with PMS?
You should seek help when you experience clinically significant distress or an impact on your ability to work, maintain normal relationships, or perform daily functions.
Symptoms of PMDD or Severe PMS
PMDD is a cyclical mood disorder, meaning symptoms occur typically in the luteal phase of the menstrual cycle (the last 14 days) and resolve within a week following the period. Premenstrual exacerbation (PME) is the worsening of an underlying condition, such as depression or anxiety, which is always present. In PME, there is no symptom-free period within the menstrual cycle. Most women with PMDD describe relief at the onset of their period, as symptoms often lift or start to improve.
Symptoms of PMDD can include:
Mood swings, tearfulness
Anger, irritability, rage
Anxiety
Low mood
Self-deprecating thoughts and hopelessness
Changes in concentration and focus
Changes in appetite
Changes in sleeping patterns
Fatigue
Feelings of overwhelm, loss of control
Physical symptoms such as breast tenderness, painful periods, joint aches, bloating, headaches
One of the most distressing aspects of PMDD is the dread of the next cycle, knowing that symptoms will return. Women often describe themselves as turning into someone they don’t recognise, as being a monster, and often experience shame and embarrassment as a result of their recent behaviour, when symptoms pass at the onset of a period.
PMS vs PMDD
PMDD is the more severe form of PMS which is characterised by having a strong mood component to your symptoms which have a clinically significant impact on your quality of life and day to day functioning.
Diagnosis
PMDD is diagnosed using the DSM-5 diagnostic criteria, which require symptoms to be tracked daily for two complete menstrual cycles. Clinical diagnosis is made according to tracked symptoms for a minimum of 2 months, the presence of symptoms in the majority of menstrual cycles, and at least one mood-related symptom. There must be a clear cyclical nature to the symptoms, with a period at the start of the cycle where symptoms are minimal or absent.
Misdiagnosis of PMDD
Women suffering with PMs or PMDD are often misdiagnosed with depression, anxiety, or even a mood condition such as bipolar affective disorder.
Treatment Options
Lifestyle
Women with PMS tend to be more sensitive to blood glucose changes and often describe themselves as getting ‘hangry.’ A consistent diet with regular meals to stabilise blood glucose levels is important. General lifestyle improvements to support good mental health include daily outdoor activities, light-intensity exercise, and good sleep hygiene.
Supplements
There is some evidence that calcium, magnesium, vitamin D, and vitamin B6 supplements may improve premenstrual symptoms and reduce severity.
Non-Hormonal Treatment Options
Selective Serotonin Reuptake Inhibitors (SSRIs):SSRIs work by normalising altered premenstrual serotonin function in PMDD and altering the metabolism of progesterone to its neuroactive metabolites (allopregnanolone). There is good clinical trial data supporting the use of SSRIs, which often work within 24 hours and have a 60% response rate. They are generally well tolerated.
Cognitive Behavioural Therapy (CBT):CBT can reduce functional impairment by decreasing neurobiological stress responses, improving coping mechanisms, and enhancing relationships.
Hormonal Treatment Options
Drospirenone-Containing Oral Contraceptive Pill: Two high-quality trials have shown this to be effective within the first month of treatment by preventing ovulation and hormonal fluctuations. Response rates are 40-60%.
Transdermal Oestrogen and Cyclical Progesterone: This treatment aims to reduce hormonal fluctuations and prevent ovulation. It is often very effective when PMDD coincides with perimenopause or follows pregnancy.
GnRH Analogues Plus Add-Back Hormones: There is strong evidence supporting this treatment, which suppresses ovulation and related hormone fluctuations. Add-back hormones are necessary to induce a chemical menopause and require hormone replacement therapy (HRT) to protect cardiovascular, cognitive, and bone health.
Some women are also progesterone intolerant, so finding an effective and well-tolerated treatment requires an individualised approach with a clinician experienced in this field.
PMDD can be effectively treated with a combination of lifestyle, supplements and medical treatment options aimed at reducing severity of symptoms and relieving impact.
No matter how mild or severe your symptoms are if they are impacting your quality of life we recommend discussing your symptoms with a PMS Specialist.
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