Premenstrual dysphoric disorder (PMDD) causes emotional and physical symptoms far beyond those of PMS.

By Amanda Gardner
Updated: August 30, 2018

Premenstrual dysphoric disorder (PMDD) is the more severe cousin of premenstrual syndrome (PMS). While some 75% of women report having mild PMS symptoms like bloating, irritability, and fatigue, PMDD rests on the other end of the spectrum, causing debilitating emotional and physical symptoms that can interfere with daily life in about 5% of women. Typically, mood symptoms are the most dominant in PMDD, and in 2013, PMDD was added to the diagnoses listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the medical “bible” used by doctors to diagnose and treat mental health conditions.

“PMS is a milder form and PMDD is diagnostic, the more severe form,” says Kara McElligott, MD, an obstetrician and gynecologist at Duke Health in Durham. “The difference is how it affects quality of life. For some people it’s debilitating. Adding it to the DSM made it a diagnosis. You can’t dismiss it.”

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PMDD causes

No one really knows what causes PMDD or why some women get milder PMS while others end up with PMDD. Clearly, both are related to hormonal changes that occur during your menstrual cycle, but it may not be the hormones themselves causing PMDD. In fact, estrogen and progesterone levels are similar in women with PMS and women with PMDD.

Some research suggests that fluctuations in hormones influence a chemical in the brain called serotonin, which is important in determining mood. “The notion is that it’s not simply hormones or hormone levels but an interaction between changes in hormone levels and the human brain,” says Kimberly Yonkers, MD, a member of the PMDD subcommittee of the DSM-5 Task Force and a professor of psychiatry at Yale School of Medicine. “Some people are vulnerable while some people are not, just like some people are vulnerable to depression or anxiety.”

Many women with PMDD may also have depression and anxiety, conditions that can involve altered serotonin, too.

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PMDD symptoms

Symptoms of PMDD usually show up about a week before your period and go away two to three days after bleeding starts.

Not surprisingly, given that PMDD is now on the list of mental disorders, emotional symptoms like mood swings and anxiety tend to be the most pronounced.

“The reason that PMDD is in the DSM-5 is because of the emotional symptoms,” says Dr. Yonkers. “For example, obligatory symptoms for PMDD are mood symptoms like low mood, anger, and irritability, which are not obligatory for PMS.”

In order to be diagnosed with PMDD, you have to experience at least five PMDD symptoms, including one mood symptom. PMDD symptoms include:

  • Depressed mood
  • Anger or irritability
  • Trouble concentrating
  • Lack of interest in activities you once enjoyed
  • Mood swings
  • Appetite changes
  • Trouble sleeping
  • Low energy
  • Feeling out of control or overwhelmed

Women may also have physical symptoms like hot flashes, breast tenderness, bloating, and cramps. PMDD is diagnosed when these symptoms interfere with work, school, or relationships–or otherwise keep you from daily activities.

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PMDD treatment

Many of the strategies used to treat PMDD are similar to treatments for PMS, often starting with some kind of hormonal regulation of your cycle.

“We do know the trigger is the hormonal fluctuations, so it makes sense physiologically that the first-line treatment is stabilizing hormonal fluctuations in your cycle,” says Dr. McElligott.

This is typically done using oral contraceptives, particularly those containing drospirenone (Yaz) and ethinyl estradiol, which are approved by the FDA specifically to treat PMDD. Instead of taking the pills for three weeks, then breaking for a week, women with PMDD often take birth control pills without any breaks (or with shorter breaks).

Antidepressants, particularly those known as selective serotonin reuptake inhibitors (SSRIs), which modulate serotonin levels in your brain, are increasingly used for both PMS and PMDD. Three are approved to treat PMDD: fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil).

“They can be administered for half of the menstrual cycles or even at symptom onset,” says Dr. Yonkers. She and her colleagues published a study showing that even when women take them for just three to five days, SSRIs helped. “There’s this immediacy of action that’s unique for PMDD,” she says.

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Lifestyle strategies can also help treat PMDD. Start by getting regular exercise, managing stress, and limiting high-salt and high-sugar foods, caffeine, and alcohol.

Those healthy habits can help you feel better overall, Dr. McElligott says. “The symptoms you’re experiencing are triggered by some hormonal fluctuation, but at baseline, if you’re feeling really good, then it’s not going to hit you as much.”

Some women also find relief for symptoms like breast tenderness or headaches in aspirin and other over-the-counter pain relievers.

“Most women will find relief but not a cure, so I think that there’s still more work to be done,” Dr. Yonkers says. “Right now, we are borrowing from other conditions [like depression]. There’s a lack of treatments that have specifically been engineered for PMDD. Understanding the basic biology will lead to additional treatments.”

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