What is PMDD?
Premenstrual Dysphoric Disorder (also known as Premenstrual Dysphoria, Late Luteal Phase Dysphoric Disorder, or PMDD) is a cyclical, hormone-based mood disorder with symptoms arising during the premenstrual, or luteal phase of the menstrual cycle and lasting until the onset of menstrual flow. It affects an estimated 2-10% of women of reproductive age. While PMDD is directly connected to the menstrual cycle, it is not a hormone imbalance. PMDD is a severe negative reaction to the natural rise and fall of estrogen and progesterone. It is a suspected genetic disorder with symptoms often worsening over time and around reproductive events including menarche, ovulation, pregnancy, birth, miscarriage, and menopause. Women with PMDD are at an increased risk for postpartum depression and suicidal behavior. Many, but not all, women with PMDD have a history of sexual trauma or depression. There is no blood or saliva test to diagnose PMDD although these tests can rule out other underlying disorders. The only way to diagnose PMDD is by tracking symptoms for at least two menstrual cycles.
Causes of PMDD
PMDD is believed to be heritable as shown in studies on families and twins.6 These same studies showed a specific variation in the Estrogen receptor alpha (ESR1) gene in those with PMDD versus those without. Other studies suggest that among women and AFAB individuals with PMDD, brain circuits involved in emotional response may activate differently in the luteal phase compared to those without PMDD.7 Additional studies show an atypical response to allopregnanolone (ALLO; a main progesterone metabolite) in those with PMDD versus those without. Individuals without PMDD typically respond to ALLO as they would to alcohol or anti-anxiety medication (i.e. calming). It is possible that women with PMDD have developed a tolerance to the calming effect and emotional regulation of ALLO.8,9
In fact, PMDD may result from a combination of these factors. In 2016, researchers at the National Institutes of Health (NIH) found that women with PMDD are more sensitive to the effects of sex hormones estrogen and progesterone, due to a molecular mechanism in their genes. Researchers compared white blood cells in women with PMDD and those without, and confirmed that women with PMDD have an altered response to sex hormones at the cellular level.3.1
Symptoms of PMDD
- Feelings of sadness or despair or even thoughts of suicide
- Feelings of tension or anxiety
- Panic attacks, mood swings, or frequent crying
- Lasting irritability or anger that affects other people
- Lack of interest in daily activities and relationships
- Trouble thinking or focusing
- Tiredness or low-energy
- Food cravings or binge eating
- Trouble sleeping
- Feeling out of control
- Physical symptoms, such as bloating, breast tenderness, headaches, and joint or muscle pain
PMS & PMDD
The term premenstrual syndrome (PMS) has a long history both clinical and colloquial. PMS is often used in the general population and popular culture in a way to explain or dismiss a woman's volatile mood, depression, anger, or behavior. Clinically, PMS is a collection of emotional and/or physical symptoms including bloating, breast tenderness, increased hunger, weepiness, and irritability. A woman or AFAB individual with PMS will have fewer, and usually less severe, premenstrual symptoms than a woman with PMDD.11 PMS is more common than PMDD, and as many as 80% of women experience some form of PMS in the second half of their menstrual cycle. Women may experience mild, moderate, or severe symptoms of PMS
PMS may interfere with a woman's quality of life, interpersonal relationships, or ability to attend work or school, according to the American College of Obstetricians and Gynecologists. However, PMS symptoms are generally more easily managed than PMDD and do not require prescription medication including antidepressants. PMS is also not classified as a mental illness in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), while PMDD is.
PMDD is characterized by a cluster of mood symptoms that recur in the luteal phase of most menstrual cycles over the course of a year. An estimated 2-8% of women meet the criteria for PMDD. PMDD may be mild, moderate, or severe. PMDD is the only form of premenstrual disorder currently classified in the DSM-V. While PMS and PMDD are often used interchangeably in mainstream media and popular culture, the etiology, diagnosis, and treatment widely differ. It is important to use the correct terminology when discussing PMDD so that awareness, education, and treatment may be correctly achieved.
The Personal Impact of PMDD
PMDD can cause severe emotional, professional, and personal harm to those who have it. Sufferers of PMDD report damaging and impulsive behaviors that may include suddenly leaving a job or a relationship. Others report sudden and increased thoughts about suicide and self-harm. PMDD can feel like a "half-life". PMDD can feel like "one week of hell and three weeks of cleaning up". As women today have an estimated 450 periods during their lifetime, PMDD is a long term diagnosis. Providing sufferers with compassion and understanding is the first step in improving patient outcomes. The free tools, resources, information, and support provided by IAPMD can help you in this journey.
Pagano, M.D., T. (Ed.). (2014, June 28). Sexual Health: Your Guide to Premenstrual Dysphoric Disorder. Retrieved April 23, 2015, from http://www.webmd.com/women/pms/premenstrual-dysphoric-disorder?page=2
Gallenberg, M.D., M. (2012, December 14). What's the difference between premenstrual dysphoric disorder and premenstrual syndrome? Retrieved April 20, 2104, from http://www.mayoclinic.org/diseases-conditions/premenstrual-syndrome/expert-answers/pmdd/faq-20058315
Goldberg, M.D., J. (Ed.). (2014, September 7). Depression, Thyroid Conditions, and Hormones. Retrieved April 23, 2015, from http://www.webmd.com/depression/guide/depression-the-thyroid-and-hormones
"Sex Hormone-Sensitive Gene Complex Linked To Premenstrual Mood Disorder". 2017. Medicalxpress.Com. Accessed January 4 2017. http://medicalxpress.com/news/2017-01-sex-hormone-sensitive-gene-complex-linked.html
Diagnostic and Statistical Manual of Mental Disorders (5th ed.), (2013), American Psychiatric Association. Washington, DC.
PMDD Research — UNC Center for Women's Mood Disorders. (2016).Med.unc.edu. Retrieved 17 March 2016, from https://www.med.unc.edu/psych/wmd/research/pmdd
Huo L, Straub RE, Roca C, et al. Risk for premenstrual dysphoric disorder is associated with genetic variation in ESR1, the estrogen receptor alpha gene. Biol Psychiatry. 2007;62(8):925-933.
Comasco E, Hahn A, Ganger S, et al. Emotional fronto-cingulate cortex activation and brain derived neurotrophic factor polymorphism in premenstrual dysphoric disorder. Hum Brain Mapp. 2014;35(9):4450-4458.
Girdler SS, Straneva PA, Light KC, et al. Allopregnanolone levels and reactivity to mental stress in premenstrual dysphoric disorder. Biol Psychiatry. 2001;49(9):788-797.
Hantsoo L, Epperson CN. Premenstrual Dysphoric Disorder: Epidemiology and Treatment. Current psychiatry reports. 2015;17(11):87. doi:10.1007/s11920-015-0628-3.
Menstruation and Menstrual Suppression Survey Fact Sheet. (2018). Arhp.org. Retrieved 22 August 2018, from http://www.arhp.org/publications-and-resources/studies-and-surveys/menstruation-and-menstrual-suppression-survey/fact-sheet
Reviewed January 14, 2019 by Dr. Liisa Hantsoo