What Is Premenstrual Dysphoric Disorder?

How to Tell the Difference Between PMS and PMDD Symptoms

Premenstrual syndrome (PMS) means something different to every woman – irritability, bloating, food cravings. And for a small percentage, it means falling into a mid-cycle depression so deep they can hardly perform daily activities. Premenstrual dysphoric disorder (PMDD) can be debilitating if undiagnosed. Here are ways to detect PMDD symptoms, and what you can do about it...

Your period is coming, and besides feeling bloated, crampy and fatigued, you’re so depressed you can barely get out of bed.

It feels like PMS on steroids, but it may be an actual medical condition, called premenstrual dysphoric disorder (PMDD), a serious psychiatric disorder characterized by severe and disabling emotional symptoms.

Up to 8% of menstruating women suffer from PMDD, says Frances Ginsburg, M.D., a reproductive endocrinologist with Stamford Hospital in Connecticut and an assistant professor of clinical obstetrics and gynecology at Columbia University Medical School in
New York.

But many women with PMDD symptoms go undiagnosed because they or their physicians aren’t familiar with the disease, according to a 2003 joint study conducted by University of California – Los Angeles (UCLA) and Keele University in Staffordshire, England.

“For years, doctors thought symptoms of PMDD were really bad cases of PMS or just something imaginary,” says Shari Brasner, M.D., an obstetrician/gynecologist in New York City.

It wasn’t until 1998 that the American Psychiatric Association recognized premenstrual dysphoric disorder as a bona-fide medical condition separate from PMS, she says.

“Having a clear-cut definition put a real name on it and validated it for women who suffer from PMDD,” Brasner says.

Diagnosing Premenstrual Dysphoric Disorder
You may have PMDD if at least one of your five symptoms includes a severe emotional symptom, such as feelings of hopelessness, major depression or anxiety, an overwhelming feeling of sadness or severe anger, explains Catherine Hansen, M.D., an obstetrician/gynecologist and assistant professor in the department of obstetrics and gynecology at the Pelvic Health and Continence Center at the University of Texas Medical
Branch in Galveston.

PMDD symptoms include:

Mood swings

Marked anger, irritability or tension

Decreased interest in usual activities

Fatigue

A change in appetite

Sleep problems

Physical problems, such as bloating and temporary weight gain

“PMDD usually strikes women in their late 20s and early 30s who have a regular menstrual cycle,” Ginsburg says. “We don’t see the disease in pregnant women, menopausal women or in women taking birth control pills.”

Mysterious conditions
What triggers PMDD? Researchers aren’t sure, although some point a finger at cyclical changes in estrogen, progesterone and other hormones.

These can disrupt the function of brain chemicals such as serotonin, a neurotransmitter that helps control mood, says Karen Deighan, M.D., an obstetrician/gynecologist and chairwoman of the OB-GYN department at Gottlieb Memorial Hospital, near Chicago.

A 2007 study conducted by the National Institutes of Health (NIH) was the first to show that PMDD is a genetic mood disorder triggered by gonadal steroids (which influence brain function) during the last two weeks of the menstrual cycle.

Women with a personal or family history of mood disorders – including major or postpartum depression – are at greater risk for PMDD, the NIH
reports.

Getting a Diagnosis for Premenstrual Dysphoric Disorder
Making a PMDD diagnosis isn’t easy. There’s no test for it, and symptoms overlap with PMS and other physical and psychiatric conditions.

Doctors must rule out those other conditions, such as thyroid disorders, diabetes, endometriosis, fibroids, menopause, major depression, panic disorder or bipolar disorder, Hansen says.

Then, your physician will ask you to track your physical and emotional symptoms for two months using a PMDD chart.

You may have PMDD if “symptoms recur 7-10 days before menstruation but disappear within a few days after your period starts,” Hansen says.

If you’re feeling depressed, angry or anxious the entire month, it’s probably another psychological condition, she says.

In some cases, doctors can’t differentiate between PMS and PMDD.

“Symptoms may get better and then worse, occur long-term or go away
and not come back,” Hansen says.

Treatment for Premenstrual Dysphoric Disorder
Most experts use a combination of lifestyle changes, medication and psychotherapy to get PMDD under control.

The Food and Drug Administration (FDA) has approved several drugs for PMDD treatment, including:

Selective serotonin reuptake inhibitors (SSRIs): These “are the drugs of choice for PMDD and work by regulating levels of the brain neurotransmitter serotonin, which controls moods,” Ginsburg says.

They can be taken throughout the month or two weeks before your period, depending on the severity of symptoms, Hansen says.

Those who take SSRIs for depression usually have to wait 4-6 weeks for it to build up in their systems and offer relief, she adds. But that’s not the case in women with PMDD.

“Many women with PMDD experience relief from symptoms very soon after taking medication,” Hansen says.

Unfortunately, SSRIs don’t work with about 40% of women with PMDD symptoms, according to the University of North Carolina at Chapel Hill’s
Center for Women’s Mood Disorders.

Oral contraceptives
If SSRIs don’t work, doctors turn next to birth control pills, which may relieve symptoms by preventing ovulation and stabilizing hormone fluctuations, Hansen says.

Yasmin (Yaz) is the only FDA-approved birth control pill for treating PMDD because research has shown it’s effective in women for three consecutive menstrual cycles. Yaz also helps relieve physical and psychological effects of premenstrual dysphoric disorder, according to a 2008 UCLA study.

Yaz is a combination oral contraceptive, which means it contains synthetic forms of both estrogen and progestin, and has some serious health risks.

New research shows that combination pills with a chemical called drospirenone may double or triple the risk for deep vein thrombosis (DVT). It occurs when a blood clot forms in the leg or pelvis and blocks blood supplies to the heart and other organs, according to an FDA safety alert issued in May 2011.

Other birth control pills with drospirenone, which include Yasmin generics (Gianvi, Ocella, Syeda and Zarah), Beyaz and Safyral, may pose
the same risk, the FDA says.

If you’re taking an oral contraceptive with drospirenone, the agency advises these steps:

Don’t stop taking it without first talking to your doctor.

If you experience symptoms of blood clots, such as persistent leg pain, severe chest pain or sudden shortness of breath, call your doctor immediately.

Avoid Yaz and other combination oral contraceptives if you smoke and/or you’re 35 or older. All raise the risk of DVT, the FDA says.

Other medication options include diuretics, “which reduce swelling and bloating associated with PMDD, and nonsteroidal anti-inflammatory drugs [NSAIDs], which alleviate painful inflammation,” Ginsburg says.

Natural Remedies for Premenstrual Dysphoric Disorder
Lifestyle changes may also reduce the severity of PMDD symptoms. Doctors recommend the following steps:

Eat more fruits and vegetables: “Increasing your intake of complex carbohydrates, such as whole grains and fruits and veggies, during the two weeks preceding menstruation may help ease symptoms by increasing serotonin levels,” Brasner says.

Cut back on salt: It may decrease water retention, which can lead to
bloating, Hansen says.

Reduce coffee consumption: Reducing caffeine can help relieve jitteriness, which may aggravate emotional symptoms, she advises.

Get more calcium: Women who took 1,200 milligrams (mg) of calcium carbonate daily saw a 50% reduction in physical and psychological PMDD symptoms, according to a 2008 Columbia University study.

Take B vitamins: Those consuming 100 mg of vitamin B-6 daily reduced PMDD symptoms, according to a 2011 study at the University of Massachusetts, Amherst. Researchers speculate that B vitamins may impact brain neurotransmitters like serotonin and dopamine, which have been linked to premenstrual dysphoric disorder.

Try chasteberry (agnus castus fruit): Women who took 120 mg of chasteberry extract daily felt less anger and were less irritable, according to a 2001 study at the Institute for Health Care and Science in Hüttenberg, Germany. Headache and breast tenderness symptoms were reduced too. Chasteberry, which is sold in health foods stores, is available as a powdered extract, liquid extract, tincture and supplement.

Get more exercise: “Daily aerobic exercise has been shown in many studies to improve mood and other PMDD symptoms by elevating serotonin levels,” says Meghan Lynch, M.D., an obstetrician/gynecologist in the division of pelvic reconstruction with Mercy Medical Center
in Baltimore.

Stress less: Stress releases cortisol, a hormone that increases fluid retention and aggravates PMDD bloating, says Ginsburg. Biofeedback and relaxation techniques, such as yoga and tai chi, are good tools for reducing anxiety, says Hansen.

Seek counseling: “Even if a woman only goes to two sessions, she can learn some important tools for avoiding things that trigger bad moods,” Lynch says.

Tame sleeping problems: “Insomnia makes symptoms worse,” she says.

For more expert advice and information, visit our Women’s Health Center.