Premenstrual Dysphoric Disorder (PMDD)

Dr Claire Phipps, GP and advanced menopause specialist at London Gynaecology, helped with the Indy100 article on PMDD.

What do we know about PMDD?

PMDD stands for Premenstrual Dysphoric Disorder. PMDD is the most severe form of PMS and is characterised by severe psychological and physical symptoms. The feeling of anxiety and depression is more intense, and some women may even feel suicidal. Behavioural changes with PMDD may affect your work and relationship to a significant degree.

The underlying basis for premenstrual syndrome/PMDD and the mood related changes that are associated are to do with fluctuating levels of hormones. Some women are thought to be especially sensitive to these changing levels particularly in the luteal phase of the cycle (the two weeks prior to a period). These changes happen due to ovulation and the hormone changes that this brings about. With ovulation, the ovaries produce increasing levels of progesterone and oestrogen levels go down. This is thought to affect the serotonergic pathway in the brain leading to mood related symptoms.

Most women get some symptoms during the premenstrual two weeks phase. Around 20-30% of women will get significant PMS symptoms and the prevalence of PMDD is estimated to be 5-8% in menstruating women.

What are the common PMDD symptoms?

· Mood swings with feelings of extreme anxiety, sadness and increased irritability

· Depression with feeling of hopelessness

· Aggressive angry feelings

· Decreased performance in work and sports

· Lack of concentration and inability to perform to usual standards

· Poor quality of sleep

· Physical symptoms including abdominal cramps, headaches, breast tenderness and hot flushes

Why is PMDD so difficult to diagnose?

Many women notice these symptoms but may take some time, sometimes years, before making the association. It encompasses a spectrum of symptoms, which can make diagnosis and the connection with periods difficult.

Mood disorders, such as major depression and bipolar disease can also worsen during the premenstrual period and can mimic PMDD and make the diagnosis tricky.

PMDD was included in the DSM (The Diagnostic and statistical Manual of Mental Disorders) in 2013 and research published in 2017 found a genetic basis for the unusual sensitivity of people suffering from PMDD to oestrogen and progesterone. As you can see this is all quite recent and the lack of consensus and knowledge leads to problems with misdiagnosis.

How can someone get a formal diagnosis if concerned?

If you are worried about your symptoms it is imperative that you speak to a healthcare professional. Ask your GP surgery if there is someone who specialises in this area.

Crucial to aiding the diagnosis of PMDD is the logging of symptoms, ideally for 2-3 cycles. This can seem frustrating, especially when you are feeling bad, but it will help your diagnosis. Symptom questionnaires can be found at pms.org.uk and the NAPS site (National Association for Premenstrual Syndromes) is a valuable resource.

What tends to be the treatment options for PMDD?

PMDD can be severe and can have a significant impact on a person’s quality of life. Recognising the symptoms and diagnosing the condition can help individuals and healthcare professionals work together to develop strategies to manage the effects of PMDD and therefore improve their quality of life.

Medications can help to address some of these symptoms, as can diet and lifestyle changes. Alongside this, recognising PMDD allows individuals to become more aware of their own physical and emotional patterns, helping them anticipate and prepare for the challenging times associated with the disorder.

When thinking about treatment for women suffering, it’s important to be aware of some of the most common risk factors for PMDD, these include:

· Stressful lifestyle

· History of depression and anxiety

· Obesity with BMI more than 30

· Smoking

· Age: Women between 20 to 35 years have stronger ovulation and have more symptoms

· Genetic risk factors

Doctors may suggest going on the contraceptive pill which evens out the hormonal levels by blocking ovulation. This is often useful in reducing PMDD symptoms. It is helpful to be aware of when the symptoms may start and to have a supportive family and colleagues.

Reducing stress through lifestyle changes is helpful and avoiding stressful situations at work and home. Mindfulness, yoga and meditation are also known to provide comfort. Avoiding caffeine, sugar, smoking and alcohol can also help. Getting 8 hours of sleep with regular exercise and balanced diet is very important. Managing physical symptoms through painkillers can also help the severity of psychological symptoms. Taking B-6 Pyridoxine vitamin and Evening Primrose Oil tablets (both available over the counter) during this two-week window can be helpful.

If the symptoms are affecting your well-being, quality of life, work or relationship, it is important to see your GP or a gynaecologist. PMDD symptoms occur up to two weeks before the period. Symptoms start with onset of ovulation and improve with menstruation. It is helpful to keep a menstrual diary of symptoms which will help your healthcare professional tailor treatment to suit your needs and assess the severity and cyclical nature of your symptoms and is an important part of the diagnosis.

Sometimes, interventions such as CBT (Cognitive Behavioural Therapy) may be helpful. For severe mood-related symptoms, your doctor may suggest SSRI (selective serotonin reuptake inhibitor) medication which also works as an anti-depressant.

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