Premenstrual dysphoric disorder (PMDD) is a more serious type of Premenstrual Syndrome. It is a diagnosable psychiatric disorder and characterised by debilitating physical and psychological symptoms occurring during the late luteal phase (phase 4) which have a significantly negative impact on a woman’s ability to live everyday life.

To be diagnosed with PMDD an individual must suffer from at least 5 different premenstrual psychological symptoms. It is believed to be caused by an abnormal response (likely an increased sensitivity) to the normal fluctuations of gonadal steroid hormones during the menstrual cycle.  

For PMDD, the symptoms must occur in the last week of the luteal phase (phase 4 - just prior to menstruation),decrease during menstruation (phase 1) and then vanish during the follicular phase (phase 2). As they are linked to your menstrual cycle, often during pregnancy, a woman will not experience symptoms. 

There are both psychological and physical symptoms.

Psychological symptoms include:

·   Mood swings

·   Fatigue and lethargy

·   Decreased interest inactivities you normally enjoy

·   Increased anxiety

·   Increased anger or irritability

·   Suicidal feelings

·   Feeling overwhelmed

·   Inability to concentrate

·  Increased anxiety over rejection 

‍

Physical symptoms include:

·   Breast tenderness or swelling

·   Muscle and joint pain

·   Headaches

·   Bloating

·   Weight gain

·   Changes to appetite (over eating or cravings)

·   Changes to sleep (hypersomnia or insomnia) 

Diagnosis is complex and requires a thorough physical and psychological assessment. 

Before diagnosis, an individual will be asked to record their daily symptoms over two months. They will be assessed to rule out the potential of other mood disorders, substance abuse or pre-existing medical conditions contributing to their symptoms. They will then be assessed against the DSM-5 criteria where they must experience at least 5 of the 11 symptoms with at least one being a key mood system.

These symptoms must be bad enough to prevent the individual from doing their daily activities. The symptoms must occur in the last week of the luteal phase, reduce during menstruation and then stop during the follicular phase. 

5 of these criteria must be met for a diagnosis of PMDD:

·        Mood swings

·        Marked irritability/anger

·        Marked depressed mood

·        Marked anxiety/tension 

One or more of the following must also be present as well as from those above

·        Decreased interest in normal activity

·        Difficulty concentrating

·        Lethargy

·        Change in appetite (cravings or overeating)

·        Changes to sleep (hypersomnia or insomnia)
 

*Managing PMDD:
A key way to manage is to track the menstrual cycle. Noting all symptoms during a cycle can help identify what triggers certain symptoms and work out strategies to prevent them. If you suffer from PMDD, tracking enables you to plan life events more effectively around your cycle, if you know that symptoms typically happen a week before your period you can avoid putting stressful things in that week and instead plan activities that you enjoy/help you to relax. 

-Exercise is recommended to alleviate some of the symptoms such as bloating, fatigue and depressive mood. 

-Dietary changes have also been recommended such as decreasing alcohol, sugar and caffeine during the luteal phase. Maintaining a healthy balanced diet throughout the menstrual cycle is also suggested. 

-There is mixed evidence that supplements such as calcium and magnesium, Vitamin D and Vitamin B6 can alleviate symptoms. Calcium may decrease low mood and somatic symptoms. However it is suggested this is only for mild symptoms and that they may have little effect on more severe cases.

-Chasteberry has also been found effective in reducing somatic symptoms as well as reducing some of the psychological effects of PMDD such as emotional lability, irritability and anger.

-Keeping a regular sleep pattern throughout the month (using a night time routine to establish this and good sleep hygiene). 

-Stopping smoking entirely or reducing the frequency is recommended as it can make people more sensitive to hormone changes. 

-There are different treatment options available including pharmacological, psychological and surgical (or a mixture).Typically lifestyle changes are recommended first before other interventions. 

-Selective Serotonin Reuptake Inhibitors(SSRIs) are a type of antidepressant and are effective at treating the psychological symptoms associated with PMDD. 

-Cognitive Behavioural Therapy (CBT) is a psychological intervention designed to help sufferers identify negative thoughts and develop coping strategies to deal with them. Weekly sessions with a qualified CBT specialist are recommended. 

-Oral Contraceptives (OC)can be effective by preventing hormonal fluctuations and/or ovulation to reduce symptoms. But, there is mixed evidence that oral contraceptives can help, with some women reporting it decreases symptoms, however others saying it makes them worse. Continuous dosing or a shortened period of the hormone-free interval (e.g four days) is recommended. 

-Gonadotropin releasing hormone (GnRH) analogues injections are usually only suggested if SSRIs or OCs have been ineffective. These injections prevent ovulation and reduce symptoms by causing a temporary menopause. However, these can cause decreased bone density, so women should receive hormonal replacement therapy alongside this to protect bone density. The injections are usually monthly. 

-Surgery: In severe cases where no other treatments have been successful surgery may be recommended to remove the uterus(total hysterectomy) and ovaries and fallopian tubes. This would stop the monthly cycle completely and get rid of symptoms. However, it is irreversible so is usually used as a last resort. 

‍

*Disclaimer: Information and content from FitrWoman are intended as general information only and should not be substituted for medical advice, diagnosis or treatment.

References:

https://www.acog.org/womens-health/faqs/premenstrual-syndrome

https://www.rcog.org.uk/globalassets/documents/guidelines/gt48managementpremensturalsyndrome.pdf

‍