Do you Have PMDD?
Sometimes PMS can feel absolutely overwhelming, and in these cases we want to consider premenstrual dysphoric disorder (PMDD) as the true cause of the symptoms that you may be experiencing.
PMDD can be experienced at all stages of life in women (about 3-8%) – but you need to be ovulating in order to have PMDD. If you have hypothalamic amenorrhea, are pregnant and/or chest/breastfeeding, or are menopausal, the symptoms you’re experiencing may not be PMDD – it’s likely something else.
What is PMDD & how does it differ from PMS?
PMDD is a collection of mainly emotional and behavioural symptoms which happen before your period in the luteal phase (so occurring after ovulation) and can continue until your period starts. Like PMS, PMDD may negatively impact your quality of life.
Why does PMDD happen?
We don’t know why PMS occurs, and like most women’s health conditions (ie. endometriosis), we don’t know why PMDD happens. Reproductive hormones, genetics, and stress can factor into your diagnosis. Although some experts agree that an altered sensitivity to normal hormonal changes can elicit PMDD.
Blood Tests for PMDD
Unfortunately there are no blood/saliva/urine tests to determine if you have PMDD. Just like there are no blood/saliva/urine tests that will diagnose you with PMS. Tracking your symptoms as you’re going through the month will be your best bet to see what’s going on.
Symptoms and Diagnosis of PMDD
PMDD typically interferes with your usual daily activities (like school or work, and your social life including relationships).
At least 5 of the following 11 symptoms must be experienced during most cycles over the past year. One of the bolded symptoms should be present each month.
- Depressed mood, feelings of hopelessness, self-deprecating thoughts
- Anxiety, tension, feelings of being keyed up/on edge
- Mood swings, feeling suddenly sad or tearful, increased sensitivity to rejection
- Anger, irritability, or increased conflict
- Decreased interest in usual activities
- Difficulty concentrating
- Lack of energy, fatigue
- Changes in appetite, over eating, specific food cravings
- Changes in sleep, hypersomnia or insomnia (trouble falling or staying asleep)
- Feeling overwhelmed or out of control
- Physical symptoms such as: breast tenderness, swelling, joint or muscle pain, bloating sensation or weight gain
Ideally you should be tracking your symptoms and period for at least 2 consecutive cycles to determine if you have PMDD.
Diagnosing PMDD is similar to diagnosing PMS. You must be experiencing some of the above symptoms during a specific time in your cycle. Moreover, it actually takes at least 2 months to diagnose PMDD. A great tracker to use is called the Daily Record of Severity of Problems or you can use an app called Me v. PMDD.
Your symptoms should occur after ovulation – ie. the last week before your period, and should improve within a few days after your period starts.
None of your symptoms should be happening because of an underlying issue (I’ll cover this below) – so if you have anxiety (for example) a worsening of your symptoms after ovulation would NOT be PMDD. It would be a premenstrual exacerbation of the anxiety.
Conditions that may worsen PMDD
There are other health conditions that may mimic the symptoms of PMDD. They include:
- Panic disorder
- Persistent depressive disorder
- Personality disorder
- Drug/medication use
First of all, these symptoms need to be tracked on the DRSP. Secondly, if PMDD is truly the reason for these symptoms, they should be disappearing at or after your period. If they are occurring all month long, then there’s probably an underlying issue that’s not PMDD, and instead these symptoms are being magnified during your period!
Usually when people seek ‘natural’ therapies, they aren’t looking to take any medications because of the risk of side effects. That’s completely understandable, but I believe its important to recognize when a pharmaceutical would be more valuable in certain conditions.
Because PMDD is a relatively ‘new’ condition where it’s becoming more widely accepted in the mainstream, there hasn’t been a ton of research to see which natural therapies have been effective.
In this case, pharmaceuticals have been shown to be the most effective treatment in treating PMDD. And it’s especially important to consider these when suicidal ideation may exist, because natural therapies usually don’t work as quickly as pharmaceuticals do.
That doesn’t mean we can’t use them in combination though, especially if there’s no potential risk for concerning interactions.
Pharmaceutical Options for PMDD
The first line treatment for PMDD are selective serotonin reuptake inhibitors (SSRIs). With this class of pharmaceuticals, studies show that they can still have a positive effect during the luteal phase of your cycle (the time of your cycle after ovulation).
This is considered a second line treatment, and not all birth control makes the cut. Birth control containing drospirenone has been studied – Yaz is one of the common pills containing this type of progestin. Keep in mind that this progestin puts women at increased risk of hypertension, blood clots, liver function disturbances, and even diabetes when compared to other progestins.
If SSRIs and birth control doesn’t work – then your doctor may consider lupron which is a GnRH agnonist. GnRH agonists essentially stop the production of ovarian hormones like estrogen and progesterone from being produced in your body. While this may be helpful, it may have unwanted side effects and should be considered if SSRIs and birth control doesn’t work.
Non-Pharmaceutical Options for PMDD
As I previously mentioned, there isn’t a plethora of studies highlighting which natural therapies can support PMDD.
Studies show that calcium homeostasis within the body has been associated with affective disorders. Also, it has been suggested that abnormalities in calcium metabolism may be responsible for some affective and somatic symptoms in women with PMS and PMDD.
Adding calcium to your diet, through food or supplements may be helpful to decrease the number of PMS symptoms you’re experiencing. I would just caution being mindful of the type of dairy that you’re eating. If it’s packed with sugar (aka. that delicious summer treat), it may aggravate your symptoms.
Chaste tree (also known as Vitex agnus-castus) is an herb that has an effect on hormones, neurotransmitters, the opioid system, and in pain and inflammatory pathways.
Chaste tree has been helpful in women with PMDD, especially for the physical symptoms as well as irritability and mood swings. Nevertheless, when compared to an SSRI, the SSRI was the superior treatment for psychological symptoms.
Omega-3 Fatty Acids
Unfortunately no studies exist looking at the relationship between omega 3 fatty acids and PMDD. However there are studies looking at its relationship with PMS. It’s thought that omega-3s may decrease mental/emotional PMS symptoms including depression, nervousness, anxiety and lack of concentration. Furthermore, it may also reduce the physical PMS symptoms including bloating, headache and breast tenderness.
Vitamin D (which acts as a hormone) is required for calcium absorption in the body. So if you don’t have enough Vitamin D (and chances are quite high that you don’t), you may need to supplement in order for that extra calcium to be absorbed. Furthermore, women experiencing PMS and PMDD are usually Vitamin D deficient.
Getting your vitamin D levels tested might be something you want to consider doing. This is because levels should be in the 100-110 zone for optimal function. And sometimes the recommended daily dose of vitamin D won’t get you there.
Stress often results from an imbalance between demands and resources. For instance, you may have a deadline at work, but no time to complete your tasks. Stress may occur due to a variety of reasons and may be daily hassles, traumatic events, or even be perceived.
Stress has many effects on the body, and it may predict cyclical mood changes, and can arise from past traumatic events, current life stressors, or perceived stressors. With respect to the cycle, stress can specifically worsen PMS symptoms, and increased stress can actually predict more severe symptoms as well. It’s the gift that keeps on giving.
Tackling the topic of stress is a huge issue on it’s own, and certainly requires a spectrum of different treatments. However, simple techniques like practicing self care and emotional regulation can be a good start-off point.
CBT & DBT
Cognitive Behavioural Therapy is a form of psychotherapy that treats problems and boosts mood by changing dysfunctional emotions, behaviours, and thoughts. Whereas Dialectical Behavioural Therapy provides you with new skills to manage painful emotions and decrease conflict in relationships.
CBT often addresses the idea of ‘hot thoughts’ (ie. I’m not good enough) in an attempt to observe your response to them as opposed to reacting to these thoughts.
DBT uses techniques like mindfulness and emotional regulation to address some of the symptoms you may be experiencing. For instance if you are feeling anger, emotional regulation will help you identify the feeling you want to change, check the facts (why you are angry – perhaps your partner is not picking up their phone), identify your action urges (send an angry text), and ask your gut if acting on this emotion is effective in this situation (will you get the response that you desire)?
You can even practice opposite reactions to help emotional regulation. For instance, if you are feeling sad the opposite reaction would be to get active (ie. do 20 jumping jacks, go for a walk, etc.).
If you’re a planner, you may want to consider listing your triggers and creating an action plan when they occur. Click here to download the action template.
Now that you’re a bit more familiar with PMDD, the first thing you should be doing is tracking your symptoms for at least 2 months using the DRSP or the app called Me v. PMDD. In order to be consistent with tracking your symptoms, consider pairing it with another activity such as brushing your teeth.
If it is PMDD, you can certainly adopt some of the treatment measures listed above. However, be mindful that if you choose to use supplements – it’s best to do so under the supervision of a Naturopathic Doctor. I strive to recommend the highest quality products, ingredient forms, and dosages.
A note on treatment for PMDD, taking a pharmaceutical may be the best option as natural therapies usually take 3-6 months to work. It’s important to have a conversation with your medical doctor about any fears or hesitations you have with a pharmaceutical so they can monitor you in an appropriate manner. If you have suicidal ideations, a natural therapy may not be the best treatment for you to start off with as it may take too long for it to work.
If you found this information helpful, please sign up for my monthly newsletter called The Flow for great and informative content like this!
If You’re in Crisis:
If you are in crisis now please call any of the crisis line numbers listed below or dial the local emergency telephone number (often 911) in your area.
- If you need emergency help, please call 911 or visit your local emergency department.
- CAM-H Psychiatric Emergency Department
- Crisis Service Canada: 1-833-456-4566
- Toronto Distress Centre: 416-408-4357
- National Suicide Hotline: 1-800-273-TALK
- Ontario Association for Suicide Prevention
Behboudi-Gandevani, S., Hariri, F., & Moghaddam-Banaem, L. (2017). The effect of omega 3 fatty acid supplementation on premenstrual syndrome and health-related quality of life: a randomized clinical trial. Journal Of Psychosomatic Obstetrics & Gynecology, 39(4), 266-272. https://doi.org/10.1080/0167482x.2017.1348496
Carlini, S., & Deligiannidis, K. (2020). Evidence-Based Treatment of Premenstrual Dysphoric Disorder. The Journal Of Clinical Psychiatry, 81(2). https://doi.org/10.4088/jcp.19ac13071
Cerqueira, R., Frey, B., Leclerc, E., & Brietzke, E. (2017). Vitex agnus castus for premenstrual syndrome and premenstrual dysphoric disorder: a systematic review. Archives Of Women’s Mental Health, 20(6), 713-719. https://doi.org/10.1007/s00737-017-0791-0
Dickerson L, Mazyck P, Hunter M. Premenstrual Syndrome. Am Fam Physician. 2003;67(8):1743-1752.
Endicott J, Nee J, Harrison W. Daily Record of Severity of Problems (DRSP): reliability and validity. Arch Womens Ment Health. 2005;9(1):41-49. doi:10.1007/s00737-005-0103-y.
Ismaili E, Walsh S, O’Brien P et al. Fourth consensus of the International Society for Premenstrual Disorders (ISPMD): auditable standards for diagnosis and management of premenstrual disorder. Arch Womens Ment Health. 2016;19(6):953-958. doi:10.1007/s00737-016-0631-7.
Kadian S, O’Brien S. Classification of premenstrual disorders as proposed by the International Society for Premenstrual Disorders. Menopause Int. 2012;18(2):43-47. doi:10.1258/mi.2012.012017.
Nevatte T, O’Brien P, Bäckström T et al. ISPMD consensus on the management of premenstrual disorders. Arch Womens Ment Health. 2013;16(4):279-291. doi:10.1007/s00737-013-0346-y.
O’Brien P, Bäckström T, Brown C et al. Towards a consensus on diagnostic criteria, measurement and trial design of the premenstrual disorders: the ISPMD Montreal consensus. Arch Womens Ment Health. 2011;14(1):13-21. doi:10.1007/s00737-010-0201-3.
Reid, R., & Soares, C. (2018). Premenstrual Dysphoric Disorder: Contemporary Diagnosis and Management. Journal Of Obstetrics And Gynaecology Canada, 40(2), 215-223. https://doi.org/10.1016/j.jogc.2017.05.018
Thys-Jacobs, S., McMahon, D., & Bilezikian, J. (2007). Cyclical Changes in Calcium Metabolism across the Menstrual Cycle in Women with Premenstrual Dysphoric Disorder. The Journal Of Clinical Endocrinology & Metabolism, 92(8), 2952-2959. https://doi.org/10.1210/jc.2006-2726
Walsh S, Ismaili E, Naheed B, O’Brien S. Diagnosis, pathophysiology and management of premenstrual syndrome. The Obstetrician & Gynaecologist. 2015;17(2):99-104. doi:10.1111/tog.12180.
Updated August 2020