The last couple weeks were intensely difficult. I’ve been feeling bloated, antisocial, moody, irritable, depressed, disconnected, and apathetic. The list goes on and on. I could barely make it through my work days, and afterwards I couldn’t seem to accomplish simple, everyday tasks. I felt paralyzed. So I’d sit on the couch, binging on junk food and crying over nothing — which would be unusual except that I’d just ovulated, and all that is actually normal for me at that point in my cycle.
The problem is that these symptoms last 10 days or longer and interfere with my daily life and relationships: I uncharacteristically pick trivial fights with my husband, cancel plans with friends, and can’t focus at work. At previous jobs, I’d call in sick because I couldn’t get out of bed or get my head on quite right, and I’d wonder what was wrong with me. Then, a few days after the start of my period, I’d feel like a completely different person. My work and personal productivity would be stellar, I’d apologize deeply to my husband for the fighting, and issues I was crying over that had seemed so urgent just days before simply didn’t bother me anymore.
After many years of enduring this every cycle, I discovered that it’s not normal PMS (premenstrual syndrome).
I’ve been diagnosed with premenstrual dysphoric disorder (PMDD).
What is PMDD and what causes it?
Premenstrual dysphoric disorder is a severe mood disorder during the luteal phase that mostly or completely resolves during the follicular phase (read the Phases of the Menstrual Cycle here) and is related to reproductive hormones (1) — but not in the way that you might think. In fact, hormone levels in people with PMDD are similar to those without it (2). Rather than the hormones themselves causing the issue, an increased sensitivity to those hormones seems to be the culprit: this sensitivity alters the brain chemistry and neurological pathways that control your mood and sense of well-being (3).
Right now, medical professionals do not know for certain what creates the symptoms or sensitivity and have a wide range of theories, including biological, psychological, environmental, and social causes (4). Further study is needed to determine the cause, but the general consensus right now is that PMDD is biological, not purely psychological or sociological, as was previously believed (5), and that genetics likely plays a role (4, 6, 7, 8, 9). In fact, a research team at National Institutes of Health found a gene complex that they suspect is responsible for the hypersensitivity to the female sex hormones estrogen and progesterone (6).
Additional risk factors could include being overweight or obese, stress, a past history of sexual abuse or other trauma (8), age (late 20s to mid-30s), history of mood or anxiety disorders or depression, and family history of premenstrual dysregulation (5).
Why haven’t I heard of PMDD before? Is it rare?
PMDD was only recently recognized as a diagnosable disorder and added to the diagnostic manual by the American Psychological Association (APA) in 2013 (10) and was added to the World Health Organization’s International Classification of Diseases in June 2019 (11, 12).
The physical symptoms of PMDD are similar to PMS, but PMDD also has severe emotional symptoms, including depression and such feelings of hopelessness (13) that 15% of patients with PMDD attempt suicide (8). Symptoms of PMDD are so extreme that they impact relationships, day-to-day function, and quality of life (14).
As with PMDD, the cause of PMS is not known, but factors like cyclic changes in hormones, chemical changes in the brain, and depression could contribute to the condition. PMS is also more common than PMDD, with about 75% of menstruators reporting some form or symptoms of PMS (15).
What are the symptoms of PMDD and how is it diagnosed?
PMDD has a broad spectrum of symptoms, and no single test can definitively determine whether or not you have it (3). Diagnostics are limited, and symptoms not only vary among individuals, but they also overlap with other disorders and illnesses; therefore, seeking professional help is critical to rule out other potential causes of your symptoms (8).
Your symptoms must include at least one related to mood, such as mood swings, feeling suddenly sad or tearful, increased sensitivity to rejection, marked irritability or anger, increased interpersonal conflicts, depressed mood, feelings of hopelessness, self-deprecating thoughts, noticeable anxiety, tension, and/or feelings of being keyed up or on edge (10).
You must also have one or more physical or behavioral symptoms such as decreased interest in usual activities, subjective difficulty in concentration, lethargy, easy fatigability, or marked lack of energy, noticeable change in appetite (overeating or specific food cravings), sleeping too much or trouble sleeping, a sense of being overwhelmed or out of control. Physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of “bloating” or weight gain may also be present (10).
According to the official diagnostic guidelines from the APA (10), to be diagnosed with PMDD, your symptoms must meet all of the following criteria:
At least one mood-related symptom and a minimum total of 5 symptoms including the physical or behavioral symptoms mentioned above.
Be present in the week before your period begins, also known as the luteal phase, for at least 2 cycles.
Improve after your period starts, and either completely resolve or be minimal in the week after your period.
Cause significant distress or interference with work, school, usual social activities, or relationships.
Not be attributed to anything else, such as a medical condition, another psychiatric or personality disorder, or medication.
Thus, a diagnosis of PMDD may be reached after a combination of evaluating the type and timing of your symptoms, including ruling out other physical and psychological possibilities with, for example, blood tests for conditions that may cause the same symptoms (3), such as hypothyroidism for fatigue (8).
What should I do if I think I have PMDD?
PMDD should not be confused with PMS (16) and is a serious, chronic condition that requires treatment. If you think you have PMDD, talk to your doctor about your symptoms right away (17). As mentioned above, your healthcare provider may perform an exam, blood tests, or other diagnostics to rule out certain conditions and may ask you to track your symptoms for at least 2 months (18).