Premenstrual Dysphoric Disorder

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What is premenstrual dysphoric disorder?

Premenstrual dysphoric disorder (PMDD) is a severe form of premenstrual syndrome (PMS). PMS encompasses a range of physical and emotional symptoms, such as breast tenderness, fatigue, and moodiness. It generally starts a week or two before a woman’s menstrual period and resolves within a day or two of it starting. PMDD follows the same pattern. However, at least one of the following must be prominent during that time frame and not present outside that time frame:

  • Marked anger, irritability, or interpersonal conflict

These symptoms cause significant distress or interfere with the ability to function at work or school or in relationships. Physical symptoms can also be present in PMDD. They can include fatigue, sleep problems, appetite changes, and bloating.

PMS is very common, with about 80% of women reporting at least one physical or emotional symptom. The incidence of PMDD is much lower. Estimates put the number around 5%.

The cause of PMDD remains unclear. It’s likely that hormonal and neurotransmitter changes trigger the symptoms of both PMS and PMDD. Many women who suffer with PMDD have underlying anxiety, depression, or seasonal affective disorder (SAD). Women with a family history of these disorders have a higher risk of developing PMDD.

Several treatments are available for PMDD, including antidepressants and oral contraceptives. There are also supplements your doctor can recommend to help minimize symptoms. Diet and lifestyle changes, such as exercise and relaxation techniques, can be helpful as well.

Left untreated, PMDD can cause significant disruption in your life and relationships. If you notice symptoms that coincide with your menstrual cycle, see your doctor. It’s important to rule out other causes before treating PMDD.

What are the symptoms of premenstrual dysphoric disorder?

Premenstrual dysphoric disorder symptoms include both physical and emotional aspects. In general, symptoms start 1 to 2 weeks before a woman begins her menstrual period. They can last until day 2 or 3 of the period and then resolve for the rest of the cycle.

Common premenstrual dysphoric syndrome symptoms

A premenstrual dysphoric syndrome diagnosis has specific criteria. The first one is that most menstrual cycles in the preceding year have at least five diagnostic symptoms. The symptoms must follow the time frame above.

At least one of the following symptoms must be present:

  • Extreme mood swings or moodiness
  • Intense anxiety or tension
  • Sadness, depression or hopelessness

Plus, at least one of the following symptoms must be present as well to reach a total of five symptoms from the two lists combined:

  • Changes in appetite, including overeating or specific food cravings
  • Decreased interest in normal activities
  • Feeling overwhelmed or out of control
  • Sleep problems, including sleeping too little or too much

Here are the other diagnostic criteria:

  • Symptoms result in significant distress or interfere with work, school, social interactions, or relationships.
  • Symptoms are not due to another mental disorder, such as major depression or a personality disorder. However, they can occur with these other disorders.
  • Symptoms are not related to a medication, substance abuse, or another medical condition, such as a thyroid disorder.

Make an appointment with your doctor if you experience symptoms of PMDD. Your doctor will need to rule out other causes and confirm the pattern of your symptoms to diagnose PMDD.

What causes premenstrual dysphoric disorder?

The exact cause of premenstrual dysphoric disorder isn’t entirely clear. The main theory is that women who suffer with PMDD are overly sensitive to changing hormone levels during their menstrual cycle. Specifically, their body reacts to falling estrogen and progesterone levels during the luteal phase—the part of the cycle after ovulation leading to menstruation. The changes in these hormone levels also have an effect on three neurotransmitters—serotonin, GABA and dopamine. These chemicals play a role in mood and mental health. In addition, these changes affect the hormone system that controls fluid and electrolyte balance. This could account for the physical symptoms of bloating and swelling.

What are the risk factors for premenstrual dysphoric disorder?

Many women who have PMDD also suffer from anxiety, depression, SAD (seasonal affective disorder), or postpartum depression. Having one of these disorders likely increases the likelihood of developing PMDD. It seems there may be a genetic link to PMDD, as well. So, having a family history of any of these disorders or PMDD itself may increase the risk.

Other possible risk factors for PMDD include:

  • Alcohol or substance abuse
  • Cigarette smoking
  • Sedentary lifestyle or being overweight
  • Thyroid disorders

Reducing your risk of premenstrual dysphoric disorder

You may be able to lower your risk of PMDD by:

  • Getting regular physical exercise
  • Limiting alcohol intake
  • Maintaining a healthy weight
  • Treating any underlying thyroid disease, substance problem, or mental health problem

If you have risk factors for PMDD, talk with your doctor about it. Find out what you can do to keep yourself healthy and what signs should prompt you to see your doctor.

How is premenstrual dysphoric disorder treated?

Premenstrual dysphoric disorder treatment focuses on relieving symptoms to help you function better. There are several options to discuss with your doctor including:

  • Antidepressants, specifically SSRIs (selective serotonin reuptake inhibitors), such as fluoxetine (Prozac, Serafem), paroxetine (Paxil), and sertraline (Zoloft). Your doctor may prescribe them continuously or only for the part of your cycle from ovulation to menstruation.
  • Oral contraceptives, which your doctor may prescribe for continuous use or with a shortened pill-free interval. When you take oral contraceptives continuously, you may not get a period. The most effective combination pill for PMDD contains drospirenone and ethinyl estradiol.
  • Vitamin supplements, particularly calcium, vitamin B6, and magnesium. L-tryptophan may also be helpful. Talk with your doctor before starting a supplement and verify the proper dose to take.
  • Other medications, including diuretics to relieve symptoms associated with fluid retention and over-the-counter pain relievers to alleviate physical symptoms of pain, cramping, and breast tenderness.

Lifestyle changes can also help lessen the symptoms of PMDD. This includes the strategies for reducing your risk of PMDD. In addition, you should try reducing caffeine intake, getting adequate sleep, and practicing relaxation techniques, such as meditation, visualization or biofeedback.

What are the potential complications of premenstrual dysphoric disorder?

Left untreated, PMDD can interfere with your ability to function at work or school or in daily life. It can decrease your quality and enjoyment of life. It can also cause difficulties with your social and personal relationships. Don’t put off talking with your doctor if you suspect you are suffering with PMDD.

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Medical Reviewer: William C. Lloyd III, MD, FACS
Last Review Date: 2020 Jul 14
  1. Hofmeister S, Bodden S. Premenstrual syndrome and premenstrual dysphoric disorder. Am Fam Physician. 2016 Aug 1;94(3):236-240.
  2. Premenstrual Dysphoric Disorder. Johns Hopkins University.
  3. Premenstrual Dysphoric Disorder. Office on Women’s Health.
  4. Premenstrual Dysphoric Disorder. MedlinePlus, U.S. National Library of Medicine.
  5. Premenstrual Dysphoric Disorder: Different from PMS? Mayo Foundation for Medical Education and Research.
  6. Treating Premenstrual Dysphoric Disorder. Harvard University.
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