BY MARLEIGH SMITH, NEUROSCIENTIST AT DITTO
Are there different subtypes of Premenstrual Dysphoric Disorder (PMDD)?
There might actually be!
Not everyone with PMDD experiences the same timing pattern in their symptoms.
For some, symptoms begin the week before their period and disappear as soon as their period starts. For others, symptoms creep in earlier or linger a few days into menstruation.
Understanding these “temporal” subtypes (meaning relating to timing of symptoms) is crucial for accurate diagnosis - as without incorporating subtypes into diagnostic criteria, doctors and gynaecologists may be missing individuals whose PMDD presents differently from the textbook pattern.
Not All PMDD Follows the Same Timeline
A 2019 study investigated if there were distinct subtypes of PMDD in a cohort of 74 women (1). They used a daily symptom report to assess PMDD symptoms across the cycle and observed three distinct subtypes of PMDD.
1. Full luteal phase subtype
17.5% of participants
This subtype was characterized by a high severity of symptoms for the entire luteal phase (typically 14 days of the cycle) and was seen in 17.5% of the cohort.
The symptoms occurred quickly after ovulation, lasted the full luteal phase, and then disappeared quickly as the period began.
Anger and irritability was more likely to follow the full luteal phase pattern compared to any other type of emotional symptoms, where 55.4% of women in the cohort had irritability across the entire luteal phase.
This subtype of PMDD suggests a vulnerability to hormone surges, as estrogen and progesterone begin to surge at ovulation and during the luteal phase.
2. Moderate premenstrual week subtype
65% of participants
This subtype had moderate rather than severe symptoms, with more “delayed onset” - presenting in the premenstrual week rather than the full luteal phase. This subtype was the most common, seen in 65% of the cohort. The symptoms disappeared quickly as the period began.
Why doesn’t it start at the beginning of the luteal phase? It could be a delay in the post-ovulatory hormone surges. Or, some studies state that this is because of altered processing of hormones, potentially through specific cells processing them differently at a genetic level (2).
Other studies have found that individuals with PMDD have varying sensitivities to different hormones, with some being estrogen-sensitive, some being progesterone-sensitive, and others being sensitive to both hormones. These differences between PMDD patients could also play a part in how the hormone fluctuations impact their symptoms differently throughout the menstrual cycle (6).
3. Severe premenstrual week with late offset
17.5% of participants
This subtype had severe symptoms starting in the premenstrual week that didn't resolve as soon as the period began (i.e. lasted days into the period). This was seen in 17.5% of the cohort.
In this subtype, depression and sadness was a common feature. In fact, 42.9% had depression that was slow to resolve and 50.7% had sudden sadness as part of mood swings.
Why are symptoms slow to resolve? It could be due to individual differences in emotional regulation strategies. Studies show that those with higher levels of rumination have a slower offset of premenstrual depressive symptoms (3). Another suggestion is that it could be due to differences in the biological response to hormone withdrawal that occurs as the period begins.
Why could subtypes be an issue for therapies?
GnRHs
This eliminates ovulatory cyclic changes all together by preventing any surges in progesterone or estrogen (1). It seems that these could cater to those with the full luteal subtype who may be more vulnerable to surges in hormones (1). In which case, those without full luteal symptoms, which was the majority in this cohort (82.5%), would be left without treatment.
SSRIs
SSRIs are seen to be effective in studies for those with PMDD, but only 60-70% of those will respond (5, 6). Additionally, some SSRIs are prescribed to be taken only in the luteal phase, which can be limiting for those who do not have a regular cycle, and also for those who have symptoms that exist past the luteal phase, like those in Group 3 in the study highlighted above. Not only that, but SSRIs come with negative side effects, such as decreased libido, weakness/lack of strength, fatigue, sweating and nausea, all which can significantly impact quality of life (5).
There has been a lack of solution for a treatment that can help those with all different types of PMDD, without adding side effects that take more from the quality of life of those suffering.
DITTO’s Cycle Supplement will help - no matter your subtype.
The Cycle Supplement can offer significant relief for PMDD sufferers, no matter if you experience symptoms throughout the entire luteal phase, premenstrual week or if you have irregular cycles. It is a daily supplement that uses nutrients and extracts targeted towards the neuroscience of PMDD, so that you can naturally build up resilience to hormonal changes throughout your cycle..
References
1. Eisenlohr-Moul TA, Kaiser G, Weise C, Schmalenberger KM, Kiesner J, Ditzen B, Kleinstäuber M. Are there temporal subtypes of premenstrual dysphoric disorder?: using group-based trajectory modeling to identify individual differences in symptom change. Psychol Med. 2020 Apr;50(6):964-972. doi: 10.1017/S0033291719000849. Epub 2019 Apr 23. PMID: 31010447; PMCID: PMC8168625.
2. Dubey, N., Hoffman, J., Schuebel, K. et al. The ESC/E(Z) complex, an effector of response to ovarian steroids, manifests an intrinsic difference in cells from women with premenstrual dysphoric disorder. Mol Psychiatry 22, 1172–1184 (2017). https://doi.org/10.1038/mp.2016.229
3. Wei SM, Wakim P, Martinez PE, Nieman LK, Rubinow DR, Schmidt PJ. Differential Effects of Ovarian Steroids in Women With and Without Premenstrual Dysphoric Disorder: A Replication and Extension of Findings. American Journal of Psychiatry. 2025 Oct 1;182(10):922–34.
4. Dawson DN, Eisenlohr-Moul TA, Paulson JL, Peters JR, Rubinow DR, Girdler SS. Emotion-related impulsivity and rumination predict the perimenstrual severity and trajectory of symptoms in women with a menstrually related mood disorder. Journal of Clinical Psychology. 2017 Sep 12;74(4):579–93.
5. Marjoribanks J, Brown J, O'Brien PM, Wyatt K. Selective serotonin reuptake inhibitors for premenstrual syndrome. Cochrane Database Syst Rev. 2013 Jun 7;2013(6):CD001396. doi: 10.1002/14651858.CD001396.pub3. Update in: Cochrane Database Syst Rev. 2024 Aug 14;8:CD001396. doi: 10.1002/14651858.CD001396.pub4. PMID: 23744611; PMCID: PMC7073417.
6. Pearlstein T, Steiner M. Premenstrual dysphoric disorder: burden of illness and treatment update. J Psychiatry Neurosci. 2008 Jul;33(4):291-301. PMID: 18592027; PMCID: PMC2440788.
