PMS & PMDD

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PMS & PMDD

The Menstrual Cycle and Mental Health: Exploring PMS and PMDD

By Dr. Anita Mitra (The Gynae Geek)

Premenstrual Syndrome (PMS)

I’m sure you’ve probably heard someone say, ‘she’s just PMS-ing!’. PMS, which stands for premenstrual syndrome is the term used to refer to a collection of mood-related and physical symptoms and the way the term can be thrown around in a derogatory fashion can really undermine the negative impact that these symptoms can have on millions of women every month. The typical symptoms that we’ve all heard of include anxiety, irritability, sleep disturbance, fluid retention and breast tenderness, but there are actually over 150 symptoms. About nine out of ten of us will experience some type of physical or emotional change that will signal that our period is around the corner, and it happens due to the hormonal changes that occur during the normal menstrual cycle. I think it’s really important to be aware of the fact that your hormonal levels aren’t the same on every day of the menstrual cycle and as a result, we can’t expect to feel the same every day, so some degree of fluctuation of our physical and mental state is to be expected. The trademark of PMS is that these symptoms occur in the luteal phase of the menstrual cycle and disappear within the first few days of your period. The most crucial thing to emphasise is that whilst PMS is unpleasant, your symptoms shouldn’t have a significant negative effect on your quality of life and ability to function, to the point where it’s unmanageable or requires the use of medication.

Here are some of the most common symptoms associated with PMS:

Emotional and behavioural

  • Depression, feeling low, hopelessness
  • Anxiety
  • Mood swings, increased sensitivity
  • Food cravings
  • Fatigue
  • Reduced concentration, reduced productivity
  • Feelings of anger & irritation towards others

Physical

  • Breast swelling and tenderness
  • Bloating
  • Headaches
  • Joint pains

There are some recognised variants of PMS that are worth mentioning:

  • Premenstrual exacerbation (PME) – This is the worsening of an existing medical condition in the lead-up to your period. It could be a psychological condition such as depression or obsessive compulsive disorder (OCD), or a physical condition such as asthma, epilepsy, migraine or irritable bowel syndrome (IBS).
  • Progestogen-induced premenstrual dysfunction – This means PMS symptoms related to taking progestogen-containing medications such as the contraceptive pill.
  • Premenstrual dysfunction with absent menstruation – This can occur if you’re taking medication to stop your periods, but the hormone production that still goes on in your body results in ongoing cyclical symptoms.

But What About Premenstrual Dysphoric Disorder (PMDD)? 

Up to eight in 100 of us have a condition called Premenstrual dysphoric disorder (PMDD) (1).  This is often described as a very severe form of PMS, which is true to some extent because the severe emotional and psychological symptoms follow the same cyclical pattern, however the negative impact they have on quality of life is severe, and in some instances can be quite simply life-threatening. A startling but very important statistic from the International Association for Premenstrual Disorders stated that 86% of women with PMDD have considered suicide, and 30% report attempting suicide at least once, which shows how seriously we need to take this condition. PMDD was only recently added to the International Statistical Classification of Diseases and Related Health Problems (ICD–11) in 2019, which is a major leap in validating a drastically under-recognised condition. The lack of awareness of PMDD has led to individuals being dismissed by doctors and ineffectively treated, if treated at all, and has even led to women being misdiagnosed with bipolar disorder. PMDD can have such a negative impact on people’s lives that is has actually been recognised as a disability under the Equality Act 2010, which means that your employer should make reasonable adjustments for you at work if you have the condition. Whilst there are plenty of gynaecological conditions that make many of my patients dread the arrival of their period, PMDD is one of the few conditions where the start of a period marks the relief of the extreme emotional and psychological symptoms. As one patient once told me: ‘I feel like I want to kill myself and everyone in sight, and the moment I see blood I think “It’s going to be OK … for the next 2 weeks at least”.’

The diagnostic criteria for PMDD were first described in 2013 in the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) of the American Psychiatric Association. These are used internationally. A diagnosis of PMDD requires at least 5 of the 11 symptoms below, one of which must be a core symptom.

Core symptoms of PMDD

  • Marked affective lability (e.g. mood swings, feeling suddenly sad or tearful, or increased sensitivity to rejection).
  • Marked irritability or anger or increased interpersonal conflicts.
  • Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts.
  • Marked anxiety, tension, and/or feelings of being keyed up or on edge. Additional symptoms of PMDD
  • Decreased interest in usual activities (e.g. work, school, friends, hobbies). •    Difficulty in concentrating.
  • Lack of energy, easily fatigued.
  • Marked change in appetite, food cravings.
  • Feeling overwhelmed or ‘out of control’.
  • Changes in sleep (hypersomnia, insomnia).
  • Physical discomforts such as breast tenderness, joint/muscle pains, headaches, bloating, weight gain.

If you have PMDD, your hormone levels themselves are probably not any different to someone who doesn’t have it. However, there appears to be a sensitivity to some of the menstrual cycle hormones, and there are a couple of theories of how this may come about. Allopregnanolone is a chemical that is made during the breakdown of progesterone. It usually has a calming effect on the brain, however if you have PMDD, it tends to have the opposite effect resulting in increased anxiety, restlessness and low mood (REF). Oestrogen and progesterone are known to interact with mood-related pathways, and studies have demonstrated that the expression of a group of genes involved such pathways in response to oestrogen and progesterone were different in women with PMDD compared to those without (2), which again explains why two individuals may respond differently to the same level of menstrual cycle hormones. There isn’t a single gene that has been identified as causing PMDD, but studies of identical twins do support the theory of a genetic predisposition (3).

How can I get diagnosed?

There isn’t a drastic difference to hormone levels between women who experience PMS/PMDD and those who don’t, so for this reason there aren’t any blood tests or scans that can diagnose it. However, your doctor may carry out blood tests based on the symptoms that you have reported, to rule out other causes before concluding that you have PMS or PMDD. Diagnosis is based on the description of your symptoms, which is why keeping a symptom diary is crucial. I recommend that you collect information about your menstrual cycle, because for PMDD to be diagnosed, there must be a clear correlation with your cycle. You need to keep this diary for at least 2 or 3 months and your doctor might also ask you to complete a special questionnaire. The Daily Record of Severity of Problems, which is the most commonly used to track symptoms of PMS and PMDD. This can be helpful for both diagnosis, but also for monitoring the impact of any lifestyle changes or medication that you try. If there is any uncertainty over the diagnosis, your doctor may suggest using a 3-month trial of an injectable medication to induce a temporary menopause which is called a GnRH analogue. Zoladex is a common trade name of this medication in England. If you indeed have PMS or PMDD, you symptoms should either improve significantly or disappear entirely. After the injection wears off your periods and symptoms would go back to normal and you wouldn’t be in a menopausal state anymore. 

Treatment options for PMS and PMDD

  • Lifestyle modification – This is the first thing to try. You may wish to record things like sleep and exercise when you keep a symptom diary, to help you work out if anything specific works well for you or makes you feel worse.
  • Diet – High-sugar, high-fat diets containing a lot of caffeine and alcohol may worsen PMS symptoms. Eating complex carbohydrates, such as peas, beans and whole grains, along with plenty of protein may increase serotonin levels and lessen PMS/PMDD symptoms by driving tryptophan, an essential amino acid, into the brain where it is used for serotonin production (4). Whole milk, chicken, tinned tuna, cheese, eggs, bread and oats are foods that are all naturally rich in tryptophan.
  • Supplements – There have been multiple clinical trials showing that certain nutrient and extract supplements can effectively reduce the severity of PMS and PMDD, for example zinc, omega-3 and saffron extract . DITTO Cycle Supplement is a formulation that has brought 10 key ingredients together with the strongest evidence behind them (5-8).
  • Stress management – Stress may worsen PMS/PMDD, and simply having these symptoms may exacerbate stressful situations, leading to a vicious cycle. It has been shown that women with PMDD may use less productive coping strategies to deal with stressful events (9), and this is where psychological interventions such as CBT, or even practising mindfulness, may be helpful.
  • Exercise – Exercise has been shown to increase serotonin levels. Multiple studies have shown that exercise can lead to symptom improvement, with walking, running, swimming and yoga most commonly cited in studies. Exercising three times per week for just 20 minutes each time can also reduce the physical symptoms of PMS, including nausea and bloating (10).

Non-hormonal treatments

  • Selective-serotonin reuptake inhibitors (SSRIs), e.g. fluoxetine, citalopram, escitalopram – These are antidepressants that, when used at a low dose, can be very effective, with up to 75% of women with PMDD showing an improvement (11). SSRIs can be used during the luteal phase of the menstrual cycle, or continuously. The former may be useful if you are particularly troubled by side effects, such as nausea, loss of libido, sweating and fatigue.
  • CBT – This can help women learn how to manage their symptoms, and has been shown to be as effective as taking an antidepressant (12).

Hormonal treatments

  • The combined oral contraceptive pill (COCP) – There are two types that can be used. They work by preventing ovulation and the fluctuations in hormones responsible for PMS/PMDD symptoms. Taking the COCP continuously without a pill-free week offers further hormonal stability. COCPs containing the progestogen drospirenone have been shown to be particularly effective, particularly for PMDD (13). This type of COCP has the highest risk of venous thromboembolism (VTE), although the absolute risk remains incredibly low. Other COCPs may also be effective, particularly when taken continuously which is something that your doctor can discuss with you. GnRH analogues with ‘add-back’
  • HRT – GnRH analogue injections induce a temporary menopause. If you wish to continue these injections, you should do so using ‘add-back’ hormones in the form of either conventional oestrogen and progesterone HRT or a medication called tibolone. The purpose of using one of these medications is to reduce the menopausal symptoms associated with the GnRH, and to protect you from bone thinning as a result of the drug-induced menopause

Surgery

  • Hysterectomy with bilateral salpingo-oophorectomy – This means removing the uterus, tubes and ovaries. This is not a decision to be taken lightly; it is only considered if all medical therapies have failed. The reason behind this surgery is to remove the ovaries, which will bring on a surgical menopause and stop the hormonal fluctuations of the menstrual cycle, stopping PMS/PMDD permanently. While the uterus doesn’t contribute to hormonal fluctuations, it’s advisable to remove it at the same time as the ovaries because leaving it behind means you would need to take progesterone as part of your HRT to protect your  endometrium which can be problematic if you have PMS or PMDD because there appears to be the same sensitivity to progesterone medications as there is to your own progesterone. If your uterus has been removed you can use oestrogen-only HRT: this helps to reduce any health complications from years of low oestrogen (which include heart disease, osteoporosis and dementia, particularly if your uterus is removed when you’re under the age of 45). Testosterone supplementation may also be required to boost your libido, because the ovaries produce 50% of testosterone in the female body, and lack of this can be profound after a surgical, compared to a natural, menopause. Patients report a high level of satisfaction after having this type of surgery – which shows me what a debilitating disease PMDD can be. It saddens me to hear about how many people are dismissed or misdiagnosed, but unfortunately, I’m not surprised. If you think you may have PMDD, you might want to take this self-screening test which may help you have a more constructive conversation with your GP of gynaecologist. It is written by the team of international experts of run the International Association for Premenstrual Disorders (IAPMD), which is a great source of further information or support.
  1. Halbreich U, Borenstein J, Pearlstein T, Kahn LS. The prevalence, impairment, impact, and burden of premenstrual dysphoric disorder (PMS/PMDD). Psychoneuroendocrinology. 2003;28 Suppl 3:1-23. 
  2.  Dubey N, Hoffman JF, 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. 2017;22(8):1172-1184. 
  3. McEvoy K, Osborne LM, Nanavati J, Payne JL. Reproductive Affective Disorders: a Review of the Genetic Evidence for Premenstrual Dysphoric Disorder and Postpartum Depression. Curr Psychiatry Rep. 2017;19(12):94. 
  4. Siminiuc R, Ţurcanu D. Impact of nutritional diet therapy on premenstrual syndrome. Front Nutr. 2023;10:1079417.
  5. Jafari F, Amani R, Tarrahi MJ. Effect of Zinc Supplementation on Physical and Psychological Symptoms, Biomarkers of Inflammation, Oxidative Stress, and Brain-Derived Neurotrophic Factor in Young Women with Premenstrual Syndrome: a Randomized, Double-Blind, Placebo-Controlled Trial. Biol Trace Elem Res. 2020;194(1):89-95
  6. Mohammadi MM, Dehghan Nayeri N, Mashhadi M, Varaei S. Effect of omega-3 fatty acids on premenstrual syndrome: A systematic review and meta-analysis. J Obstet Gynaecol Res. 2022;48(6):1293-1305 
  7. Rajabi F, Rahimi M, Sharbafchizadeh MR, Tarrahi MJ. Saffron for the Management of Premenstrual Dysphoric Disorder: A Randomized Controlled Trial. Adv Biomed Res. 2020;9:60.
  8. Beiranvand S, Beiranvand N, Moghadam Z, et al. The effect of Crocus sativus (saffron) on the severity of premenstrual syndrome. European Journal of Integrative Medicine. 2016. 55-61
  9. Beddig T, Reinhard I, Kuehner C. Stress, mood, and cortisol during daily life in women with Premenstrual Dysphoric Disorder (PMDD). Psychoneuroendocrinology. 2019;109:104372.
  10. Mohebbi Dehnavi Z, Jafarnejad F, Sadeghi Goghary S. The effect of 8 weeks aerobic exercise on severity of physical symptoms of premenstrual syndrome: a clinical trial study. BMC Womens Health. 2018;18(1):80.
  11. Marjoribanks J, Brown J, O'Brien PM, Wyatt K. Selective serotonin reuptake inhibitors for premenstrual syndrome. Cochrane Database Syst Rev. 2013;2013(6):CD001396.
  12. Hunter MS, Ussher JM, Browne SJ, Cariss M, Jelley R, Katz M. A randomized comparison of psychological (cognitive behavior therapy), medical (fluoxetine) and combined treatment for women with premenstrual dysphoric disorder. J Psychosom Obstet Gynaecol. 2002;23(3):193-199.
  13. Lopez LM, Kaptein AA, Helmerhorst FM. Oral contraceptives containing drospirenone for premenstrual syndrome. Cochrane Database Syst Rev. 2012;(2):CD006586.
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