What is premenstrual dysphoric disorder (PMDD)?

Premenstrual dysphoric disorder (PMDD) is a much more severe form of premenstrual syndrome (PMS). It is a cyclical hormonal disorder – meaning it comes in cycles and is linked to your menstrual cycle. It can be a severe and chronic medical condition that needs attention and support for mental and physical wellbeing.

By Caren Wigmore, ND

What causes PMDD?

Although it is triggered by hormones; PMDD does not necessarily mean your hormones are “out of balance”. Essentially your brain is sensitive to the natural changes in hormones across the menstrual cycle – in other words, an abnormal reaction to normal hormonal changes. So getting “hormones balanced” is not always the right approach to PMDD. Helping your brain cope with the changes is where the emphasis lies. The big players here involve progesterone, allopregnanolone, GABA receptors and the serotonin system. The serotonin system is often not working as it should and supporting this pathway in the luteal phase of the cycle can be very effective. Histamine and chronic inflammation can influence these neurotransmitters and how they function in the brain. As you can see in the image below: hormones are always changing through the cycle and it’s this natural change that challenges those with PMDD.

Illustration by Marta Pucci

What can ‘trigger’ PMDD to start?

PMDD can begin at any stage of life. It is not yet fully understood why some women develop PMDD. We do know it can be triggered or become worse with stressful life events/periods. Both perceived stress and work-related stress are considered equal triggers and as are reproductive events such as pregnancy, birth, miscarriage, and perimenopause, which all carry a certain degree of stress, have been identified as common triggers. A history of trauma has also been identified as a possible co-factor.

A note on perceived stress: This is the feelings or thoughts that someone has about how much stress they are under at a given point in time or over a given period. It is a measure of not how stressful someone’s life actually is but rather how they feel about it and also that person’s ability to handle such stress. This links directly back to the neurochemicals your body produces in response to the perceived stress. Our genes can influence this too.

It is in this space that lifestyle adjustments, Cognitive Behavioural Therapy (CBT), meditation, time in nature and nutrients and herbs can come into their own and are an important element in supporting someone with PMDD. I will often suggest a cortisol test to help me understand how your body is perceiving the stress you are under – this aids me in tailoring my treatment plan according to your nervous system.

What are the symptoms of PMDD?

PMDD is similar to PMS, but its symptoms, especially the emotional ones, are much more severe.

Symptoms of PMDD can appear from a few days, up to 2 weeks before your period and usually end within a few days after your period starts. Symptoms are commonly seen to intensify 6 days before your period and 2 days before is classically the worst. It is important to note that there is ALWAYS a break in PMDD symptoms after your period and until ovulation. Symptoms of PMDD are so severe that women have trouble functioning at home, at work, and in relationships during this time. This is markedly different than other times during the month.

5 or more of the following symptoms starting around 10 days before your period are the most common symptoms of PMDD:

• mood swings
• marked irritability or anger
• depressed mood
• feelings of hopelessness
• anxiety or tension
• reduced interest in friends, work, and other activities
• trouble concentrating
• fatigue, lack of energy
• appetite changes
• trouble sleeping or sleeping too much
• feeling out of control
• physical symptoms, such as bloating, breast tenderness, joint or muscle pain, and headache

These symptoms are severe enough to interfere with activities of daily life and reduce productivity at home or work and impact relationships – both marital and parental.
As PMDD is a spectrum disorder there are varying levels of severity. Not everyone will experience it the same way so tracking your symptoms for at least 2 months is important.

Please note that suicide is a risk for those who have PMDD – it is imperative to seek help if this is a concern for you. If you don’t already have a mental health care team, please access this resource for emergencies.

How is PMDD diagnosed?

• There is no blood test or pathology test available to diagnose PMDD.
• Other disorders like thyroid disorders/ depression/ chronic anxiety/bipolar should be ruled out
• The DSM-5 is an assessment tool used to confirm PMDD: if 5 of the above listed symptoms are present the week before the onset of menses and are ongoing for 2 or more cycles with a minimum of 5 cycles per year that would constitute a high likelihood of PMDD
• Symptoms cause significant impairment
• Symptoms are absent after menstruation and recur in the luteal phase.
• If I suspect PMDD I will ask my clients to complete the Daily Record of Severity of Problems for at least two months.
• World Health Organization (WHO) added PMDD to the International Statistical Classification of Diseases and Related Health Problems in 2019, validating PMDD as a medical diagnosis – this is relatively recent. Therefore there will be a lag in health care professionals who know how to address this effectively.

How is PMDD treated?

As PMDD can be a serious and chronic condition it takes multiple treatment approaches. Several of the following treatment approaches may help relieve or decrease the severity of PMDD symptoms:

• Changes in diet to a low inflammatory and glycaemic index diet including reducing caffeine, and alcohol.
• Regular exercise – at least 3 x per week for 40min
• Stress management – CBT, working with a therapist, herbal nervines and adrenal tonics to help your body cope and better manage its stress response: I love mixing herbal tonics for my clients as I can tailor it to each individual
• Cortisol testing can be helpful for us to measure your perceived stress and adjust our treatment approach to your biochemistry
• Vitamin supplements in specific forms and dosages are key (such as vitamin B6, calcium, and magnesium)
• Reducing any systemic inflammation which can exacerbate histamines which interact with how our hormones affect us
• Supporting the serotonin pathway (mainstream medicine will often prescribe anti-depressants in the SSRI class of drug) Naturopathically I look to support the serotonin pathway directly with herbs and nutrients.

If you have concerns or wonder if this could be part of your picture, book a consult with me today as I’d love to get you back to better mental, emotional and physical health so you can focus on your life and not this condition.