What is PMDD?

Premenstrual dysphoric disorder (PMDD) is the most severe form of PMS (premenstrual syndrome). The symptoms associated with PMDD can impair a woman’s ability to function properly each day and to engage in normal activities. 

It's normal for women to experience some uncomfortable symptoms just before their period - such as irritability, bloating, and cramps. However, 5% to 8% of women have symptoms that can cause significant distress and functional impairment.

PMDD is described in the DSM-V as characterized by moderate to severe psychological, behavioural and physical symptoms beginning up to two weeks prior to menstruation (the luteal phase of the menstrual cycle) and significantly interfering with daily functioning. Symptoms usually resolve soon after the onset of menstruation. However, these affective and somatic symptoms are equivalent to major depression, panic disorder, and post-traumatic stress disorder.

If left untreated, PMDD symptoms can severely affect mental wellbeing and overall quality of life.

What are the causes of PMDD ?

PMDD appears to develop in women of reproductive age after they are exposed to progesterone at the time of ovulation. Researchers have suggested that PMDD is partly a result of abnormalities in serotonin levels during the luteal phase of the menstrual cycle. Women with PMDD who exhibit these serotonin abnormalities when estrogen levels decline may be more sensitive to the effects of estrogen on serotonin function in the brain.

PMDD also may be linked to certain receptors in the brain that are triggered by exposure to allopregnanolone (Allo), a metabolite of the sex hormone progesterone.  Reduced levels of allopregnanolone are found to be associated with major depression, anxiety disorders, and PMDD. 

What are the symptoms of PMDD ?

The most frequent core symptoms of PMDD are irritability, anger conflict, and emotional lability.

Symptoms usually begin in the week before menstruation and improve when menstruation begins. The most severe symptoms occur around 3-4 days before bleeding begins and last for up to three days. Most women are symptom-free in the week after menstruation finishes and up until ovulation (the proliferative phase).

Diagnostic criteria for PMDD must include at least five of the following symptoms in the final week before the onset of menstruation. These symptoms start to improve within a few days after menstruation begins, and dissipate in the week after menstruation ends.

• Severely depressed mood and feelings of hopelessness

• Anxiety, tension, feeling “on edge”

• Persistent irritability and anger 

• Instances of interpersonal conflicts

• Loss of interest in usual routines or activities (including at work and socially) 

• Struggling to concentrate 

• Lethargy, fatigue, general lack of energy

• Noticeable changes to appetite: cravings for certain foods or overeating 

• Difficulty sleeping and/or insomnia

• Feeling constantly overwhelmed or out of control

• Physical symptoms that are similar to PMS: breast pain, tenderness or swelling; headaches, muscle or joint pain, bloating, weight gain

What is the treatment for PMDD ?

Treatment for PMDD can include pharmacological and non-pharmacological methods. 

Pharmacological treatment methods:

• Serotonin Reuptake Inhibitors (SSRIs): SSRIs are the most common medical  approach in treating PMDD. Other psychotropic agents such as benzodiazepines may also be used to alleviate mood and somatic symptoms. Fluoxetine is shown to provide symptomatic relief for around 60-80% of women with PMDD, although this generally only lasts for a few days after menstruation begins. Side effects of SRIs may include nausea and reduced libido.
  

• Hormonal therapies: For very severe symptoms, hormonal drugs can be used to suppress ovulation and/or inhibit the hypothalamic-gonadal cycle. However, this can cause “medical menopause” and menopausal symptoms such as hot flashes and an increased risk of osteoporosis.
  

• Oral contraceptive pill: Although commonly prescribed, OCPs are not known to be significantly effective in treating PMDD. Contraceptives that contain progestins can potentially exacerbate PMDD symptoms.
  It should also be noted that despite the efficacy of SSRIs and low-dose OCPs, more than 40% of women with PMDD do not respond to these, and nearly 50% of women with menstrually-related mood disorders who are prescribed SSRIs do not take them or discontinue within six months.

How can I fix my PMDD naturally?

Women who wish to avoid the potential side effects of pharmacological treatments for PMDD may find relief through natural methods,  many of which are backed by clinical studies.

Naturopathy treatment for PMDD

• Exercise

  While there are no studies specifically on PMDD and exercise, several studies have shown the benefits of exercise for PMS.
  Regular physical activity can improve mood symptoms and reduce pain by boosting beta-endorphins. Exercise may also help to regulate progesterone and oestrogen synthesis and promote the production of anti-inflammatory compounds.

• Diet
  Increased intake of complex carbohydrates or proteins may increase tryptophan availability, which can then increase serotonin levels.
  Depending on specific needs, dietary intervention may also include removing dairy products and/or caffeine from the diet, and increasing essential fatty acids. High intake of bread, sugary foods, fast food, deep-fried meals, coffee, and alcohol are significantly associated with the development of PMS, and are likely to worsen PMDD.
  Increasing foods rich in calcium, vitamin D, and magnesium have been shown to reduce the severity of both PMS and PMDD. Omega-3 fatty acids can also support cognitive function and help to reduce inflammation associated with premenstrual disorders.

• Herbal medicines
  Phytoestrogens such as Chaste berry/Vitex agnus-castus may be helpful for PMS/PMDD. Chaste tree is shown to exert dopaminergic effects which can help to relieve psychological symptoms such as depression and anxiety. It may also reduce breast pain and tenderness, swelling, cramps, and food cravings.
  Other herbal medicines used to treat PMDD include Xiao yao san (a traditional Chinese herbal medicine), Hypericum perforatum, Crocus sativus, and Ginkgo biloba. A Chinese study found that Xiao yao san was more effective in improving overall symptoms of PMS than hormone replacement therapy.
  Hypericum perforatum (St John’s Wort) was found to be superior to placebo for the treatment of physical symptoms of PMS, but did not have a significant impact on mood symptoms, including depression, anxiety or irritability.

• Mindfulness

  Stress management and mindfulness techniques have demonstrated effectiveness in addressing mood symptoms associated with PMDD. A large pilot study found that mindfulness-based stress reduction training provided clinically and statistically significant reductions in seven premenstrual emotional symptoms.
  Previous research has also supported the efficacy of cognitive therapy for PMDD, with some evidence that the benefits are equivalent to the SSRI drug fluoxetine. Cognitive therapy is also found to be superior to hormone therapy for alleviating PMDD symptoms.

What vitamins should I take for PMDD?

Good nutrition is vital for supporting mind and body health during hormonal change, and there is good evidence to suggest that PMDD sufferers may benefit from specific vitamins and minerals. 

Calcium supplementation is shown to reduce major premenstrual syndrome symptoms, including low mood, water retention, food cravings, and pain during the luteal phase of the menstrual cycle.
Other studies have reported that supplementing with calcium can improve emotional and physical symptoms over placebo. 

Combined supplementation of calcium and vitamin B6 was found to significantly reduce the symptoms of premenstrual syndrome as compared with vitamin B6 alone. While each t seems that the combination of calcium and vitamin B6 can be used for better controlling of the premenstrual syndrome symptoms.
Calcium supplements have the added benefit of boosting overall intake of calcium and therefore contributing to the prevention of osteoporosis.

Another study found that a taking broad-spectrum micronutrient formula (consisting mainly of minerals and vitamins) was more effective than a single vitamin B6 supplement for treating PMS-like symptoms. The micronutrient supplement appears to improve overall quality of life to a greater degree than B6 alone, particularly for those with more severe symptoms. 

How does naturopathy and acupuncture help with PMDD?

PMDD and naturopathy go well together. PMDD is a very personal condition in that symptoms vary between sufferers. Unlike conventional practitioners, a naturopath assesses a client’s full spectrum of needs and seeks to treat the cause rather than the symptoms. Treatment is specific rather than general; that is, a treatment plan is designed to fit the individual’s lifestyle and symptoms. 

A systematic review found that using herbal medicine and acupuncture to treat both premenstrual syndrome and PMDD resulted in a 50% or better reduction of symptoms compared to the initial state.

Research into PMDD and acupuncture has also suggested significant benefits. Studies documenting acupuncture treatments for PMS include general acupuncture points, manipulated techniques of acupuncture, and hand acupuncture. Acupuncture is shown to relieve physical symptoms of PMDD such as headache, cramps, backache, breast pain, swelling of hands and feet, and abdominal pain by as much as 50%. The same study found that hand acupuncture therapy and hand moxibustion therapy was shown to be particularly helpful for rapid mood swings, abdominal pain and bloating.

Do hormones matter in regards to PMDD ?

The interesting thing about PMDD is that women who are affected do not necessarily have abnormal levels of ovarian hormones or any other form of hormonal dysregulation. However, the timing of PMDD symptoms indicates that some kind of sensitivity to hormonal fluctuation is involved. Recent research suggests that women with PMDD may be more sensitive to monthly hormonal fluctuations, particularly oestrogen and progesterone.

In PMS, the response systems within the brain known to be involved in PMS symptoms are the serotonin and GABA systems. Progesterone metabolites, especially allopregnanolone, are neuroactive, acting via the GABA system in the brain.
These hormones can impact central nervous system function. Progesterone and allopregnanolone, for example, increase in the luteal phase (around day 15 of a 28-day cycle) and fall quickly around the start of menstruation. This period of exposure to ovarian hormones followed by their rapid withdrawal is thought to be a key factor in PMDD.

Does PMDD affect fertility?

There is no evidence to suggest that PMDD affects fertility. Unfortunately, this is also one of the reasons that PMDD is often left untreated.

Does PMDD affect pregnancy

PMDD only occurs while women are menstruating. During pregnancy, a woman is not menstruating, and therefore will not be affected by PMDD. However, a woman’s sensitivity to hormone fluctuations may continue. 

Is there a link between endometriosis and PMDD?

Previous research has revealed a high prevalence of mood disorders in women with endometriosis, which has led to speculation about a hormone or neurotransmitter link as a possible cause.

Women with endometriosis - especially those with pelvic pain - are also more vulnerable to developing psychiatric disorders. Pelvic pain, infertility and psychic vulnerability usually leads to markedly lower quality of life for women of reproductive age, which can then affect work, social life, and overall functioning.

A longitudinal study from Taiwan investigated the link between endometriosis and depression and anxiety disorders. It reported that women with endometriosis had a higher risk of developing depressive and anxiety disorders compared to those without endometriosis. This was the case for all women, regardless of age. PMDD is considered a depressive disorder by the DSM-5. 

Does PMDD go away after menopause?

PMDD symptoms are not present when there is no menstrual cycle, so the disorder will technically ‘resolve’ after menopause. However, it should be noted that other mood disorders may persist throughout life. Menopause is also a time of hormonal flux, so those who have been affected by PMDD should be aware that their sensitivity to hormonal change may lead to further mood issues. 

How to help someone with PMDD?

The best way to support someone with PMDD is to understand that they cannot help how they are feeling. They may be angry, irritable, or difficult to spend time with, but this should not be taken personally. Those who are not receiving treatment may also be experiencing severe depression, so it’s crucial to look out for them and show that you care. It can help to remind them that PMDD is a medical condition and that they are not at fault. Encourage them to seek help from a qualified health practitioner, such as a naturopath who specialises in women’s health. Seeing a psychologist or counsellor may also be beneficial.

Peer support is invaluable for someone with PMDD as it can be a lonely and isolating experience. Schedule time around their menstrual cycle so that you can be available when they experience symptoms. It can help to suggest activities together, such as taking a walk, watching a movie, or simply offering company.