What is Premenstrual Dysphoric Disorder (PMDD)?

What is PMDD?

Premenstrual dysphoric disorder (PMDD) is a cyclical, hormone-based mood disorder that affects women who have a menstrual cycle. It’s characterised by symptoms that show up during the luteal phase of the cycle (aka, the two weeks before your period) and subside within a few days of getting your period. People typically refer to it as ‘severe PMS’, but for those living with PMDD, this can feel like a real understatement.

The key difference between PMS and PMDD is that, with PMDD, the symptoms are much more intense. Painful cramps can become debilitating pain, food cravings manifest as insatiable hunger and low mood becomes depression or extreme anxiety. In the UK, PMDD is estimated to affect between 3 to 8% of women, but because so few people know about the condition, it could be higher than this.

It’s only in the past few years that PMDD has been included in medical training programmes. It first appeared in the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 2013 and was recently included as a diagnosis in the latest edition of the WHO’s International Classification of Diseases.

The DSM defines PMDD as a "depressive disorder not otherwise specified”. People with PMDD are frequently mis- or underdiagnosed with bipolar, personality, anxiety or depressive disorders, and some health professionals still refuse to believe it even exists. (Trust us, it definitely does!)

The exact cause of PMDD is unknown. It’s thought that there are many different factors that come into play. Many media outlets like to point the finger at hormones, but with most things, it’s not quite that simple.

Considering most of us go through a ‘standard’ 28-day menstrual cycle, if PMDD was caused by hormones alone, we’d all have it, which isn’t the case.

The main factor is thought to be our individual sensitivity to the steroid produced when progesterone is broken down: allopregnanolone. It affects GABA receptors  which are associated with emotions such as anxiety, stress, and fear. In high concentrations, allopregnanolone has an anti-anxiety and calming effect. But, in lower concentrations, it causes negative mood and triggers feelings of depression. 

It’s thought that people with PMDD are more sensitive to allopregnanolone, and their GABA receptors may respond differently to it. Once we enter the second half of the luteal phase levels of both progesterone and allopregnanolone drop, triggering symptoms of PMDD.

Other factors such as genetics, stress levels, and lifestyle also likely play a role. You can read more about the potential causes of PMDD here.

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There are said to be over 150 different symptoms. These can be grouped into physical, psychological and behavioural symptoms. It’s important to note that the symptoms we experience can change every single cycle, so no two experiences (whether that’s cycle to cycle, or person to person) will be the same. 

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Psychological 

Irritability

Anger

Anxiety

Feelings of depression

Suicidal ideation

Nervousness

Emotional sensitivity and crying

Loneliness

Hopelessness

Guilt

Confusion and forgetfulness

Brain fog

Feeling overwhelmed

Mood swings

Fatigue

Low self-esteem

Lack of pleasure in life

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Physical

Pain 

Breast swelling and tenderness

Headaches

Back pain

Bloating

Sore nipples

Blurred vision

Acne

Cramps

Constipation

Diarrhoea

Worsening of allergies

Worsening of eczema

Hot flashes

Dry skin

Sensitivity to touch

Heartburn

Ringing in the ears

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Behavioural 

Lack of sex drive

Insomnia

Social withdrawal

Recklessness

Indecisiveness

Defensiveness

Crying

Sudden outburst

Aggression

Agitation

Avoiding responsibilities 

Lack of coordination

Lack of control

Increase in addictive behaviours (drinking, gambling, spending money, drugs)

Self-harm

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Perhaps the most terrifying symptom of all is feeling suicidal, or having suicidal thoughts or ideation. People who experience PMDD are 7X more likely to contemplate suicide compared to those who don’t, and 34% have acted on it to try to escape the debilitating symptoms. To put that in context, that’s over 190,000 people in the UK who have attempted to take their own life because of their menstrual cycle.

If you or someone you know is experiencing extreme anxiety, or any other symptoms that are significantly affecting your/their quality of life, it’s important to seek help from a GP. If you’re having suicidal thoughts and are worried you may act on them, you should call 999, go to A&E, or contact the Samaritans.

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Why do I need a diagnosis?

Whilst you’re under no obligation to visit the GP for a PMDD diagnosis, it can help you 1) get prescription medication, 2) find additional support, and 3) get notes/support for work adjustments. 

Diagnostic criteria

To be diagnosed with PMDD, the doctor will need to see evidence that you experience a particular  combination of at least five symptoms, including one mood-related symptom, during the luteal phase of your menstrual cycle. To classify as PMDD, the symptoms must disappear once you get your period, and you need to be able to show you’ve experienced them for at least two to three months. 

How can you collect this data? Track your cycle! Head to Evelyn’s Instagram stories for a detailed breakdown of how to get started with tracking your cycle. 

If you or someone you know is experiencing extreme anxiety, or any other symptoms that are significantly affecting your/their quality of life, it’s important to seek help from a healthcare professional right away. If you’re having suicidal thoughts and are worried you may act on them, you should call 999, go to A&E, or contact the Samaritans now. 

PMDD can be tricky to spot for a number of reasons. Very few people, and sadly very few medical professionals, know about PMDD. PMDD therapist Ally McHugh points out that one of the biggest barriers preventing PMDD diagnosis is because “It’s so often dismissed as 'normal PMS'. It can also be misdiagnosed as rapid cycling bipolar disorder, due to its cyclical nature.” Because not all doctors have diagnosed PMDD before, self-advocacy is key. Being prepared with all the information the doctor might need, plus what an ideal outcome might look like for you, is really important.

Evelyn Health has a free 78-page guide which contains all the information you need before, during, and after visiting the GP for a PMDD diagnosis. Download your copy here.

PMDD is very personal. The symptoms we get, and their severity, are affected by so many factors including diet, stress levels, gut health, medication, vitamin and mineral levels, and more.

Therefore, it’s important to remember that 1) what works for one person might not work for another person, 2) finding the treatment combination that’s right for you can be a trial-and-error process and take a little while, and 3) many treatments can take a bit of time to have an effect. This is because our brain and body need time to adjust to the new routine and allow the changes to take effect.

Medical treatments include

• Talking therapies including cognitive behavioural therapy and interpersonal therapy
• Selective serotonin reuptake inhibitors (SSRIs)
• Combined oral contraceptives
• Anti-inflammatory medicines
• Water pills (diuretics) 
• GnRH analogue injections
• Surgery

The final two treatments on this list are usually only recommended in very severe cases of PMDD. GnRH analogue injections are used to treat conditions like endometriosis by halting egg production and creating a ‘menopausal’ state. The treatment is otherwise known as chemical menopause. These injections block the hormones that stimulate the ovaries, essentially switching them off and lowering oestrogen and progesterone levels to prevent the cyclical spikes in hormones that usually occur. Chemical menopause can take a couple of months to have an effect, but the treatment is reversible, and once you stop the injections, ‘normal’ hormone production will resume.

As a last resort, your healthcare professional may suggest surgery. This is considered the only ‘cure’ for PMS and may either involve removal of the ovaries (‘bilateral oophorectomy’) or removal of the ovaries, uterus, fallopian tubes, and cervix. Your doctor will advise which is best for you depending on how you react to specific progesterones. As this removes the ovaries and eggs, no more oestrogen can be released, inducing surgical menopause. Hormone replacement therapy (HRT) may subsequently be recommended depending on your age. 

Alternative therapies include

• Acupuncture
• Reflexology 
• Aromatherapy

Lifestyle solutions include:

• Changes in diet and decreasing sugar, caffeine and alcohol intake
• Introducing regular exercise into your routine
• Practising methods of stress management, like meditation or yoga
• Taking vitamin supplements (the most frequently suggested include vitamin B6, calcium and magnesium)

1. Be kind to yourself, especially during the luteal phase. PMDD symptoms can be extremely tough, mentally and physically, and we don’t need to pile extra pressure on ourselves to make it even tricker. There’s nothing wrong with a rest day, or taking time out for you. 
2. Seed cycling. This is a super easy way to incorporate some of the essential vitamins and minerals that people with PMDD are deficient in. Check out our guide on seed cycling. In a nutshell, it really is as simple as adding a teaspoon of specific seeds onto your breakfast or lunch each day.
3. Love your gut. Did you know that 90% of the body’s serotonin (one of the chemicals that makes us happy) is made in the gut? Having a diverse microbiome and strong gut integrity not only helps boost our mood, but it helps optimise brain function, balance hormone metabolism, and support a strong immune system, too. Get yourself some probiotics, load up on fermented foods, and keep your eyes peeled for Evelyn’s brand-new PMDD and PMS supplement coming in the next few months.
4. Get moving. During PMDD, levels of neurotransmitters (dopamine, serotonin, etc) can get really low. Because these help us feel good, we’ve got to do everything we can to boost them back up. Exercise (even if that’s a walk) and getting outdoors have been scientifically proven to help boost neurotransmitter levels. 
5. Stress - if possible, you’ve got to reduce it, especially in the luteal phase. Cortisol is the main stress hormone. If our brain perceives stress, it needs to make more cortisol. And it does this by dipping into our progesterone stores. Because progesterone helps us feel calm and relaxed, this sets us into a negative spiral whereby we’ve got increasingly more stress hormones and increasingly less chill hormones, making the current situation (and the rest of our cycle) a whole lot worse!