Premenstrual dysphoric disorder: causes, symptoms, and treatments

The premenstrual dysphoric disorder is a condition that involves severe mood changes and physical symptoms occurring before the period. It is the most severe form of premenstrual syndrome (PMS). The disorder can affect a person’s daily functioning and relationships due to intense effects on their moods and mental health.

The causes of the premenstrual dysphoric disorder include hormonal changes or imbalances and changes in serotonin levels.

Symptoms of the premenstrual dysphoric disorder include sadness or hopelessness, anxiety or tension, extreme moodiness, and marked irritability or anger. This disorder can be described as PMS depression which may also cause physical symptoms such as muscle pain, breast tenderness, or headache.

Treatments for the premenstrual dysphoric disorder include medications such as selective serotonin reuptake inhibitors, birth control pills, over-the-counter products like nutritional supplements and herbal remedies, in addition to diet and lifestyle changes. 

What is premenstrual dysphoric disorder?

Premenstrual dysphoric disorder (PMDD), formerly known as a late luteal dysphoric disorder, is the most severe form of premenstrual syndrome (PMS) with the greatest impairment of women’s quality of life and functioning. Since dysphoria is a profound state of dissatisfaction or unease, the answer to the “what does premenstrual dysphoric mean” is clear. It is a state of deep dissatisfaction, unease, or anxiety occurring before the period starts. Anyone who has ovaries can have PMDD.

Symptoms of the disorder occur in the luteal phase, which happens in the second part of the menstrual cycle. The luteal phase begins around day 15 of a 28-day menstrual cycle and ends with the onset of a period. The main function of the luteal phase is to prepare the uterus for pregnancy by thickening the uterine lining.

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), released in 2013, by the American Psychiatric Association lists PMDD as a separate entity under Depressive disorders. It first appeared in DSM when the fourth edition (DSM-4) was introduced in 1994. The premenstrual dysphoric disorder was introduced to the World Health Organization’s International Classification of Diseases 11th Revision (ICD-11) on January 1, 2022, where it is placed under gynecological diseases. It still remains a controversial diagnosis, Dr. Jeppe Bennekou Schroll and Mette Petri Lauritsen of the University of Copenhagen reported in their post from the May 2022 issue of AOGS (Acta Obstetricia et Gynecologica Scandinavica).

Even though premenstrual symptoms have been recognized for a long time, the diagnostic criteria have been specified recently. Over the years, the nomenclature for premenstrual disorders changed and evolved. For example, in the 18th century, premenstrual symptoms were called menses moodiness whereas in the early 19th century the term premenstrual tension came into use. In the 1950s, the term premenstrual syndrome was adopted and is still used today. The term premenstrual syndrome was coined by Dr. Katharina Dalton, a British gynecologist, and physician.

How common is premenstrual dysphoric disorder?

The premenstrual dysphoric disorder is not as common as PMS and it affects about 2% of menstruating women, according to Dr. Kimberly A. Yonkers and Dr. Robert F. Casper’s post on UpToDate. The same report explained the prevalence of PMS and PMDD has been overestimated due to the failure to apply strict diagnostic criteria. The prevalence of PMS has been estimated at up to 80%, the report suggested, but they don’t consider whether the symptoms are moderate or severe. When strict inclusion criteria are applied, the prevalence of PMDD is around 2%, doctors explained.

A French population-based survey carried out by J. Potter et al. and published in the January 2009 issue of the Journal of Women’s Health found that 4.1% of women qualified for severe PMS. That means up to 5% of women of childbearing age have PMDD, the Office on Women’s Health confirms.

A prevalence of 3% to 8% in women of reproductive age has been reported in a review by U. Halbreich et al. published in the August 2003 issue of Psychoneuroendocrinology. The same review suggested that 13% to 18% of women of reproductive age may have symptoms of PMDD severe enough to induce distress and impairment, but the number of symptoms may not meet the arbitrary count of five symptoms on the PMDD list.

The 12-month prevalence of 5.8% was reported by H.U. Wittchen et al. in a paper from the January 2002 issue of Psychological Medicine. The prevalence of PMDD was based on DSM-4 diagnostic criteria. In the study, concurrent major depression and dysthymia reduced the prevalence rate only slightly to 5.3%. Researchers reported that 18.6% were near-threshold cases due to failure to meet the mandatory impairment criterion. During the follow-up period of 48 months, a few new cases were observed thereby making cumulative lifetime incidence 7.4%. The same study, which included 1488 women, also revealed that 12-month and lifetime comorbidity rates were high and only 26.5% of women had no mental disorder.

In a study of 661 female medical and paramedical students, 5.04% screened positive by Premenstrual Symptoms Screening Tool (PSST) and the prevalence of premenstrual dysphoric disorder was 4.43%. Authors P. Thakrar et al. published their findings in the April 2021 issue of the Journal of Affective Disorders Report and confirmed that 70.33% of subjects with PMDD experienced impairments in work/school efficiency or productivity and 36.23% had impairments in social activities.

What are the causes of premenstrual dysphoric disorder?

The causes of the premenstrual dysphoric disorder are still unclear. The premenstrual dysphoric disorder starts in women of reproductive age. The average age of onset is 26 years, according to a January 2022 post by Jessica Truschel on Psycom. It occurs during the luteal phase of the menstrual cycle, a time between ovulation and period. It usually lasts two weeks. Studies focusing on PMDD are necessary in order to elucidate all the causes and the mechanisms behind them. The causes of the premenstrual dysphoric disorder are listed below:

• Hormonal changes
• Serotonin levels

1. Hormonal changes

Hormonal changes or imbalances are defined as having insufficient or excessive amounts of one or more hormones. More precisely, hormonal imbalance occurs when the levels of a specific hormone are higher or lower than normal. Hormonal changes start a chain of reactions that affect a person’s physical and mental health alike. For example, fluctuations in sex hormones affect neurochemical pathways associated with depression, as per a paper from the July 2008 issue of the Journal of Psychiatry and Neuroscience published by Claudio N. Soares and Brook Zitek of McMaster University. Hormonal changes contribute to the development of premenstrual dysphoric disorder as well.

Hormonal changes become a cause of premenstrual dysphoric disorder because decreasing levels of hormones estrogen and progesterone after ovulation and before menstruation can trigger symptoms, according to Cleveland Clinic.

Scientists have postulated that symptoms of PMDD result from a decline of progesterone during the late luteal phase, which causes changes in the central nervous system (CNS), i.e. in gamma-aminobutyric acid (GABA) and progesterone metabolites that interact with GABA-A receptor complex. However, there are also scientists who disagree with that hypothesis, according to a post by S. Mishra et al. on the website of the National Library of Medicine. Scientists who disagree with the abovementioned hypothesis suggest that symptoms of PMDD can occur at ovulation in the early luteal phase before the levels of progesterone decrease. When it comes to progesterone, it’s useful to mention a metabolite of this hormone called allopregnanolone, which also fluctuates during the menstrual cycle. Women with PMDD have a reduced functional sensitivity of GABA-A receptor due to inadequate response of allopregnanolone to stress.

According to the same post, a preovulatory peak in estradiol (a form of estrogen), a postovulatory increase in progesterone, or both can trigger symptoms of PMDD. That being said, it is unclear why symptoms start with ovulation in certain women with PMDD, but the majority of patients experience them during the late luteal phase.

Hormonal changes are a cause of premenstrual dysphoric disorder because women with this condition are more sensitive to normal hormonal changes that occur during the monthly menstrual cycle. Fluctuating levels of estrogen and progesterone are normal in menstruating people, but those with PMDD are more vulnerable to the imbalances of these hormones, which paves the way to the severe symptoms they experience. A clinical trial by P.J. Schmidt et al. from the January 1998 issue of the New England Journal of Medicine confirmed that in women with premenstrual syndrome, the occurrence of symptoms results from an abnormal response to normal hormonal changes. Additionally, a review by J. Cunningham et al. from the February 2009 issue of Harvard Review of Psychiatry suggested that individual sensitivity to cyclical variations in levels of gonadal hormones may predispose women to experience behavioral, mood, and somatic symptoms associated with PMDD.

2. Serotonin levels

Serotonin levels are changes in the levels of the neurotransmitter serotonin. Serotonin is a neurotransmitter that also acts as a hormone. It plays a role in a wide range of functions including sleep, mood, digestion, bone health, wound healing, blood clotting, and sexual desire. Changes in serotonin levels are associated with the development of mental health conditions such as depression, according to a paper by S-H Lin et al. from the December 2014 issue of Clinical Psychopharmacology and Neuroscience. Serotonin levels are also associated with the development of premenstrual dysphoric disorder.

Serotonin levels become a cause of premenstrual dysphoric disorder because sex hormones may affect serotonergic transmission. A paper by J. Bancroft et al. from the May 1991 issue of Psychological Medicine found that neurotransmitter abnormalities that occur with altered endocrine responses interact with neuroendocrine changes that typically happen before menstruation. This results in vulnerability to depression in this phase of the menstrual cycle. Additionally, a study by O. Eriksson et al. from the March 2006 issue of Psychiatry Research found that worsening of mood symptoms was inversely associated with changes in brain serotonin precursor (11C-labeled 5-hydroxytryptophan) trapping. Researchers explain these findings confirm the role of serotonin in premenstrual dysphoria.

Women with the premenstrual dysphoric disorder exhibit specific serotonin abnormalities, that are particularly evident in the late luteal phase when estrogen levels decline, according to a paper by Liisa Hantsoo and C. Neill Epperson of the Penn Center for Women’s Behavioral Wellness published in the November 2015 issue of Current Psychiatry Reports.

Additionally, Dr. Teri Pearlstein of The Warren Alpert Medical School of Brown University and Women’s Behavioral Health Program and Dr. Meir Steiner of McMaster University published a paper in July 2008 issue of the Journal of Psychiatry and Neuroscience where they confirmed the role of serotonin abnormalities in women with PMDD. The paper suggested that women with PMDD have altered affective information processing and regulation during the luteal phase, with abnormal activation patterns in specific brain areas such as the amygdala, the orbitofrontal cortex, and the ventral striatum. Abnormalities in the serotonin system are also present in women with PMDD, the paper continued. These include abnormal levels of whole blood serotonin, serotonin platelet uptake, and abnormal responses to serotonergic probes.

When it comes to serotonin, it’s useful to mention that this neurotransmitter plays a role in the development of mood disorders such as depression. Women with PMDD also experience sadness and hopelessness, which are depression symptoms. In November 2022, The Guardian reported that scientists at Imperial College London found the first direct evidence that people with depression have lowered capacity for releasing serotonin in the brain.

Serotonin levels are a cause of premenstrual dysphoric disorder because, in people with this condition, post-synaptic serotonergic responsivity is altered during the late-luteal-premenstrual phase of the cycle. It’s also possible that serotonergic functions of women with this condition are altered during the entire menstrual cycle and are associated with vulnerability traits, according to a review that U. Halbreich and H. Tworek of the State University of New York published in the January 1993 issue of the International Journal of Psychiatry in Medicine.

What are the symptoms of premenstrual dysphoric disorder?

Symptoms of premenstrual dysphoric disorder vary from patient to patient. They can be emotional, behavioral, and physical. Around 10 days before the period symptoms may occur or a week or two before menstruation. Every woman with PMDD may experience this condition differently. They may experience severe fatigue, poor self-image, forgetfulness, fluid retention, gastrointestinal symptoms (cramps, bloating, nausea, constipation, vomiting, backache, pelvic pain), skin problems (acne, skin inflammation), headache, dizziness, and heart palpitations. The symptoms go away within a few days after the period starts. The most significant symptoms of the premenstrual dysphoric disorder are those affecting mental health and they are listed below:

• Sadness or hopelessness
• Anxiety or tension
• Extreme moodiness
• Marked irritability or anger

1. Sadness or hopelessness

Sadness is an emotional state of unhappiness or emotional pain linked with a clear cause such as the loss of a loved one. Persistent sadness is a hallmark symptom of a depressive episode. Hopelessness is defined as a feeling of despair, lack of motivation, or absence of hope and optimism. Sadness and hopelessness are symptoms of mental health disorders such as depression. They may also occur in women with premenstrual dysphoric disorder.

Sadness or hopelessness becomes a symptom of premenstrual dysphoric disorder due to low levels of serotonin. According to a paper by D. Dfarhud et al. from the November 2014 issue of the Iranian Journal of Public Health, neurotransmitter serotonin mediates satisfaction, happiness, and optimism. That means low levels of serotonin can lead to depressive symptoms such as sadness.

Sadness or hopelessness is a symptom of premenstrual dysphoric disorder because serotonin levels drop when estrogen levels decrease. Serotonin is at its lowest in the two weeks before menstruation, according to Fairview Health Services. A study by J. Sacher et al. from the January 2023 issue of Biological Psychiatry found that the central nervous system in patients with PMDD increases serotonin transporter density from the peri-ovulatory phase (when estradiol levels are high) to the premenstrual cycle (when progesterone and estradiol are decreasing). The study showed an 18% change in the midbrain, a brain area with the most abundant serotonin transporter expression. The increase in serotonin transporter density was linked to the severity of depressed mood before menstruation. This explains why sadness and hopelessness are symptoms of PMDD. The study confirmed that patients with PMDD experience short-term serotonin changes throughout their menstrual cycle.

Sadness or hopelessness, as a symptom of premenstrual dysphoric disorder, is identified as a loss of interest and enthusiasm, lack of motivation, low self-esteem, low mood, and feeling helpless, worthless, or thinking negatively. These symptoms occur before the period.

2. Anxiety or tension

Anxiety or tension is a feeling of unease, worry, fear, or panic that ranges in intensity from mild to severe. Everyone experiences anxiety at some point in their lifetime because it is a normal reaction to stressful circumstances. However, it can become persistent and overwhelming to the point it affects a person’s everyday life and functioning. Anxiety or tension occurs due to various causes ranging from anxiety disorders to the buildup of stress, substance abuse, to medical or chronic illnesses. The premenstrual dysphoric disorder can also cause anxiety or tension.

Anxiety or tension becomes a symptom of premenstrual dysphoric disorder due to low serotonin levels that occur before menstruation. Serotonergic dysfunction contributes to negative mood states in affective disorders and is associated with anxiety, according to a study by M. Reimold et al. from the June 2008 issue of Molecular Psychiatry. The study showed that high anxiety correlated with low serotonin transporter availability. The role of a serotonin transporter is to regulate the concentration and signaling of this neurotransmitter.

When it comes to serotonin, it’s important to mention that exaggerated context-dependent fear memory and shock reactivity resulting from brain serotonin deficiency involves dysfunction of fear-related behavior responses and contributes to anxiety, according to a paper that J. Waider et al. published in the April 2019 issue of Frontiers in Neuroscience.

Anxiety or tension is one of the symptoms of premenstrual dysphoric disorder because levels of hormones estrogen and progesterone fluctuate dramatically during the luteal phase of menstruation. As a result, PMS symptoms including anxiety may occur, Healthline explained. Speaking of hormones, estrogen exhibits potent serotonin-modulating effects from the level of neurotransmitter synthesis through regulation of tryptophan hydroxylase and degradation of serotonin to the density and binding of serotonin receptors, according to a paper by C. Barth et al. from the February 2015 issue of Frontiers in Neuroscience. The same paper also showed that progesterone increases serotonergic neurotransmission by regulating the expression of serotonin-related genes and proteins. Since estrogen and progesterone are important for serotonin function, fluctuations of these hormones can cause problems associated with impaired serotonin. Anxiety is one of them.

Anxiety or tension, as a symptom of premenstrual dysphoric disorder, is identified as a feeling of restlessness or being on edge, intense worry, nervousness, and difficulty concentrating. These symptoms develop in one or two weeks leading up to the period.

3. Extreme moodiness

Extreme moodiness is any oscillation in mood, especially between feelings of sadness and happiness. The term extreme here represents sudden or abrupt and intense changes in mood. Causes of extreme moodiness are numerous including major life changes, unresolved stress, and lack of sleep. Moodiness can also result from mental health problems including bipolar disorder. The premenstrual dysphoric disorder can cause extreme moodiness as well.

Extreme moodiness becomes a symptom of premenstrual dysphoric disorder due to serotonin deficiency. Serotonin plays a major role in the nervous system and has a significant effect on mood, as per a post on the website of the National Library of Medicine. Authors, Arjun Bakshi at Mercer University School of Medicine and Prasanna Tadi at Asram Medical College in India explained that serotonin in the brain changes mood, happiness, and anxiety by increasing electrical impulses and nerve stimulation. When serotonin levels are insufficient, changes in mood may occur.

Extreme moodiness is one of the symptoms of premenstrual dysphoric disorder because changes in hormone levels affect serotonin concentration. Premenstrual syndrome is closely linked to mood disorders through estrogen-serotonin regulation, according to a post by Pratyusha R. Gudipally and Gyanendra K. Sharma at Louisiana State University on the website of the National Library of Medicine. That means fluctuations in hormones such as estrogen affect serotonin, which in turn causes mood swings or extreme moodiness. It’s also useful to mention that premenstrual dysphoric disorder can be overwhelming due to emotional and physical symptoms, all of which may affect a person’s mood.

Extreme moodiness, as a symptom of premenstrual dysphoric disorder, is identified as a sudden change in one’s mood and behavior. For example, a person goes from being happy to becoming sad out of the blue. This symptom happens a week or two before the period.

4. Marked irritability or anger

Marked irritability or anger is an emotional process indicated by negative affective states, which may or may not be outwardly expressed. It is normal to feel irritable or angry from time to time. They are normal reactions to situations where a person perceives unfairness, but irritability or anger can also occur due to many mental health problems. Good examples of those mental illnesses are anxiety, depression, and bipolar disorder. The premenstrual dysphoric disorder can also cause irritability or anger.

Marked irritability or anger becomes a symptom of premenstrual dysphoric disorder due to hormonal changes. Hormone fluctuations in the menstrual cycle affect the mood of women and may trigger negative emotions such as anger, but the underlying mechanism is unclear, according to the March-April 2019 paper from Pakistan Journal of Medical Sciences by Turkish professors Havva Yesildere Saglam of Eskisehir Osmangazi University and Fatma Basar at Kutahya University of Health Sciences. Impaired sensitivity of cognitive-affective brain circuits to progesterone and its metabolite allopregnanolone underlies PMDD symptomatology, confirmed E. Kaltsouni et al. in their paper from the April 2021 issue of Neuropsychopharmacology. That means changed sensitivity to progesterone fluctuations could be behind irritability or anger in patients with the premenstrual dysphoric disorder.

Marked irritability or anger is one of the symptoms of premenstrual dysphoric disorder because serotonin levels decrease in this period of the menstrual cycle. Serotonin fluctuations affect brain areas that regulate anger, according to results of the University of Cambridge research published in September 2011. The study showed that low serotonin levels in the brain weakened communications between specific brain regions of the emotional limbic system (amygdala) and the frontal lobes. These results indicate that low serotonin levels make it difficult for the prefrontal cortex to regulate emotional responses to anger that are generated in the amygdala.

Marked irritability or anger, as a symptom of the premenstrual dysphoric disorder, is identified as getting frustrated or angry easily, being irritated quickly, and finding it difficult to control anger before the period even though a person normally manages to control this emotion.

What can I expect from premenstrual dysphoric disorder?

The premenstrual dysphoric disorder causes severe depression or anxiety. Women tend to develop symptoms of PMDD a week or two before their period starts. The symptoms tend to go away two or three days after the onset of a period. The condition causes feelings of despair and may cause panic attacks.

When symptoms appear, a woman with PMDD loses interest in daily activities and relationships. They experience difficulties with thinking and focus or concentration. It’s also possible that symptoms of PMDD lead to food cravings and unhealthy eating behavior such as binge eating. Women with PMDD experience trouble sleeping and may feel out of control.

In addition to mood and emotional changes, women with PMDD experience physical symptoms as well. These symptoms include breast tenderness, cramps, bloating, headaches, and joint or muscle pain.

The good news is that with adequate treatment, patients with PMDD can manage their symptoms and improve their quality of life.

Who is at risk for premenstrual dysphoric disorder?

Women of childbearing age with a family history of PMS or PMDD are at risk of premenstrual dysphoric disorder, Johns Hopkins Medicine reports. Personal history of mood disorders such as depression or postpartum depression is also a risk factor for PMDD. Risk factors for this condition also include cigarette smoking and lower education. A comparative study by E.R. Bertone-Johnson et al. from the October 2008 issue of the American Journal of Epidemiology found that cigarette smoking, particularly in adolescence and young adulthood, may increase the risk of moderate and severe PMS. The risk is elevated for former smokers as well and it tends to increase with the quantity of cigarette smoking, the study showed.

Being overweight or obese and extra stress or a traumatic life event are risk factors for PMDD, according to Winchester Hospital. For example, a case-by-case review that H-U Wittchen et al. published in the November 2003 issue of Archives of Women’s Mental Health showed that women with traumatic events and PTSD are more susceptible to PMDD. In the study, most subjects reported childhood abuse, but there were also women who experienced physical attacks or witnessed traumatic events.

When it comes to being overweight or obese, a study by E.R. Bertone-Johnson et al. from the November 2019 issue of the Journal of Women’s Health found a strong linear relationship between body mass index (BMI) at baseline and the risk of PMS. For each 1kg/m2 increase in BMI, the risk of PMS increased by 3%. The higher BMI is, the greater the risk for PMS, which leads to its more severe form i.e. PMDD.

Genetics is a risk factor for PMDD that is worth exploring. In a study that V. Dhingra et al. published in the October 2007 issue of Obstetrics and Gynecology, the C(-1019) allele was associated with the risk of premenstrual dysphoria. At the same time, the October 2007 issue of Biological Psychiatry published a study where L. Huo et al. found that genetic variation in ESR1, the estrogen receptor alpha gene, is associated with an increased risk for PMDD. That means a person can have a genetic predisposition to PMDD by inheriting specific gene variants.

How is premenstrual dysphoric disorder diagnosed?

The doctor discusses a patient’s health or medical history and performs a physical exam. The patient may need to track their symptoms through one or two menstrual cycles. Since patients experience mental health symptoms, the doctor will recommend psychological evaluation as well. In order to be diagnosed with this disorder, patients need to have five or more PMDD symptoms including one mood-related symptom.

Diagnostic criteria from DSM-5 for premenstrual dysphoric disorder indicate that in the majority of menstrual cycles, at least five symptoms must be present in the final week before the onset of menses. The symptoms should improve within a few days after the onset of the period and become minimal or absent in the week post menses. To diagnose PMDD, one or more of the following symptoms must be present such as marked affective lability, marked irritability or anger or increased interpersonal conflicts, markedly depressed mood, and marked anxiety or tension. In addition to these symptoms, a patient must also have one or more of the following symptoms to reach a total of five symptoms for diagnosis of PMDD: decreased interest in usual activities, difficulty concentrating, lethargy, change in appetite, hypersomnia or insomnia, sense of being overwhelmed or out of control, and physical symptoms such as breast tenderness, bloating, and joint or muscle pain.

The symptoms should cause significant distress or interference with school, work, and relationships. Additionally, symptoms shouldn’t be attributable to the physiological effects of a substance (medication or drug abuse) and they must not be a result of worsening of other mental health problems such as depression, panic disorder, or personality disorder.

What are the available treatments for premenstrual dysphoric disorder?

The available treatments for premenstrual dysphoric disorder are based on the severity of symptoms, the patient’s personal preferences, or plan to get pregnant. These include:

• Selective serotonin reuptake inhibitors
• Birth control pills
• Nutritional supplements
• Herbal remedies
• Diet and lifestyle changes

1. Selective serotonin reuptake inhibitors

Selective serotonin reuptake inhibitors (SSRIs) are the most frequently prescribed antidepressants. Doctors prescribe them for the management of depression and other conditions such as anxiety disorders. Examples of SSRIs are citalopram (Celexa), Escitalopram (Lexapro), fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft). A healthcare professional may also prescribe SSRIs to patients with the premenstrual dysphoric disorder.

Selective serotonin reuptake inhibitors help treat a premenstrual dysphoric disorder by improving levels of the neurotransmitter serotonin in the brain. Low serotonin in the luteal phase is behind symptoms of PMDD. More precisely, selective serotonin reuptake inhibitors prevent the blood from absorbing serotonin from the brain. These medications inhibit the reuptake of serotonin by serotonin transporters found on presynaptic neurons (neurons that fire the neurotransmitter or transmit the signal). As a result, the synaptic availability of serotonin at postsynaptic receptors (receptors that receive the signal) increases, according to the April 2020 post Selective Serotonin Reuptake Inhibitors (SSRIs) on Elsevier Mental and Behavioral Health. The therapeutic action of these antidepressants occurs due to presynaptic and postsynaptic adaptive mechanisms ensuing from reuptake inhibition. The abovementioned post also reports that an important mechanism of action of SSRIs is the desensitization of the serotonin 1A receptor (5-HT1A receptor). Since SSRIs block the reuptake of serotonin and prevent the nerve cells from reabsorbing it, more serotonin is available to pass further messages between nerve cells. Increased levels of serotonin improve symptoms of the premenstrual dysphoric disorder, such as sadness, anxiety, moodiness, and anger.

Selective serotonin reuptake inhibitors are one of the treatments for the premenstrual dysphoric disorder because they act on one of the causes of PMDD symptoms and work well in combination with psychotherapy. Additionally, their safety profile is better compared to other antidepressants. The abovementioned paper reported that SSRIs don’t affect other neurotransmitters in the brain and they have a more favorable safety profile than first-generation antidepressants such as tricyclics and monoamine oxidase inhibitors. Moreover, A.N. Edinoff et al. confirmed in their paper from the June 2021 issue of Neurology International that SSRIs are generally better tolerated than other antidepressants.

Selective serotonin reuptake inhibitors are effective for the management of premenstrual dysphoric disorder and their benefits are scientifically proven. For example, a clinical trial by K.A. Yonkers et al. in the September 1997 issue of JAMA found that SSRI sertraline was effective at managing symptoms of the premenstrual dysphoric disorder. Significant improvement was observed for all symptoms of PMDD including anger/irritability, depression, and physical symptoms. Depression scores were reduced by 44% in participants who took this antidepressant and end-point global ratings showed an improvement of 62%. Scientists concluded the study confirming that SSRIs such as sertraline are useful therapeutic options for women with PMDD.

The different clinical trials, involving SSRI fluoxetine, also confirmed the effectiveness in the treatment of the premenstrual dysphoric disorder. The trial was carried out by M. Steiner et al. and published in the June 1995 issue of the New England Journal of Medicine. Researchers found that fluoxetine at a dose of 20 or 60 mg per day was superior to placebo in alleviating PMDD symptoms such as tension, dysphoria, and irritability. M. Steiner et al. published another clinical trial in the May 2001 issue of BJOG, which also found that 20mg or 60mg of fluoxetine a day was better than a placebo at treating physical symptoms of PMDD. In a clinical trial by L.S. Cohen et al. from the September 2002 issue of Obstetrics and Gynecology, a daily premenstrual dose of 20mg of fluoxetine was effective at alleviating symptoms of PMDD, but 10mg wasn’t.

Overall, a growing body of evidence confirms the effectiveness of SSRIs for the treatment of premenstrual dysphoric disorder. A meta-analysis by P.W. Dimmock et al. from the September 2000 issue of The Lancet showed women with severe premenstrual syndrome were 6.91 times more likely to respond to SSRIs, which were effective at treating physical and behavioral symptoms. Another review by K.M. Wyatt et al. from the April 2002 issue of The Cochrane Database of Systematic Reviews confirmed SSRIs were highly effective at managing premenstrual symptoms, both physical and behavioral. The authors elaborated there is now good evidence to support the use of SSRIs in the management of severe PMS.

Selective serotonin reuptake inhibitors take a few weeks to take effect. According to the UK’s NHS, patients may need to take SSRIs for two to four weeks before they feel improvements. SSRIs are a prescription medicine and the most suitable dosages are decided by the treating physician.. They may start with the lowest dosages first and adjust if or when necessary.

2. Birth control pills

Birth control pills are oral contraceptives i.e., medications taken to prevent pregnancy. There are two main kinds of birth control pills: combination birth control pills that contain both estrogen and progesterone and progestin-only pills i.e., the minipill, Mayo Clinic explains. The main goal of birth control pills is to prevent pregnancy by stopping or reducing ovulation, thickening cervical mucus to prevent sperm from entering the uterus, and thinning the lining of the uterus so that fertilized egg doesn’t attach. In addition to preventing pregnancy, doctors can recommend birth control pills for the management of conditions such as polycystic ovary syndrome (PCOS), endometriosis, and even for the management of premenstrual dysphoric disorder.

Birth control pills help to treat premenstrual dysphoric disorder because they regulate the menstrual cycle. These pills contain synthetic versions of the hormones estrogen and progesterone. Birth control pills establish a balance of hormones that tend to fluctuate during the menstrual cycle. By balancing out estrogen and progesterone, birth control pills may decrease the severity of symptoms of the premenstrual dysphoric disorder.

Birth control pills are one of the best treatments for premenstrual dysphoric disorder because they help patients reduce the severity of PMDD symptoms while also preventing unwanted pregnancy, Healthline explains. The only birth control approved by the FDA for the management of PMDD symptoms is Yaz. This birth control pill was approved in October 2006 and it contains drospirenone (synthetic progestin) and ethinyl estradiol (synthetic estrogen). Yaz is specifically labeled for oral contraception and premenstrual dysphoric disorder. It is a form of daily combination pill and it’s necessary to take hormone-containing pills for 24 days and the placebo pills for four days before starting the cycle again.

Birth control pills are effective at managing premenstrual dysphoric disorder, but more research is necessary on this subject. Current evidence shows promising results. A good example is a review that E.W. Freeman et al. published in the May 2012 issue of the journal Contraception. The review found that continuous use of birth control pills containing levonorgestrel (90mcg) and ethinyl estradiol (20mcg) may decrease the severity of PMDD symptoms and is a good option for women who are appropriate candidates.

A randomized controlled trial by T.B. Pearlstein et al, whose findings were published in the December 2005 issue of Contraception, revealed that a combination of drospirenone and ethinyl estradiol in a 24/4 regimen was superior to placebo for treatment of PMDD symptoms. A Chinese randomized controlled trial by Y. Fu et al. from the July 2014 issue of the Chinese Journal of Obstetrics and Gynecology found that Yaz has the potential to improve symptoms of premenstrual dysphoric disorder better than placebo.

When it comes to drospirenone, it’s useful to mention a study that Dr. Jirath Wichianpitaya and Surasak Taneepanichskul of the Chulalongkorn University from Bangkok, Thailand, published in the February 2013 issue of the Obstetrics and Gynecology International. The study compared the effectiveness of low-dose combined oral contraceptives containing desogestrel and drospirenone for the treatment of premenstrual symptoms. Desogestrel is also a synthetic progestin. The study showed that low-dose combination birth control pills containing desogestrel and drospirenone reduced premenstrual symptoms, but the latter was more effective and led to the earlier reduction.

How long it takes for birth control pills to take effect depends on when a person starts taking them. If a person takes the first dose within five days of their period starting, the effects occur immediately. However, if they start taking the birth control pills at any other time, it takes seven days to work.

3. Nutritional supplements

Nutritional supplements are products specifically created to supplement a person’s diet with vitamins, minerals, and healthy compounds such as Omega-3 fatty acids that are necessary for good health and well-being. They are sold in over-the-counter form. People take nutritional supplements to make sure they get sufficient amounts of vitamins and minerals during the day, which they wouldn’t be able to obtain from diet alone. Nutritional supplements can improve a person’s immune system, prevent deficiencies, and aid the management of health conditions including premenstrual dysphoric disorder.

Nutritional supplements help to treat premenstrual dysphoric disorder because they support hormonal balance and are important for neurotransmitter synthesis. Good examples of supplements that may help treat PMDD symptoms are vitamin B, vitamin D, calcium, and magnesium, according to a paper by S. Kaewrudee et al. in the January 2018 issue of the Cochrane Database of Systematic Reviews. The same paper explained that deficiencies in certain vitamins and minerals could play a role in premenstrual syndrome. For example, magnesium is important for dopaminergic synthesis, and an imbalance in the neurotransmitter dopamine can affect mood and cause anxiety.

Nutritional supplements are one of the best treatments for the premenstrual dysphoric disorder because they manage or prevent nutritional deficiencies, which could worsen premenstrual syndrome. Additionally, nutritional supplements support the body’s mechanisms and functions, meaning they are a natural alternative for persons who want to manage their PMDD symptoms.

Nutritional supplements can be effective for the treatment of premenstrual dysphoric disorder, but it is necessary to carry out more research since studies tend to focus on PMS primarily. The good news is that the growing body of evidence confirms the benefits of specific vitamins and minerals in the treatment of PMDD. For instance, calcium supplementation can significantly improve the incidence of PMS and its related symptoms, according to a systematic review by A. Arab et al. from the September 2020 issue of the International Journal of Preventive Medicine. The same paper explained that estrogen exhibits calcium-antagonistic effects. During the menstrual cycle, estradiol reaches two peaks. One peak occurs immediately before the luteinizing hormone surge and ovulation. The second peak happens during the luteal phase. Rising estrogen levels lead to a reduction in calcium levels with compensatory increases in the parathyroid hormone that prevent hypocalcemia. Women who already have underlying calcium disturbance, such as those with PMS, may be subjected to further decrements in calcium levels on exposure to rising estrogen during the luteal phase. Considering that extracellular calcium is the source of intracellular calcium, the latter could be perturbed thus causing neurotransmitter abnormalities. In turn, fluctuating estrogen alters the availability of serotonin and its binding and neurotransmission, thereby causing premenstrual mood symptoms.

Speaking of calcium, a combination of this mineral and vitamin D can help with premenstrual symptoms, according to a paper by F. Abdi et al. in the March 2019 issue of Obstetrics and Gynecology Science.

Vitamin B6 is also effective at treating symptoms of PMDD because this micronutrient participates in the production of neurotransmitters. It works well in combination with calcium to reduce symptoms of premenstrual syndrome, according to S.Z. Masoumi et al. whose randomized clinical trial was published in the March 2016 issue of the Journal of Caring Sciences. Additionally, N. Fathizadeh et al. published a study in the December 2010 issue of the Iranian Journal of Nursing and Midwifery Research, which found that a combination of magnesium and vitamin B6 was effective at alleviating symptoms of premenstrual syndrome. The March-April 2016 issue of the same journal confirmed the effectiveness of vitamin D and vitamin E in the treatment of premenstrual symptoms. Vitamin E efficiently reduces stress, anxiety, and low social activities among participants.

It takes about three to six weeks for nutritional supplements to take effect. In order to achieve the best results, it is necessary to take them exactly as recommended by the manufacturer or a healthcare professional. Persons who are taking prescription medications for their health conditions may want to consult their doctor before they start using nutritional supplements.

4. Herbal remedies

Herbal remedies are plants with medicinal properties. Throughout history, people have been using roots, stems, leaves, seeds, or flowers or plants to address injuries or manage illnesses. Those remedies are still used today for many purposes. Herbal remedies are also helpful for women with premenstrual dysphoric disorder. Examples of herbal remedies that are good for PMDD are chaste berry, ginkgo biloba, St. John’s wort, and dong quai.

Herbal remedies help to treat premenstrual dysphoric disorder because they can manage physical or emotional symptoms of this disorder. The underlying mechanisms of action require further research. For example, chasteberry (Vitex agnus-castus) may alleviate irritability, breast tenderness, mood swings, cramps, and food cravings associated with PMDD, according to Mayo Clinic.

Herbal remedies are one of the best treatments for premenstrual dysphoric disorder because they contain natural compounds that support hormonal balance, the function of neurotransmitters, or make it easier for the body to resist stress, all of which is necessary for the management of premenstrual dysphoric disorder symptoms. Additionally, herbal remedies are natural products that are safe for general consumption. They may particularly appeal to women who want to treat their symptoms in a more natural manner.

Herbal remedies are effective for the treatment of premenstrual dysphoric disorder. A good example is chasteberry, which was superior to a placebo in the treatment of premenstrual syndrome, according to a January 2001 review in BMJ by R. Schellenberg from the Institute for Health Care and Science in Huttenberg, Germany.

Supplementation with 40mg of ginkgo biloba three times a day can decrease the severity of symptoms of premenstrual syndrome, according to a randomized controlled trial by G. Ozgoli et al. from the August 2009 issue of the Journal of Alternative and Complementary Medicine.

A clinical trial by S. Canning et al. from the March 2010 issue of CNS Drugs found that St. John’s wort was statistically superior to placebo in relieving both physical and behavioral symptoms of premenstrual syndrome.

In a review that M.L. Hardy from Cedars-Sinai Hospital in LA published in the March-April 2000 issue of the Journal of the American Pharmaceutical Association, dong quai was described as potentially effective for the treatment of premenstrual syndrome. Dong quai or Angelica sinensis is known as female ginseng.

It may take two to three weeks for herbal remedies to take effect. People who are taking medications for their health conditions may want to check with their healthcare provider whether specific herbal remedies could interact with their medicines.

5. Diet and lifestyle changes

Diet and lifestyle changes are modifications in nutrition and everyday life that can help improve a person’s health and well-being. Just by making certain tweaks in foods a person eats or daily habits, they can support their physical and emotional health including the management of the premenstrual dysphoric disorder. These changes include avoiding unhealthy foods and eating a well-balanced diet, regular exercise, reducing or avoiding alcohol or caffeine intake, getting enough sleep, quitting smoking, and managing stress with relaxation techniques such as meditation, yoga, and deep breathing.

Diet and lifestyle changes help to treat premenstrual dysphoric disorder because they exhibit specific effects such as supplying the body with healthy nutrients (diet), supporting physical and emotional functions and health (sleep and exercise), or they support hormonal balance and making the body more resilient to stress. Lifestyle changes also include avoiding stressful situations and emotional triggers whenever possible.

Diet and lifestyle changes are one of the best treatments for premenstrual dysphoric disorder because they act on the root causes of symptoms that people experience. These root causes are disturbances in neurotransmitter functioning or hormone levels. Changes in lifestyle and diet can tackle hormonal imbalances, boost energy levels, and reduce the severity of symptoms associated with this condition. Additionally, reducing the intake of certain foods such as those containing too much salt can prevent or manage physical symptoms such as bloating. Dietary changes such as lowering the intake of sugar can improve mood because high sugar intake can worsen fatigue and mood swings.

Diet and lifestyle changes are effective at managing the premenstrual dysphoric disorder and a good example is a review by Hariharasudhan Ravichandran and Balamurugan Janakiraman from Mekelle University in Ethiopia, which was published in the August 2022 issue of the International Journal of Women’s Health. The review found that aerobic exercise was effective at relieving premenstrual symptoms. Aerobic exercise effectively reduced symptoms such as nausea, headache, bowel disturbance, abdominal bloating, flushing, and backache. According to the paper, exercise works by regulating hormone levels.

Getting enough sleep is an important aspect of the management of PMDD symptoms. S. Jehan et al. in their paper from the August 2016 issue of the Journal of Sleep Medicine and Disorders suggested that sleep disturbance and reduced melatonin secretions caused by hormonal fluctuations in the luteal phase of the menstrual cycle are behind sleep problems in women with PMDD. Since sleep-related problems are a major component of premenstrual dysphoric disorder, it’s important to modify your lifestyle to get enough sleep. Seven to nine hours of sleep per night are ideal, but even more so is important to establish a regular sleep schedule that involves going to bed at the same time every night and waking up at the same time every morning.

The premenstrual dysphoric disorder includes symptoms such as stress and anxiety, but yoga can help manage them. In fact, yoga could be even more effective than aerobic exercise according to a study that N. Vaghela et al. published in the Journal of Education and Health Promotion. Also, Su-Ying Tsai from I-Shou University in Kaohsiung, Taiwan published a paper in the July 2016 issue of the International Journal of Environmental Research and Public Health, which found that yoga helped improve physical function and bodily pain in women with premenstrual syndrome. Yoga also reduced breast tenderness, abdominal swelling, cold sweats, and abdominal cramps.

How long it takes for diet and lifestyle changes to take effect depends on the specific change and a person’s adherence. It may take a few weeks to get the best results when the body adapts to the new change.

What are the complications of premenstrual dysphoric disorder treatment?

Complications of premenstrual dysphoric disorder treatment are listed below:

• Stomach problems: they become a complication of PMDD treatment because they are side effects of SSRIs. Examples of stomach problems include indigestion, diarrhea, or constipation. They are one of the complications of PMDD treatment because SSRIs can stimulate certain serotonin receptors thereby increasing gastrointestinal (GI) motility, which may lead to diarrhea as per Dr. Flavio Guzman’s post on the Psychopharmacology Institute website. According to a paper by K. Kelly et al. from the December 2008 issue of Dialogues in Clinical Neuroscience, antidepressants such as SSRI paroxetine can cause constipation due to its high affinity for muscarinic receptors, which are also found in the GI tract. Stomach problems, as a complication of PMDD treatment, are identified as indigestion, diarrhea, or constipation that occur once a patient starts taking these medications.
• Headaches: become a complication of PMDD treatment because they are an adverse reaction of SSRIs. A meta-analysis by S. Telang et al. in the August 2018 issue of the Journal of Affective Disorders found that SSRIs are associated with a significantly increased risk of headaches. Headaches are one of the complications of PMDD treatment because of changes in serotonin levels. Additionally, headaches occur as a side effect of birth control pills due to changes in female sex hormones. As a complication of PMDD treatment, headaches are identified as pain in the head that starts when a person begins SSRI or birth control treatment.
• Low sex drive: it becomes a complication of PMDD treatment because it’s a side effect of SSRIs and birth control pills. According to a March 2022 post on Harvard Health Publishing, SSRIs can lead to loss of interest in sex, difficulty to become aroused or sustain arousal and reach an orgasm. Low sex drive is one of the complications of PMDD treatment because a serotonin boost produces a sense of calm, but may also prevent the hormones that cause the body to respond to sex from transmitting the message to a person’s brain. Hormone changes caused by birth control pills are also the reason behind low sex drive. As a complication of PMDD treatment, low sex drive is identified as reduced interest in sex, low sexual desire, and a feeling of concern or worry about lack of sexual desire.
• Weight gain: it becomes a complication of PMDD treatment because it is a side effect of birth control pills and may be an adverse reaction of long-term SSRI treatment. Weight gain is one of the complications of PMDD treatment because, as Medical News Today explains, birth control pills can increase fluid retention or water weight, and may also increase muscle or fat mass. As a complication of PMDD treatment, weight gain is identified as putting on a few pounds after the onset of treatment with birth control pills.

How to deal with premenstrual dysphoric disorder?

To deal with premenstrual dysphoric disorder more effectively, make sure to follow the self-care tips listed below:

• Maintain weight in a healthy range: since being overweight or obese increases the risk of this condition and may worsen the symptoms, it is important to prioritize a healthy weight. Overweight or obese women may benefit from weight loss whereas women who are already within a healthy weight range may need to focus on its maintenance. Weight loss is achievable through a healthy, well-balanced diet and regular exercise.
• Rely on a person you trust: having a person who listens to you and shows they care can be helpful. There are many ways to rely on a person you trust. Good examples are spending time with them, texting them, and keeping in touch. The first step toward feeling better, according to Mind, a mental health resource from the UK, is to tell others (e.g. friends or family) about what’s going on. It may be difficult at first, but it is necessary in order to feel better.
• Contact a specialist organization: make sure to contact organizations that help women with PMDD because they provide support and information that help improve their quality of life. A good example is The International Association for Premenstrual Disorders (IAPMD), whose mission is to inspire hope and end suffering for those affected by premenstrual disorders through education, peer support, advocacy, and research.
• Join a support group: people with PMDD may find it helpful to connect with women who experience the same problem. That’s why support groups are so important. People with the same problem, in this case, PMDD, gather and share their experiences and support one another. IAPMD has support groups, but it’s also possible to find them elsewhere or on a more local level e.g. Spark Chicago Therapy has its PMDD support group.
• Learn more about your menstrual cycle: if the symptoms of PMDD follow a specific pattern, it’s possible to figure out when you are most likely to experience them in the future. The ability to predict the onset of PMDD symptoms may make it easier to handle or manage this condition. That’s why it’s important to learn more about your menstrual cycle, especially the onset of symptoms. For example, if they appear a week before the period, it could help them learn when to anticipate them in the upcoming months. When you know when to anticipate symptoms, there’s a lot you can do to reduce their severity. Good examples are rearranging stressful events and tasks, planning relaxing activities to boost mood, creating a self-care box, and establishing a support plan that outlines how you’d like to be supported when symptoms appear. Women with unpredictable cycles may want to use period-tracking apps.
• Self-care box: create a self-care box in advance so that it’s ready for the time when symptoms appear. The self-care box should contain things that improve a person’s mood and cheer them up such as a favorite book, and notes with feel-good messages.
• Take care of your mental health: by taking care of your emotional and mental well-being it becomes easier to handle the symptoms of PMDD. For instance, managing stress builds emotional resilience. Make sure to engage in activities you find relaxing such as spending time outdoors, practicing relaxation techniques such as deep breathing, and practicing mindfulness. The latter helps reduce stress and aids in the management of unwanted thoughts.
• Take care of your physical health: your physical health is equally important for building resilience. Things to do include getting enough sleep, eating a well-balanced diet, and exercising regularly. Sleep and proper diet make it easier to handle difficult experiences. Exercise exhibits positive effects on both the mind and body.

Is premenstrual dysphoric disorder a mental illness?

Yes, premenstrual dysphoric disorder is a mental illness since it is included in DSM-5. Dr. Marlene P. Freeman of Harvard Medical School wrote in her post on Psychiatrist.com that the introduction of PMDD to DSM-5 is a good thing and it is an advancement in women’s health. She continued that the luteal phase of the menstrual cycle is linked to premenstrual symptoms that are minimized. However, women may suffer on a monthly basis during the luteal phase and it’s important to make sure they know this is not normal and that treatments are available.

However, Dr. Tamara Kayali Browne wrote in her paper from the June 2015 issue of the Journal of Bioethical Inquiry that PMDD shouldn’t be listed in DSM-5 or ICD, adding to the call to recognize this illness as a socially constructed disorder. According to Dr. Browne, PMDD is a culture-bound phenomenon, not a universal one, and even if medications work or there are biological correlates with premenstrual distress or anger. None of the factors are enough to attribute premenstrual anger or distress to a mental disorder, the paper continued. Additionally, Dr. Browne explains that premenstrual distress shouldn’t be pathologized and adds it is unethical to use the term mental disorder to describe this illness. It is important to change societal attitudes toward women’s suffering instead of labeling them mentally ill, the paper concluded.

Dr. Browne is not the only healthcare professional to express disappointment in the classification of PMDD as a mental disorder. A post by Jennifer Daw in the October 2002 issue of Monitor on Psychology by the American Psychological Association discussed how PMDD as a mental disorder is unfair to women who have this illness. The paper cited Joan Chrisler, a psychology professor at Connecticut College, explaining that PMDD is a culture-bound syndrome and there is not much evidence that it exists. At the same time, author and feminist psychologist Paula Caplan elaborated, it is appalling to use PMDD for women who want recognition for the discomfort they experience and described it’s like confirming to believe them, but describing those women as mentally ill. Caplan believes language surrounding PMDD is misleading and it stigmatizes women as mentally ill thereby concealing the true reasons behind their anguish, especially because normal behaviors for men are considered mental illness for women.

What is the difference between PMDD and PMS?

The difference between PMDD and PMS is that premenstrual dysphoric disorder is severe, sometimes disabling and an extension of premenstrual syndrome. When it comes to PMDD vs. PMS, it’s important to mention that both have physical and emotional symptoms, but PMDD is associated with extreme mood shifts that damage relationships and affect a woman’s quality of life, according to Mayo Clinic. In premenstrual dysphoric disorder, at least one of four emotional or behavioral symptoms stands out. These symptoms are sadness or hopelessness, anxiety or tension, extreme moodiness, and marked irritability or anger.

Women with PMS may be depressed, WebMD explained, but PMDD causes sadness to be so extreme that patients feel hopeless and may even develop suicidal thoughts. Anxiety may also affect women with PMS, but with PMDD, anxiety that patients feel is more severe as it causes tension or feeling “on edge”. Women with PMDD experience strong mood swings in a way that they are irritated by things they normally don’t find annoying.