Beyond PMS: Why We Need to Talk About Premenstrual Dysphoric Disorder
Chances are, you’ve experienced some form of premenstrual syndrome (PMS) since you first got your period. But what’s going on when your symptoms go further than food cravings, cramps, tender breasts, moodiness, and fatigue?
You may have premenstrual dysphoric disorder (PMDD) — a hormone-based mood disorder with debilitating emotional and physical symptoms that typically show up the week before your period and last until a few days after it begins.
While it’s normal for women who menstruate to have hormonal fluctuations at different points in their cycles, women with PMDD don’t respond to these changes the way other women do.
“Research indicates that women with PMDD have particularly sensitive serotonergic pathways that respond abnormally to normal hormone fluctuations, with the end result being classic PMDD symptoms,” says Carly Snyder, M.D., a physician at Mount Sinai Beth Israel Medical Center in New York City.
Having finally been recognized as a distinct mental disorder in the Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (the most popular diagnostic system for mental disorders in the United States) in 2013, it is concerning to note that variable diagnostic practices remain, which threaten clarity over the issue.
“Our society often shies away from uncomfortable topics, especially when related to a woman’s body and health, and instead trivializes or minimizes the degree to which a woman legitimately suffers,” Dr. Snyder told HealthCentral via email. “Questioning the legitimacy of PMDD is de facto ignoring the mounting research-based evidence indicating it is a biologically mediated illness caused by abnormal response in the brain to normal hormone fluctuations that occur monthly in advance of menses.”
There remains much debate around whether PMDD should be classified as a mental disorder at all.
“Some say classifying PMDD as a mental disorder ‘pathologizes the female experience’ and/or leaves out the hormonal aspect of the disease,” says Amanda LaFleur, co-founder and executive director of the Gia Allemand Foundation, which promotes the recognition of PMDD as a hormone-based mood disorder. Dr. LaFleur spoke with HealthCentral via email.
Symptoms of PMDD
The main symptoms of PMDD are feelings of hopelessness, anxiety, and marked anger, that are typically non-existent outside of the luteal phase of your cycle. (This phase begins after ovulation and continues until the start of the next menstrual period, and lasts for 14 days on average, although 10 to 16 days is considered normal.)
“Severe cases of PMDD may include suicidal ideation and/or behavior,” LaFleur adds.
The effects of PMDD can’t be overestimated. Common physical symptoms include bloating, change in appetite, sleep disturbances, and breast pain, but it’s what goes along with it that needs to be taken seriously. This condition diminishes concentration and focus, impacts the ability to work and maintain healthy interpersonal relationships, and turns an otherwise calm, relaxed woman into a profoundly irritable, easily angered, anxious, sad, even violent person.
“At its worst, PMDD can threaten to rob a woman of two weeks of every month because she feels out of control physically and emotionally,” says Dr. Snyder. “If a woman suffers a mood disorder like depression, anxiety, or bipolar disorder in addition to PMDD, her mood symptoms will likely be exacerbated during the second half of her menstrual cycle.”
Treatment is possible
Many treatment options exist for PMDD, with lifestyle changes being the first line treatment, including reducing stress, getting more exercise, and cutting down on inflammatory foods like sugar, gluten, dairy, alcohol, and caffeine. The second line treatment includes hormones, which may include oral contraceptives, progesterone creams, and/or estrogen patches. However, in some cases these treatments can make PMDD symptoms worse, so patients need to be carefully monitored.
Antidepressants (SSRIs) may be prescribed in lieu of hormone therapy.
“These have been proven effective, but do not treat the underlying systemic issue of PMDD,” says LaFleur. “It is also important to note that specific genetic makeups respond differently to various SSRIs. Genetic testing is available and recommended for those seeking SSRI therapy.” If these options fail, the next step is chemical menopause, which involves injecting Lupron to shut down the ovaries.
“Lupron is not recommended for long-term use and is typically a precursor to surgery,” says LaFleur. “Surgical menopause (removal of the ovaries, cervix, and uterus) is the last line treatment option and has been shown to be highly effective in stopping the symptoms of PMDD.” PMDD is often treated by psychiatrists, especially those trained in women’s mental health related issues, but can also be diagnosed and treated by an obstetrician/gynecologist, family medicine physician, or internist.
If you think you have PMDD but your doctor doesn’t agree, well, it could be time to find a new doctor.
“If you have tracked their symptoms and cycle for a minimum of two menstrual cycles and a clear connection between PMDD symptoms and the menstrual cycle is seen, you need to be their own best advocate and find a provider that will not only accurately diagnose and treat your symptoms but also provide compassionate care,” says LaFleur.
See more helpful articles: