PMDD What Is It? And Do You Have It?

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Discover what PMDD is and if you have it

Recently, my girlfriends and I were talking about periods and we realized how ridiculous how little we understood about them, considering we were women in our late twenties and early thirties (who by this point have lived with our periods for over half our lives).

For instance, we all agreed that PMS symptoms sneak up on us. One day a month we wake up incredibly grumpy, angry, irritable or depressed and think “WTF is wrong with me” until we look at our period tracker apps and realize our period is due in a week. How we haven’t cottoned on to these links naturally is beyond us. We’re all intelligent women. I even studied biology at University. But I’m sure we aren’t alone in these monthly mood surprises.

A Lack of Education on Menstruation

We agreed that part of this is a lack of education around our periods growing up. We all grew up in different parts of the world, I grew up in New Zealand, and they were all from various countries in Europe. Partly, we think because people simply don’t understand the weird complexities of the female body themselves. I mean, how the female orgasm works (or if it even exists) is still under debate in certain circles, and for the most part, remains a mystery. 

Period education had improved by the time I went to school since my mum was young. She recently told me they explained their periods to them as this beautiful coming of age womanhood thing. She was so excited to get hers and then extremely horrified when it came. “Why didn’t they tell me all this?” she thought. 

So I hope it has improved more since I was young and that Millenials will read this and think, “Duh, everyone knows about PMDD,” but in case the education system hasn’t reached this levels yet, and for all those who don’t know what it is, I write this article. 

PMDD versus PMS

PMDD, aka Premenstrual dysphoric disorder, is like an extreme version of PMS (premenstrual syndrome). While 80% of women report some form of PMS in their reproductive lifespan, it is estimated that 5% of women experience PMDD, the more extreme version.

The problem with PMDD is that it is not merely usual irritability like PMS. PMDD symptoms seriously impair a women’s ability to cope with normal daily activities. 

Symptoms of PMS

Most women are probably familiar with PMS symptoms, but to help everyone understand PMDD, I thought this would be a helpful comparison. For both PMS and PMDD, these symptoms start between 5 and 11 days before your period starts and usually finish once menstruation begins. The severity of symptoms varies between cycles and between people.

  • Acne
  • Feeling bloated
  • Pain in the abdominal area
  • Sore breasts
  • Food cravings
  • Tiredness
  • Irritability
  • Anxiety
  • Depression
  • Sadness
  • Emotional
  • Altered sleep patterns
  • Constipation &/or diarrhea 
  • Headaches
  • Light sensitivity

Symptoms of PMDD

After the conversation I had with my friends, I realized that my PMS symptoms were by no means typical. So I decided to do some research, and this is how I came across PMDD. I’ve only found one friend who has heard of it; she saw a documentary about it. Based on what I told her and what she saw in the documentary, she agreed that I probably have it. 

According to the American Psychiatric Association fourth edition diagnostic and statistical manual of mental disorders, the eleven symptoms of PMDD are as follows:

  1. Markedly depressed mood, feelings of hopelessness, or self-deprecating thoughts
  2. Marked anxiety, tension, feelings of being “keyed up” or “on edge.”
  3. Marked affective lability (e.g., feeling suddenly sad or tearful or increased sensitivity to rejection)
  4. Persistent and marked anger or irritability or increased interpersonal conflicts
  5. Decreased interest in usual activities (e.g., work, school, friends, hobbies)
  6. Subjective sense of difficulty in concentrating
  7. Lethargy, easy fatigability, or marked lack of energy
  8. Marked change in appetite, overeating, or specific food cravings
  9. Hypersomnia or insomnia
  10. A subjective sense of being overwhelmed or out of control
  11. Plus (if that wasn’t enough), all the physical symptoms of PMS listed above. 

Diagnosing PMDD

To be diagnosed with PMDD, you must experience between five or more of the listed symptoms for most of the week before your period starts, with at least one of the symptoms being 1, 2, 3, or 4. These symptoms must also significantly interfere with your normal daily activities and relationships for more than two days in a row and occur in two or more of your cycles in a row. 

Preparing For a Doctors Visit

If you suspect you may have PMDD, the first thing you need to do is keep a calendar diary of your symptoms. This diary will help your doctor determine if you have PMDD and rule out other causes such as other forms of depression, anxiety, personality disorders, or drug and alcohol abuse. PMDD is linked explicitly to the week before your period, though it may be in addition to another mood-related disorder as well. 

You may also have hormone tests which look at estrogen and progesterone levels. Links between low-serotonin production and PMDD have also been found, so be sure to ask your doctor for a serotonin test. They may conduct a physical exam, gynecological exam, blood count, and liver function test to rule out any other potential physical causes. 

Causes of PMDD

No-one really knows, unfortunately. It seems to be a combination of biological, psychological, environmental, and social factors. Genetics may also be to blame. Women diagnosed with PMDD have typically struggled with depression throughout their life. However, many do not have the symptoms of depressive disorder, so they should not be treated as such.

Low Serotonin

Some research suggests that low serotonin production during the luteal phase (the time after you release your eggs and before your period starts) could be a common cause of PMDD. Serotonin is essential for regulating mood, social behavior, appetite, sleep, and sexual desire. 

Life-Long Depression and PMDD

I suspect that this life long struggle with depression that many women experience could be the result of having undiagnosed PMDD for much of their life. After all, for up to one week a month, that’s 23% of a year, a woman with PMDD experiences feelings of helplessness, anxiety, irritability, anger, extreme emotions, and/or depression sometimes to the point of having suicidal thoughts.

Then once that’s over, they have to deal with the physical cramping, general irritability, emotions, and blood loss all women with periods go through. That’s up to 50% of the year spent in some form of distress. The joys of womanhood!

However, this pre-menstrual luteal phase can exacerbate other depression, anxiety or mental health struggles. History of depression or other issues should be discussed with your doctor to help find the best treatment plan for you.

Treating PMDD

The first step in treating PMDD is to focus on living a healthy lifestyle; food is medicine, and exercise is uplifting. Looking after your body through a healthy diet and exercise will help your body naturally balance hormone levels and function. 

Lifestyle Changes 

  • Experiment with low-carbohydrate, low-sugar, high-fat diets such as the ketogenic or paleo diets and see how you feel. 
  • Exercise daily to help boost serotonin levels. 
  • Try meditation to manage mood fluctuations. 
  • Reduce intake of mood-altering substances such as caffeine, tobacco, alcohol and illicit drugs

Nutritional Supplements

  • Vitamin B-6 (< 100 mg per day)
  • Vitamin E (< 600 UI per day)
  • Calcium carbonate (1200 to 1600 mg per day)
  • Magnesium (< 500 mg per day)
  • Tryptophan (< 6 mg per day)
  • Herbal supplements such as evening primrose oil and chaste tree berry may help alleviate symptoms.

N.B. The body uses L-tryptophan to produce serotonin. Additionally, pyridoxine helps the body convert tryptophan into serotonin. 

Other Treatments

  • Self-care practices to reduce stress
  • Learn stress and anger management tools
  • Counseling or therapy
  • Cognitive-behavioral therapy
  • Light therapy
  • Acupuncture

Antidepressants 

If all else fails or PMDD symptoms are especially severe, you may want to experiment with serotoninergic antidepressants. Personally, I have found St John’s Wort useful. Most of these should only be taken during the luteal phase of menstruation to effectively boost serotonin during this time, which reduces the symptoms of PMDD. I recommend reading Diagnosis and Treatment of Premenstrual Dysphoric Disorder by Bhatia and Bhatia published in the American Family Physician in 2002 for more information on treatment antidepressant treatment options. Talk to your doctor if you want to dive down this route.

Living with PMDD

If you think you might have PMDD or know someone who might have it, one of the best things you can do is educate yourself and others. Learning about PMDD helps people to figure out the best way to manage it. It also helps the people around them understand what’s going on. 

My Experiences with PMDD

For me, tracking my cycles and learning about PMDD have helped me to understand my body better. When that first terrible day strikes, I can reassure myself that it’s temporary. I just have to batten down the hatches for a few days, be really nice to myself, don’t make any major life decisions, and everything will be OK. To help cope I developed my own Depression Day Checklist for these sorts of days with tasks like exercise, eat healthy, self-care, clean something, etc.

By tracking my cycles I noticed that when I was generally struggling with other life stressors my PMDD was worse and longer-lasting. Knowing this helped me to plan ahead. I could tell friends that if they don’t hear from me, please contact me and invite me out to dinner or something. Or I would schedule a meet up in advance.

I know that getting out and talking to friends helps bring me out of depression, but once it hits, it’s incredibly hard to force myself to do anything social. If the obligation is already there with someone I am close to, I will make myself go and ultimately feel better afterward rather than wallowing in self-pity and thoughts of hopeless demise.

Being prepared also helped me to plan work and study obligations in advance. I was able to leave the less mind-numbing tasks or tasks that require less attention to detail and focus for the week before my period begins. And I know to cut myself some slack when I don’t get through everything I planned to.

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    2021 Update:

    Over the past six or so months I have been learning more about different types of energy and leaning into those. At first this was to learn more about myself and manage my PMDD but the past few months I’ve noticed my terrible day strikes have dispersed. My period keeps sneaking up on me because previously I was using this as a signal to be aware that next week it was coming.

    Yin and Yang Energy

    We all have Yin and Yang or Feminine and Masculine energy within us. It’s a balance. We all naturally lean towards a dominant energy type, but our biological sex doesn’t determine this.

    Yang or Masculine energy is a more active energy. It’s strong, vibrant, and independent. It’s focused on a purpose, making fast decisions and seeing a problem, then jumping right in to fix it. This energy is linked to the element fire.

    Yin or feminine energy is a softer, more flowy energy- like water. It’s creative, nurturing, intuitive, empathetic, compassionate. Decisions are often made more thoughtfully and feelings based.

    I’m sure you both relate to one of these energy types more and recognize parts of both in yourself. Imbalances in yang energy lead to dominant, machismo-type behaviors. An imbalance of yin energy leads to loss of power and feelings of weakness. While we all have both, women’s monthly cycles accentuate these energies.

    Women’s Energy Cycles

    During the follicular stage and ovulation, when hormones like estrogen, testosterone, and serotonin are pumping, women’s energy tends to be more active. Yang energy dominates.

    During the luteal phase, the lining of your uterus starts to break down in preparation for your period, estrogen drops, then progesterone increases. This is a lower energy yin phase. This time is often associated with the not-so-fun PMS and PMDD symptoms.

    Mindset shift

    We live in a very yang-energy-type society. It’s all go-go-go, and often, yin energy is seen as a weakness. But the fundamental shift for me, and many women, is realizing our luteal phase is a gift, reminding us to ground, rest, be compassionate and creative. It’s not a burden holding us back.

    I heard a theory many years ago that the negative symptoms of menstrual cycles, including PMS and cramps, were caused by women being shamed to be women. These symptoms were a construct of society.

    At the time, I thought it was mad, but I think there is some truth to it (we’ll see, I still get cramps). We are raised being told we can do anything men can, and we have to step up and prove it. But we’re then forced into a system where we must “do it all” from a yang energy perspective, not a yin one. I’m not necessarily sure it’s always because we’re ashamed to be females, but we just don’t fully understand what that means.

    Neither way of working is wrong; they’re just different. We must recognize each of us is different and celebrate this.

    Manging PMDD Using Energy Cycles

    The big change for me has been organizing my work, as much as I can, around my cycles. After my period, I focus on new projects and finishing projects (yang energy). Before my period, I lean into the design and creative work when I can (yin energy).

    I recognize that being my own boss makes this easier but researching the topic; many women apply this at work by being very clear with to-do lists. Ask yourself, “what are the vital tasks and what can I move around?”

    Your luteal phase is also a reminder to tap back into any self-care rituals you may have been missing lately. Take time to meditate, journal, and pamper with a face mask. Switch HIIT exercises and power Yoga for gentler yin and slow vinyasa flows.

    If anything I get more done because I know when my strengths are at their peak rather than painstakingly trying to force jobs that I’m not in the zone for and the more leveled my moods are—the bliss of balance for the first time in my adult life.

    Final Comments

    Understanding your cycles and learning what best helps you is the best thing you can do, whether you have PMDD or the milder PMS, which let’s face it is no walk in the park either.

    Interestingly, while writing this email, I found that one of the key contributors that makes people more likely to get PMDD is lower education. Doesn’t that say it all?

    I’d love to hear your thoughts on this. It’s something I’ve talked to with many of my close friends, and no matter which corner of the globe we grew up in, we each conclude that we should better understand our bodies than what we do by now (late twenties and early thirties).

    I don’t think it has always been this way; women have been women for thousands of years. Women across a variety of cultures used to gather during their menstrual cycles. I’m sure passing knowledge between generations. Then somewhere along the line, these conversations became “improper” (Thank you Victorian period and British Imperialism).

    Sharing your experiences is one of the most valuable things you can do to help others. What’s your experience with PMDD or PMS? Do you have any tricks (other than chocolate ????) to get you through these difficult days?

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