What is PMDD?
Premenstrual Dysphoric Disorder (PMDD) is a more severe form of Premenstrual Syndrome (PMS). PMS is defined as a consistent pattern of physical, behavioural or emotional symptoms that occur after ovulation and disappear within a few days of a women's period beginning. PMS symptoms are normally mild to moderate, mainly physical and only last for a few days.
Sympotoms of PMDD are more severe. They are related to the woman's menstrual cycle and are primarily changes in mood and behaviour. The symptoms often last up to two weeks and have a serious impact on the woman, her family, relationships, work or school. Between 3% and 9% of women who are of reproductive age suffer from PMDD.
Some typical symptoms of PMDD are:
- major shifts in mood that are extremely difficult to live with
- depressed mood, anxiety, irritability and unreasonable anger
- a feeling of being overwhelmed or out of control
- decreased ability to focus and a feeling of being unable to think clearly
- tension and restlessness.
PMDD can arise at any time during a woman’s reproductive years although the average age of onset is 26 years. There are some similarities with symptoms of depression and it is important to differentiate between major depression and PMDD although both may occur at the same time. Women who experience PMDD may have a history of depression, sometimes related to the postpartum period. One noted difference between PMDD and depression is that the symptoms of PMDD occur in the two weeks before the menstrual period and disappear within a few days of the onset of her menstrual flow and depression symptoms are present all the time throughout the month.
PMDD is thought to be a physiological problem in which the brain’s biochemistry is temporarily disturbed, resulting in mood and behavioural distress at particular times in the menstrual cycle. The exact mechanisms are not clearly understood but PMDD is not simply a ‘hormonal imbalance’ and is more likely to be related to how hormones affect the brain receptors.
Risk Factors for PMDD
As with all mental health challenges and disorders, some people are more at risk of developing PMDD than others. You may be at greater risk with:
- a history of depression
- a history of postpartum depression
- a history of depression in close family members
- a family history of PMDD.
In addition, it is known that some lifestyle factors may contribute to PMDD:
- stress that is ongoing in family relationships or at work
- stressful life events such as bereavement, moves, unexpected life events
- poor eating habits; excess caffeine or alcohol
- lack of sleep; lack of social supports,
- lack of exercise; a sedentary lifestyle; weight gain.
Treatment Options for PMDD
There are a range of treatment options for women with PMDD. They may include:
- self care
- counselling and psychotherapy, including group therapy
Self Care Strategies for PMDD
Increasing your self care (taking time for oneself) is an important and necessary step in helping your PMDD. If you find this difficult, ask yourself ‘What do I enjoy doing?’ ‘What relaxes and calms me?’ Part of self-care is reducing unhelpful stress in your life. This is particularly important during your premenstrual phase.
Examples of self care are:
- getting enough sleep, rest and relaxation.
- doing some exercise
- practicing yoga and/or mindfulness
- being with friends
- down time
- healthy diet
Sleep, Rest and Relaxation
Getting enough sleep is an important and necessary self care requirement in managing your PMDD. Most women need at least 8 hours of sleep to function optimally. Furthermore, going to sleep before midnight is more restorative than going to sleep after midnight. Here are some suggestions for improving your sleep:
- Establish a regular time to go to sleep at night and waken in the morning. Keep to this routine even on weekends.
- Avoid caffeinated beverages (coffee, some teas) or food containing caffeine (chocolate) after 3pm.
- Alcohol and drugs may disrupt sleep and should be limited or avoided.
- Limit or eliminate naps during the day (no more than 30 minutes).
- Do not exercise immediately before going to sleep as it may stimulate your brain and body.
- Make sure that your bedroom is dark, quiet, well ventilated and comfortable.
- Try some relaxation techniques in the evening (a warm bath, a good book, mindfulness, guided imagery etc.).
- Do not go to sleep hungry. A light snack such as warm milk, may improve your overall quality of sleep.
- Do not try hard to fall asleep. If you are not asleep after a reasonable time in bed, get up and do something until you feel sleepy and then try again.
Regular exercise - a natural antidepressant and mood booster
- increases the level of endorphins - the body’s mood-enhancing substances
- energizes you and reduces jitteriness
- increases levels of serotonin and dopamine in the brain, therefore helping your brain to regulate itself
- increases your ability to deal with daily stressors
- may diminish premenstrual symptoms and depression in some women
Eating a healthy diet
Can nutrition help you manage PMDD symptoms? Irritability, fatigue and food cravings are some possible symptoms of PMDD. Skipping a meal will cause blood sugar to fall which is likely to worsen these symptoms. To maintain a stable blood sugar, eat healthy food at regular intervals and try not to let more than 4 hours elapse between meals or healthy snacks. Seek the advice of a dietitian if you need to review or change your diet.
Here are some more pointers:
- Include some protein in your meals (eg. meat, fish, poultry, eggs, dried beans, lentils, or tofu) to help satisfy hunger and keep your blood sugar stable.
- Limit your intake of sugar and salt.
- Include grain products, vegetables, and fruit.
- Avoid alcohol and drugs as they act as a depressant on the brain, possibly worsening depressed mood. Alcohol is not helpful in reducing stress.
- Consider decreasing caffeinated drinks such as coffee, tea and cola to see if irritability, jitteriness and sleep difficulties improve. Do this gradually, decreasing by not more than one caffeinated drink per week to prevent withdrawal symptoms such as headache.
Canada’s Food Guide gives guidance on what to include in a balanced and healthy diet and how to manage such things as sugar and salt.
Should I take herbal supplements?
Herbal pills and liquids receive little government regulation and so amount and purity of herb in preparations is not known. This makes it difficult to know if those herbal products found in Canada will have the positive effects on anxiety and depression found in some studies.
Although herbal products may be thought of as natural, they do act as drugs in the body and can alter the effect of other medications being taken. If you are considering using a herbal preparation, it is essential to discuss with your doctor before beginning.
The latest research indicates that serotonin dysregulation is involved in PMDD. Women with severe PMDD symptoms can be treated with serotonin-reuptake inhibitors (SSRIs) or serotonin and norepinephrine reuptake inhibitors (SNRIs). These medications work by increasing the amount of serotonin and norepinephrine available to the brain which stabilizes the serotonin even as the hormones fluctuate throughout the menstrual cycle.
Each woman reacts differently to medications. Therefore, women are encouraged to talk to their physician about the medication and possible side effects.
Some women may need medication only for the last two weeks of their menstrual cycle, while other women may need to take medication daily to alleviate their symptoms. SSRIs and SNRIs will not affect your normal menstrual cycle.
Research has found most hormones to be an ineffective treatment for PMDD. Some of the newer birth control pills may help to reduce symptoms but there are some risks associated, eg. increased risk of blood clots.
Progesterone used to be considered helpful but recent research has not found progesterone to be better than a placebo (sugar pill) in reducing symptoms.
Medications which suppress all the hormones may reduce symptoms but there are many serious side effects and the medications themselves are expensive.
The ultimate goal is to optimize the appropriate treatment strategies with each woman experiencing PMDD. A combination of therapies may be required.
There is more information on PMS and PMDD, treatment options and more detail on whether nutrition can help you manage PMS/PMDD symptoms in the guide A Positive Approach: Premenstrual Syndrome (PMS) and Premenstrual Dysphoric Disorder (PMDD).