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Premenstrual dysphoric disorder is a severe form of premenstrual syndrome. It is considered a health condition that can benefit from treatment with lifestyle changes and sometimes medication.

Between 20 and 40 percent of women experience moderate to severe premenstrual symptoms (PMS). Between 3 and 8 percent of these experience symptoms that prevent them from functioning in normal daily life. This is premenstrual dysphoric disorder (PMDD).

The difference between PMDD and premenstrual syndrome (PMS) is that the symptoms of PMDD are severe and debilitating. PMDD involves a set of physical and psychological symptoms that affect daily living and threaten the individual’s mental wellbeing.

PMDD is a chronic condition that necessitates treatment when it occurs. Available treatments include lifestyle modifications and medication.

This article examines the causes, symptoms, and diagnosis of this debilitating condition, along with the treatment options that are available for people who are affected by it.

Fast facts on PMDD

  • The symptoms of PMDD disrupt normal daily functioning, and they require medical treatment.
  • PMDD is less common than PMS, and the symptoms are more severe.
  • Symptoms are most commonly experienced during the second half of the menstrual cycle.
  • The symptoms of PMDD can last until menopause.
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Severe stress and emotional upheaval are symptoms of PMDD that can affect working life and relationships.

The symptoms of PMDD are similar to but more severe than those experienced in PMS.

Symptoms are typically present during the week before menses and resolve within the first few days after menstrual onset.

Those who experience PMDD are often unable to function at their normal capacity while symptoms are present.

The condition can affect relationships and disrupt routines at home and work.

Symptoms of PMDD, both common and rare, include:

  • severe fatigue
  • mood changes, including irritability, nervousness, depression, and anxiety
  • crying and emotional sensitivity
  • difficulty concentrating
  • heart palpitations
  • paranoia and issues with self-image
  • coordination difficulties
  • forgetfulness
  • abdominal bloating, increased appetite and gastrointestinal upset
  • headaches
  • backache
  • muscle spasms, numbness or tingling in the extremities
  • hot flashes
  • dizziness
  • fainting
  • sleeplessness
  • vision changes and eye complaints
  • respiratory complaints, such as allergies and infections
  • painful menses
  • decreased libido
  • easy bruising
  • heightened sensitivity

Fluid retention may lead to breast tenderness, decreased urine production, swelling of the hands, feet and ankles, and temporary weight gain.

There may also be skin problems, such as acne, inflammation and itching, and a worsening of cold sores.

Most of these symptoms are affective or linked to anxiety.

The exact cause of PMDD and PMS remains unclear.

It is suggested that PMDD stems from the brain’s abnormal response to a woman’s fluctuation of normal hormones during the menstrual cycle. This, in turn, could lead to a deficiency in the neurotransmitter serotonin.

Some women are more likely than others to experience PMDD, including those who have had a personal or family history of postpartum depression, mood disorders, or depression.

The symptoms of PMDD can be similar to those of other conditions, so health care providers will likely perform a physical exam, obtain a medical history, and order certain tests to rule out other conditions when making a diagnosis.

A symptom chart is also used in the diagnostic process to determine any correlation between the symptoms and the menstrual cycle.

Guidelines from the American Psychiatric Association (APA) Diagnostic and Statistical Manual 5th Edition (DSM-V) require that the symptoms of PMDD be present for a minimum of two consecutive menstrual cycles before making a diagnosis of PMDD.

According to the guidelines, symptoms must:

  • be present a week before the onset of menses
  • resolve after the start and within the first few days of flow
  • interfere with normal daily living
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Headaches and fatigue that frequently occur around menses may be a sign of PMDD.

For a PMDD diagnosis to be made, a patient must experience at least five symptoms, including at least one of the following:

  • feelings of sadness or hopelessness
  • feelings of anxiety or tension
  • mood changes or increased sensitivity
  • feelings of anger or irritability

Other symptoms of PMDD can include:

  • apathy to routine activities, which may be associated with social withdrawal
  • difficulty concentrating
  • fatigue
  • changes in appetite
  • sleeping problems, whether excessive sleeping (hypersomnia) or insomnia
  • feeling overwhelmed or having a sense of a lack of control

Other physical symptoms of PMDD can include breast tenderness or swelling, headaches, joint or muscle pain, bloating, and weight gain.

Two types of medication may help with PMDD: those that affect ovulation and those that impact the central nervous system (CMS).

Examples include the use of:

  • SSRI antidepressants such as fluoxetine (Prozac, Sarafem), sertraline (Zoloft), paroxetine (Paxil), and citalopram (Celexa)
  • oral contraceptives that contain drospirenone and ethinyl estradiol
  • gonadotropin-releasing hormone analogs such as leuprolide (Lupron), nafarelin (Synarel) and goserelin (Zoladex)
  • danazol (Danocrine)

Cognitive therapy (CT) has been shown to help those with PMS. Combined with medication, CT may also help those with PMDD.

Supplements

A number of supplements have been recommended for treating premenstrual symptoms, but studies are lacking to support efficacy and long-term safety with their use.

Examples include:

  • chasteberry extract to relieve physical symptoms
  • evening primrose oil
  • magnesium oxide
  • dietary supplementation with calcium, vitamin B6, magnesium, and vitamin E

A meta-analysis published in the Journal of Chemical and Pharmaceutical Science (JCPS) in 2016 concluded that vitamin B6 could be a “beneficial, inexpensive, and effective treatment for PMS symptoms.”

Evening primrose oil has not been proven effective, according to at least two systematic reviews, published in 2009 and 2011.

The 2009 study also found magnesium oxide to be ineffective, and the 2011 study concluded that St. John’s wort had no effect.

Other researchers have concluded that vitamin D and calcium supplements can reduce both the severity of symptoms and the risk of PMS, as well as protecting from osteoporosis. It is possible that this could also, therefore, help with PMDD.

Chasteberry supplements are available for purchase online, but it is a good idea to speak to a health professional before taking supplements.

Alternative remedies

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Yoga can sometimes relieve stress.

Possible alternative remedies that have been tried for PMS and may help with PMDD include:

However, more research is needed to confirm the effectiveness of these treatments.

Diet and exercise

Dietary changes include:

  • decreasing intake of sugar, salt, caffeine, and alcohol
  • increasing protein and intake of complex carbohydrates

Exercise, stress management techniques, and help in viewing menstruation in a positive light may help.

Other tips

Other strategies that may help include:

  • taking it easy on the days leading up to menstruation
  • talking to a partner or trusted friend
  • finding relaxing activities that relieve tension, such as reading, watching a movie, going for a walk, or having a bath

Speak with your health care provider right away if you think you may be experiencing symptoms of PMDD.

As the symptoms of PMDD can be long-lasting, it is advisable to seek treatment as soon as possible.