CONTENT WARNING: This article mentions suicidal ideation in the context of PMDD

What is PMDD?

PMDD (Pre-Menstrual Dysphoric Disorder) is a debilitating form of Pre-Menstrual Syndrome (PMS). Most of us have experienced some level of run-of-the-mill PMS over our lifetimes. Many of us experience it every month. PMS includes such lovely symptoms as bloating, breast tenderness, headaches, nausea, irritability, anxiety, and food cravings. PMS tends to set in somewhere in the luteal phase and goes away over first couple of days of your period.

Researchers think that the cause of PMS is linked to the drop in estrogen and progesterone that occurs post ovulation (if you aren’t pregnant), and specifically to the link between these hormones and serotonin levels. It’s likely more complex than this, and may also be linked to genetic factors, stress levels, and nutritional status.

PMS is what makes you think “why is my partner/child/workmate being such a pain in the butt?” all of a sudden. It’s what drives you to buy a whole family sized block of chocolate out of the blue, just because.  It’s the reason for that monthly “why am I acting like this?” moment, followed by the usual realization that it was in fact PMS when your period arrives three days later (seriously I’m in my 40s now and STILL am surprised by my mood fluctuations each month, you’d think I’d have figured it out by now….but apparently not).

PMDD however is NOT your run-of-the-mill PMS. It’s like PMS on a LOT of steroids and is a severe and chronic condition. Clients I have worked with who have PMDD have described things like feeling completely irrational, being unable to stop crying, experiencing severe anxiety and depression, and at the most extreme end, feeling suicidal for 2 weeks of every month. Psychological symptoms can include extreme mood swings, irritability and anger/rage, depression, anxiety, hopelessness, and suicidal ideation. People with PMDD have a higher risk of suicide than the general population. Physical symptoms are often similar to PMS, however the fatigue and sleep disturbances can be more extreme, and there can be cognitive symptoms as well, include difficulty concentrating, and problems with memory.

PMDD is truly debilitating, and people who experience it are often unaware that their symptoms are worse than others, or they may have been misdiagnosed with mental health issues such as bipolar disorder or borderline personality disorder. Surprising no-one with a uterus who has waited an eternity for a diagnosis, PMDD is often diagnosed quite late, around the mid 30’s, which could mean a delay in diagnosis of 20 years if it started at onset of menstruation. 20 years! The diagnosis of PMDD often coincides with life events like childbirth, or the onset of perimenopause which adds an extra complication to an already challenging experience.

One of the most striking features of PMDD is that the person’s mental state returns to a relatively normal state in between the onset of their period and the next luteal phase. I have found it quite common for people with PMDD to come for therapy one week experiencing debilitating symptoms of depression and anxiety, to the point I’ve been really concerned about them, and then they rock up a week or two later smiling with minimal signs of low mood. It is very much an emotional rollercoaster for those who experience it.

To meet criteria for a diagnosis, a person needs to meet at least 5 out of a total of 11 specific symptoms, over a period of one week prior to onset of period, and this occurring over the majority of cycles in a year. In addition, the symptoms must cause significant distress and/or impairment of functioning in work, education or social settings, and not be due to another condition like hyperthyroidism or substance use (for example). There are quite a few things that can mimic PMDD, and if you have pre-existing mental health difficulties then getting a diagnosis can be more complex and requires careful tracking of symptoms alongside your cycle.

PMDD and Neurodivergence

There is a close link between neurodivergence (specifically Autism and ADHD) and PMDD. A study from 2008 by Obaydi and Puri found that 92% of the autistic women in their sample met criteria for a diagnosis of PMDD. The true number may not be quite that high, but it is still likely to be a significant percentage. The data for ADHD suggests that at least 40% of women with ADHD will meet diagnostic criteria for PMDD. There is not a huge amount of research in this area, and the reasons for this relationship are theorized to be complex. Like, another whole article complex, so I won’t get into it here, but safe to say if you have ASD, ADHD or AuDHD, and you have a gnarly time with your period and/or mood fluctuations, you might want to get assessed for PMDD.

I think I might have PMDD, what can I do about it?

Thankfully, there are some treatments and lifestyle changes that can help with PMDD.

Hormonal birth control can help to regulate the hormone cycle and reduce the severe changes that occur with PMDD. Antidepressant medication can help with mood regulation. Other hormone regulation or mood regulation medications may also be helpful. Anti-inflammatory medications can be helpful in some cases, as can supplementation of particular vitamins.

If you have the financial capacity, you could see a psychiatrist who specializes in PMDD, and/or a reproductive endocrinologist to help you with getting the right medications, although your GP can make a start if they are experienced in the area. It is often a case of trial and error to see what works, as there’s likely a unique combination of factors occurring for each person, that need to be treated individually.

A psychologist can help with coping with the PMDD symptoms – setting you up with a range of emotional regulation strategies, stress management strategies, and self-care ideas to help manage through that incredibly difficult couple of weeks.

A dietician can be helpful to assist you in working out which foods are helpful or unhelpful during this time – for example caffeine and alcohol during the luteal phase are likely to be huge no-no’s if you are a person who has terrible anxiety with PMDD.

Regular exercise can be helpful – and may also be very challenging depending on your mental state at different times of the month, so it can be useful to set yourself up with some options that are easy and gentle for the days when you are really struggling.

A final note….

As with so many women’s health issues, PMDD can take a very long time to be diagnosed accurately and can be misdiagnosed as a number of other physical and mental health issues. If you have read this article today, and think that you might have PMDD, please advocate for yourself, and take a support person with you to appointments if you feel that you need to. You are most likely to be able to get a *relatively* quick diagnosis if you have been tracking your cycle and symptoms for at least several months prior to your appointment, so start doing this today if you can – it doesn’t matter where you are in your cycle when you start tracking.