A severe, biologically-based mood disorder linked to the menstrual cycle
1. Definition & Diagnostic Criteria (DSM-5)
PMDD requires ≥5 symptoms in the final week before menses, improving within a few days after onset, with minimal symptoms post-period:
✅ Core Emotional Symptoms (≥1 required):
- Mood swings (sudden sadness/irritability)
- Marked irritability/anger
- Depressed mood/hopelessness
- Anxiety/tension
✅ Additional Symptoms (≥4 total):
- Decreased interest in activities
- Difficulty concentrating
- Fatigue/lethargy
- Appetite changes/overeating
- Sleep disturbances
- Feeling overwhelmed
- Physical symptoms (breast tenderness, bloating)
Key Features:
- Symptoms cause significant distress or impairment (work, relationships)
- Confirmed over ≥2 menstrual cycles (symptom tracking required)
2. PMDD vs. PMS: Key Differences
| Feature | PMDD | PMS |
|---|---|---|
| Mood Symptoms | Severe, disabling | Mild-moderate |
| Functional Impact | Work/social life disrupted | Minimal disruption |
| Suicidality Risk | Increased (30% report SI) | Rare |
| Prevalence | 3-8% of menstruators | 80% experience some symptoms |
Red Flag: PMDD is not “just bad PMS” – it has distinct neurobiological markers.
3. Causes & Risk Factors
| Category | Key Contributors |
|---|---|
| Biological | • Abnormal serotonin response to hormonal shifts • Genetic predisposition (30% heritability) • Enhanced sensitivity to ALLO (allopregnanolone) fluctuations |
| Psychological | • History of trauma/depression • High stress sensitivity |
| Environmental | • Smoking (↑ symptom severity) • Vitamin D deficiency |
Myth Buster:
❌ “It’s just hormones – tough it out” → PMDD involves brain receptor dysfunction, not just hormone levels.
4. Diagnosis Process
Step 1: Symptom Tracking
- Use daily charts for ≥2 cycles (e.g., PMDD Symptom Tracker apps)
- Rule out:
- Premenstrual exacerbation of other disorders (depression, anxiety)
- Thyroid dysfunction
Step 2: Confirm DSM-5 Criteria
- Symptoms must disappear post-menstruation
5. Evidence-Based Treatments
A. First-Line Medications
| Class | Examples | Mechanism |
|---|---|---|
| SSRIs | Sertraline, Fluoxetine | Rapid serotonin modulation (often dosed only in luteal phase) |
| Oral Contraceptives | Yaz (drospirenone/EE) | Stabilizes hormonal fluctuations |
B. Advanced Options
- GnRH Agonists (e.g., Leuprolide) – For severe, refractory cases
- ALLOS Modulators (e.g., Zuranolone – investigational)
C. Lifestyle & Complementary
- Calcium/Vitamin B6 supplementation (modest benefit)
- Cognitive Behavioral Therapy (for emotional regulation)
- Vitex Agnus-Castus (limited evidence)
6. PMDD Across the Lifespan
- Perimenopause: Symptoms may worsen initially, then resolve post-menopause
- Postpartum: High relapse risk after pregnancy
- After Hysterectomy/Oophorectomy: Requires careful hormone management
7. Emergency Management
For Acute Suicidal Ideation:
- Increase SSRI dose (even mid-cycle)
- Consider short-term benzodiazepine (for extreme anxiety)
- Crisis support: 988 Lifeline
8. Patient Support Strategies
✅ Cycle Awareness: Plan demanding tasks for follicular phase
✅ Partner/Family Education: PMDD is not voluntary irritability
✅ Advocacy: Workplace accommodations (flexible deadlines)
9. Key Resources
- IAPMD (International Association for Premenstrual Disorders): iapmd.org
- Me v PMDD (Symptom Tracker App)
- Book: The PMDD Phenomenon (Diana Dell)