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For those of you who don’t know which is an astonishing amount of people, Premenstrual Dysphoric Disorder (PMDD) according to the Gia Allemand Foundation, is a hormone-based mood disorder. Mayo Clinic reports that PMDD as a disabling and severe form of PMS. The psychiatric “bible” the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM V) now includes PMDD as an official mental health diagnosis. PMS is also not classified as a mental illness. The manual states, “in the majority of menstrual cycles, at least 5 symptoms must be present in the final week before the onset of menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week post menses.”

International Association for Premenstrual Disorders reports that while PMDD is directly connected to the menstrual cycle, it is not a hormonal imbalance. PMDD is a severe negative reaction to the natural rise and fall of estrogen and progesterone. It is a suspected genetic disorder with symptoms often worsening over time and around reproductive events including menarche (your first period), ovulation, pregnancy, birth, miscarriage, and menopause. Women with PMDD are at an increased risk for postpartum depression and suicidal behavior. Many, but not all, women with PMDD have a history of sexual trauma or depression. There is no blood or saliva test to diagnose PMDD, although these tests can rule out other underlying disorders. The only way to diagnose PMDD is by tracking symptoms for at least two menstrual cycles.

Many women have suffered with this ailment and have struggled to be correctly diagnosed and treated. Luckily, I was diagnosed in my early 20’s. Personally, I’ve gone on and off medications throughout the years trying to combat this disorder. I didn’t realize I even had an issue until a pattern in my mood changes started presenting itself every month and my boyfriend pointed it out. What I had thought was normal PMS (according to friends, women family members and the media), was actually something much worse. Because I thought it was normal to behave the way I was behaving, I didn’t address it.

At first, I actually thought my boyfriend was out of his mind for suggesting my PMS was on another level. I figured he just did not know what he was talking about and honestly how could he…he’s a man and had no idea what I was going through! Once he started pointing out some things, it did make me realize that indeed something was off. I would purposely pick fights, I was severely agitated and angry, my thinking was irrational, I craved carbs like none other and felt very stressed and overwhelmed.

Additionally, I had miserable physical symptoms like fatigue, terrible cramping, sore breasts and migraines every month around the same time. Once my menstrual cycle had started, within just a couple days I would feel markedly better and wonder why I was acting so crazy and irrational just days before…then I had to make amends with my boyfriend for starting ridiculous fights over minor things. This was significantly impacting our relationship in a negative way.

Does this sound like you? I’ve had many patients throughout my nursing career admit to my facility with many mental health issues, but rarely had any of them carried a diagnosis of PMDD. During assessments I would talk with them and occasionally they would endorse similar symptoms and it was cyclic in nature. This had me wondering if women were being diagnosed incorrectly.

According to the International Association for Premenstrual Disorders, PMDD affects an estimated 2-10% of women of reproductive age. I believe this is grossly under diagnosed. I’ve encouraged pts to start keeping a mood log to help them identify if they could possibly be suffering from PMDD. This doesn’t mean that other mental health issues aren’t present, and this one thing covers it all, it just helps to know that there are patterns, and other methods available to get your symptoms under control.

As mentioned above, women must present with only 5 of the following symptoms to be considered for this diagnosis (NCBI):

Timing of symptoms A) In the majority of menstrual cycles, at least 5 symptoms must be present in the final week before the onset of menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week post menses.

Symptoms B) One or more of the following symptoms must be present: 1) Marked affective lability (e.g., mood swings, feeling suddenly sad or tearful, or increased sensitivity to rejection) 2) Marked irritability or anger or increased interpersonal conflicts 3) Markedly depressed mood, feelings of hopelessness, or self-deprecating thoughts 4) Marked anxiety, tension, and/or feelings of being keyed up or on edge C) One (or more) of the following symptoms must additionally be present to reach a total of 5 symptoms when combined with symptoms from criterion B above 1) Decreased interest in usual activities 2) Subjective difficulty in concentration 3) Lethargy, easy fatigability, or marked lack of energy 4) Marked change in appetite; overeating or specific food cravings 5) Hypersomnia or insomnia 6) A sense of being overwhelmed or out of control 7) Physical symptoms such as breast tenderness or swelling; joint or muscle pain, a sensation of “bloating” or weight gain

Severity D) The symptoms are associated with clinically significant distress or interference with work, school, usual social activities, or relationships with others.

E) Consider Other Psychiatric Disorders The disturbance is not merely an exacerbation of the symptoms of another disorder, such as major depressive disorder, panic disorder, persistent depressive disorder (dysthymia) or a personality disorder (although it may co-occur with any of these disorders).

Confirmation of the disorder F) Criterion A should be confirmed by prospective daily ratings during at least 2 symptomatic cycles (although a provisional diagnosis may be made prior to this confirmation) Exclude other Medical Explanations G) The symptoms are not attributable to the physiological effects of a substance (e.g., drug abuse, medication or other treatment) or another medical condition (e.g., hyperthyroidism).

So, what can be done? First, start documenting your symptoms for at least 2 cycles with this journal. Do include anything no matter how minute it might seem. Next, get to your OB/GYN or primary care physician. There are numerous ways to treat PMDD. Personally, I needed to get in touch with my body before I could pinpoint what worked for me. By tracking my ovulation, the length of my cycle and nutritional factors, I was able to better predict when symptoms would occur. Additionally, when I was not able to manage my symptoms with non-pharmacological factors, I did opt to take a monthly dose of Prozac initially, and currently I am taking it every day. Ideally when I get back to a more manageable state, I will discontinue or wean off the medications with the help of my doctors.

Here are some ways to ease your PMDD symptoms and start to feel better!

• Getting enough sleep – You may need extra sleep in the days prior to your cycle. Studies have shown that women, in general, need more sleep than men. For women, reduced sleep was associated with a significant increased risk of heart disease and diabetes, as well as more stress, depression, anxiety, and anger. While racing thoughts and anxiety (two common symptoms of PMDD) can easily contribute to lack of sleep according to IAPMD. This device can help you fall asleep without medications. If you enjoy sleep sounds, please consider checking out the playlists I have curated on my YouTube channel Cloud Nine Sleep.
• Exercise – Exercise in general has numerous health benefits and aerobic exercise specifically can help you sleep better.
• Nutritional factors – I have had to eliminate caffeine the first day of my cycle as it directly caused severe cramping (it took me years to figure that out). It may also help to decrease or eliminate the intake of alcohol, nicotine, sugar, and sodium. A diet high in proteins, complex carbohydrates, fruits, and vegetables will help keep you in balance. IAPMD reports a common symptom of PMDD is an intense craving for food during the luteal phase of your cycle, specifically foods high in carbohydrates and with good reason. Carbohydrates influence the production of serotonin which directly and indirectly controls mood, sexual desire and function, appetite, sleep, memory, body temperature, and social behavior. While serotonin is produced in the brain, about 90% of our serotonin supply is in the digestive tract and blood platelets. The connection between mood and food is clear. When a meal high in carbohydrates is consumed, the resulting insulin aids in getting more tryptophan to the brain and increased levels of serotonin. Foods high in the carbohydrate sugar will have the opposite effect and reduce serotonin. Choosing whole grains will achieve the desired boost.
• Supplements – B vitamins, especially Vitamin B6, Vitamin E, Calcium carbonate, Magnesium and Tryptophan can help with PMDD symptoms. As mentioned in a previous post, 5-HTP can help with serotonin levels, but it must be discussed with your medical provider first if you are taking any other medications, as there can be a contraindication.
• Medications – Anti-depressants (SSRIs) and birth control pills have been effective at easing PMDD symptoms. Birth control pills can offer symptom relief by regulating the fluctuation of hormones throughout a woman’s menstrual cycle. Be careful, with some birth control pills, you may have the opposite effect that can lead to worsening mood disturbances. Make sure you clearly communicate your symptoms in their entirety to your doctor. Several medications called selective serotonin re-uptake inhibitor (SSRI) have been approved by the FDA to treat the anxiety and depressive symptoms PMDD. These medications work by regulating the levels of the neurotransmitter serotonin in the brain and are often considered first-line treatment for PMDD. Women with PMDD are often misdiagnosed with bipolar disorder due to the cyclical nature of both disorders. Some mood stabilizers might also be helpful, and it is worth exploring your options with your doctor.
• Hormone therapy – Supplementing progesterone may be beneficial in relieving symptoms. Ask your doctor to do a thorough lab panel to check your hormones.

Buzzfeed has a great article about women’s experience with PMDD.

The free tools, resources, information, and support provided by IAPMD can help you on this journey. Click here to take the self-assessment. This tool can help you talk to your provider and establish a diagnosis.