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P.’s Story

P. is a thirty-something-year-old woman who has always had problems with her periods. Over the past year or so, they’ve gotten worse. Every time she’s about to have her period, it feels like she is depressed. Her mood is low, and along with crying spells, she has trouble sleeping and increased fatigue. She also feels bloated and her joints are stiff. P has noticed that these symptoms are usually gone within a few days of her period starting. The symptoms are so severe that she is unable to work on those days. She hasn’t told her doctor about this because she thinks it must just be PMS.

What is Normal?

Premenstrual syndrome (PMS)

Many women feel different just before their periods, with symptoms of premenstrual syndrome (PMS), which consist of:

• Physical complaints such as problems with sleep, appetite, feeling bloated, breast tenderness, and aches/pains.
• Mood symptoms such as mood swings, crying spells, and irritability.
• Symptoms that happen around the same time every month, coinciding with their period, and which go away when the period starts.
• Although symptoms of PMS can be challenging, they do regularly interfere with a person’s daily life.

About 75% of women who have periods may have symptoms of PMS.

However, when those symptoms are so severe that it causes problems in life, it may be something more severe, known as PMDD.

Do You Get Any of the Following?

Are you female, and have monthly symptoms of PMS? (e.g. bloating, breast tenderness, mood swings).

Are those symptoms with PMS so severe that it gets in the way of your life?

If so, then read on…

What is PMDD?

Premenstrual dysphoric disorder (PMDD) is similar to PMS in that it consists of various symptoms that start in the week before your period and then lessen or disappear in the week after your period.

In PMDD however, symptoms are much more severe than in PMS:

• Mood swings are more severe, with severe sadness or depression.
• Significant irritability or anger
• Significant increase in anxiety or tension
• Physical changes such as
  • Sleep: Changes in sleep pattern (increase or decrease)
  • Appetite: Overeating or food cravings
  • Energy: Decreased energy
  • Weight: Weight gain or feeling bloated
  • Breast tenderness or swelling
  • Joint and or muscle pain

Symptoms of PMDD are so severe that can stop one from doing usual activities at school, home or work.

How Common is PMDD?

PMDD is common -- about 8% of females will experience it during their lifetime.

With adolescents up to 20% of adolescents will experience symptoms suggestive of PMDD but do not have “full-blown” symptoms that meet the full criteria for diagnosis.

It can occur anytime after menstruation begins but is more likely to happen as menopause approaches and then it stops once menopause occurs.

What Causes PMDD?

The exact cause is unknown, but it is believed that changes in hormone levels play a key part. In the week before your period, levels of estrogen and progesterone drop, which affects neurotransmitters in the brain.

Certain things, such as too much salty foods, stimulants (such as caffeine) and alcohol, may make things worse.

People are at a higher risk of having PMDD if they have:

• Experienced stress and trauma in their lives, such as neglect or abuse.
• Family history of PMDD or premenstrual syndrome.

Is it PMDD / PMS or Something Else?

There are other conditions where one might see similar symptoms as with PMDD / PMS such as:

• Physical
  • Perimenopause, i.e. the time that starts several years before menopause; during this time, your ovaries start making less estrogen.
  • Chronic fatigue
  • Thyroid disease
  • Irritable bowel disease
• Mood
  • Depression or anxiety

The key difference is that with PMS, symptoms come and go each month, month after month.

I’m Wondering about PMDD

Are you wondering about PMDD?

• If so, then see your primary care provider (e.g. family physician). 
• Consider gathering more information about your symptoms to make it easier to describe them. There are different ways such as:
  • A printable sheet that you can use to track your symptoms
    https://iapmd.org/symptom-tracker
  • Daily Record of Severity of Problems list
    https://iapmd.org/provider-resources
  • Symptom tracking apps such as
    • The Me V PMDD app.
      https://iapmd.org/symptom-tracker

Dealing with PMDD: Self-Help Strategies for PMDD

Lifestyle strategies

Dietary suggestions

• Try to have less
  • Caffeine,
  • Sugar,
  • Salt
  • Fatty foods

• Try to have more
  • Complex carbs such as whole-grain bread and cereals that are high in fibre (instead of white bread with low fibre).
  • Foods that are high in thiamine (pork, Brazil nuts) and riboflavin (eggs, dairy products) have been shown in a study to reduce one’s risk of developing PMS (Chocano-Bedoya, 2011). Note that simply taking supplements did not have the same effect.

Physical activity

• Regular low-impact exercise. Aim for 30 minutes of moderate physical activity on most days or vigorous activity on fewer days. Do this regularly, not just when you are having mood symptoms.

Soothing routines

• Some people report that having a warm bath can help with PMDD symptoms, including menstrual cramps. Create your own spa experience by adding soothing scents (e.g. lavender) and relaxing music.

Sleep

• Get enough sleep. The average teen (aged 13-18) needs at least 8-10 hrs/sleep while the average adult aged 18-60 needs at least 7-9 hrs/sleep. Put away your devices and get enough sleep.

Over-the-counter (OTC) drugs

• Are you having physical symptoms such as breast tenderness, headaches, back pain or cramps?
• For symptoms associated with PMS, many people report that aspirin, ibuprofen and naproxen may be helpful.

Supplements and natural remedies.

• Although many supplements and natural remedies have been touted as being helpful for PMS / PMDD symptoms, most people do not find they are adequate for actually treating severe symptoms such as PMDD.
• Studies on PMS (not PMDD) have shown the following may be helpful:
  • Calcium (1,000 mg to 1,300 mg). For PMS, studies suggest that calcium may be helpful for symptoms including depression by the 2nd or 3rd treatment cycle (Canning, 2006).
  • Fatty acids (containing gamma-linolenic acid 210 mg, oleic acid 175 mg, linoleic acid 345 mg) in combination with Vitamin E (20 mg), were shown in one study to be helpful (Filho, 2011).

• For most other supplements, studies have either been mixed (some studies positive, others negative) or simply negative for the following:
  • Vitamin B6 (50 mg to 100 mg). For PMS, there is mixed evidence (Thys-Jacobs, 1998; Canning, 2006). One positive study used B6 80 mg daily (Kashanian, 2007).
  • Magnesium: For PMS, there is mixed evidence (Canning, 2006).

Natural remedies

• Evidence is also mixed for natural remedies such as the following (Canning, 2006).
  • Evening primrose oil
  • St. John’s wort

Dealing with stresses. 

• Everyone has stresses, such as with school, work and relationships. These stresses aren't the cause of the PMDD symptoms, but they certainly don't help and can worsen things. 
• Ask yourself
  • What are my top stresses?
  • What would I like to see different with these stresses? 
  • Can anything be done to address or manage those stresses?
  • Who can I ask for more help and support regarding these stresses? 

Dealing with PMDD: Medications

Have you tried strategies such as making changes to your diet and physical activity but are still noticing significant symptoms?

If so, then talk to your doctor about other options such as

• Specific serotonin reuptake inhibitors (SSRIs) may be helpful. SSRIs are a class of medications that can be used to treat depression and anxiety and have also been found to be helpful in PMDD.
• Oral contraceptive pill (OCP), which blocks you from ovulating each month.
  • There is one pill, Yaz (drospirenone and ethinyl estradiol), which is FDA-approved in the USA for the treatment of PMDD.

P.’s Story, Part 2: “I’m so glad I told my friend about this... “

One day, when P. is unable to meet a friend for coffee due to being bedridden with her symptoms, her friend states that it sounds like more than just PMS. Her friend suggests that she see her family doctor.

She goes to see her family doctor, who diagnoses PMDD. Her doctor recommends various strategies which make a slight difference. Ultimately, the doctor recommends starting an SSRI, and she responds to treatment.

A few weeks later, P. is having her period when she realizes that she has been able to have her period without feeling like she has major depression and without having to take time off work. “I’m so glad I told my friend -- and so glad that I spoke to my doctor.”

Looking for More Information?

International Association for Premenstrual Disorders

Information for patients and care providers, online support group and individual peer support with a response within 24 hours

https://iapmd.org/

Me V PMDD app

Provides various features to help cope with PMDD including symptom and treatment tracking and journaling.  “Me V PMDD Symptom Tracker is the app every PMDD warrior needs to take back control over your cycle, your PMDD, yourself.” (from the developer’s website).
https://mevpmdd.com/

National Association for Premenstrual Syndrome (NAPS).

UK based organization that provides awareness about premenstrual syndromes.

https://www.pms.org.uk/

References

Filho E et al.: Essential fatty acids for premenstrual syndrome and their effect on prolactin and total cholesterol levels: a randomized, double-blind, placebo-controlled study. Reproductive Health, 2011; 8 (1): 2 DOI: 10.1186/1742-4755-8-2
https://reproductive-health-journal.biomedcentral.com/articles/10.1186/1742-4755-8-2

Canning S et al.: Dietary supplements and herbal remedies for premenstrual syndrome (PMS): a systematic research review of the evidence for their efficacy. 2006. In: Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK72353/

Chocano-Bedoya P et al.: Dietary B vitamin intake and incident premenstrual syndrome, The American Journal of Clinical Nutrition, Volume 93, Issue 5, May 2011, Pages 1080–1086, https://doi.org/10.3945/ajcn.110.009530

Kashanian M, Mazinani R, Jalalmanesh S. Pyridoxine (vitamin B6) therapy for

premenstrual syndrome. Int J Gynaecol Obstet 2007;96(1):43–4.

Leonard J, 2018. What can I take for PMDD? Accessed May 13, 2021, from

https://www.medicalnewstoday.com/articles/321965#_noHeaderPrefixedContent

Maharaj S and Trevino K. A comprehensive review of treatment options for Premenstrual Symptom and Premenstrual Dysphoric Disorder. Journal of Psychiatric Practice. 21(5): 334-350.

Raphkin AJ. and Mikacich JA. Premenstrual Dysphoric Disorder and Severe Premenstrual Syndrome in Adolescents. Pediatric Drugs. 2013. 15: 191 - 202.

Rapkin AJ. and Lewis EI. Treatment of Premenstrual Dysphoric Disorder. Women’s Health. 2013. 9(6):937-956.

Thys-Jacobs S, Starkey P, Bernstein D, et al. Calcium carbonate and the premenstrual syndrome: effects on premenstrual and menstrual symptoms. Am J Obstet Gynecol 1998;179:444–52.

About this Document

Written by Esther Carefoot, Psychiatry Resident, Class of 2023. Special thanks to Khalid Bazaid (Psychiatrist, Royal Ottawa Mental Health Centre), Jasmine Gandhi (Psychiatrist, Ottawa Hospital). Reviewed by members of the eMentalHealth.ca Team, including Michael Cheng, Psychiatrist.

Disclaimer

This information is offered ‘as is' and is meant only to provide general information that supplements, but does not replace the information from your qualified expert or health provider. Always contact a qualified expert or health professional for further information in your specific situation or circumstance.

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