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What Is Premenstrual Dysphoric Disorder (PMDD)?

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Premenstrual dysphoric disorder (PMDD) is a more severe form of premenstrual syndrome (PMS). In addition to physical PMS symptoms, such as fatigue, bloating, and breast soreness, PMDD can cause intense mood changes, anxiety, and depression in the week or two before a menstrual period.

 While most people have some uncomfortable symptoms before their period, PMDD symptoms are intense enough to disrupt daily life.

Like PMS, PMDD happens when hormone levels drop after ovulation, but PMDD symptoms are much more intense. Symptoms should go away within a couple of days after a period starts, but they may reappear monthly. Some people with PMDD need medicine to manage their symptoms.

PMDD symptoms start in the week or two before a period. The condition includes both physical and emotional symptoms that are severe enough to interfere with work, school, social life, and other aspects of daily living.

Physical symptoms include:

  • Swollen or tender breasts
  • Headache
  • Bloating
  • Weight gain
  • Muscle or joint aches
  • Fatigue or low energy
Emotional symptoms include:

  • Depressed or sad mood
  • Irritability and anger
  • Feeling on edge or overwhelmed
  • Anxiety
  • Mood swings
  • Crying without an obvious cause
  • Less interest in friends, school, work, and other activities
  • Difficulty concentrating
  • Changes in appetite, eating more or less than usual
  • Changes in sleep habits, sleeping more or less than usual
  • Thoughts of suicide
Researchers don't know what causes PMDD. They suspect it happens when levels of the hormones estrogen and progesterone plunge before a period. Another possible factor is falling levels of serotonin, a brain chemical that helps regulate mood. Some women are more sensitive to these hormonal and chemical changes than others.

A few factors may increase the risk of PMDD, including:

  • A personal or family history of PMDD, PMS, depression, or postpartum depression
  • Cigarette smoking
  • Obesity
  • Past abuse or other traumatic experiences
  • Anxiety
Doctors diagnose PMDD based on a physical exam and a questionnaire of symptoms. It may be helpful to keep a diary of symptoms to share with your doctor. You must have at least five symptoms, including one mood symptom such as irritability or anxiety, to be diagnosed with PMDD.

The symptoms need to start in the week before menstruation and go away within a few days after a period starts. They must cause enough distress to interfere with daily life.

Treatments for PMDD include antidepressant medicines, hormone therapy, and lifestyle changes.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) help with symptoms like headaches, cramps, sore breasts, and joint pain. These pain relievers include:

  • ibuprofen (Advil, Motrin)
  • naproxen (Aleve)
  • aspirin

Antidepressants

Antidepressants called selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs) treat PMDD by increasing the amount of serotonin available in the brain.

 Women with PMDD can take an antidepressant continuously, or only in the two weeks before a period.

Commonly used SSRIs include:

  • citalopram (Celexa)
  • escitalopram (Lexapro)
  • fluoxetine (Prozac)
  • sertraline (Zoloft)
Venlafaxine (Effexor) is an SNRI prescribed to treat PMDD, and tends to be used if you experience unpleasant side effects with SSRIs.

Hormone Therapy

Hormone therapy using birth control pills may reduce PMDD symptoms. A pill containing the progestin hormone drospirenone and a form of estrogen called ethinyl estradiol is FDA approved for treating PMDD.

Leuprolide (Lupron), a type of medicine called a gonadotropin-releasing hormone (GnRH) agonist, reduces PMDD symptoms by essentially stopping ovulation and menstruation. Because it has a lot of side effects, including hot flashes, vaginal dryness, and bone loss, Lupron is only used when SSRIs and birth control pills haven't helped.

Researchers are studying new medications that might help relieve the symptoms of PMDD. A class of drugs called selective progesterone receptor modulators that's under investigation might be helpful for the emotional symptoms of PMDD. These drugs work by blocking the hormone progesterone.

Light Therapy

Research suggests that exposure to bright light in the morning may improve mood in people with PMDD. Though light therapy is safe to try, additional studies are needed to confirm that it works.

Cognitive-Behavioral Therapy (CBT)

This form of talk therapy focuses on changing a person's perceptions to improve their symptoms. Early evidence suggests that CBT may offer some benefit for PMDD without the side effects of medication, but it warrants further investigation.

Surgery

Surgery to remove the uterus, fallopian tubes, and ovaries (hysterectomy and bilateral salpingo-oophorectomy) is a final option for women who have tried every other treatment but still have debilitating symptoms.

 Surgery relieves PMDD symptoms by stopping ovulation. It will put you into menopause and you won't be able to get pregnant afterward.

Complementary and Integrative Therapies 

Some research suggests that chasteberry (Vitex agnus castus) may improve PMDD symptoms. Dosing recommendations vary, so it may take some trial and error to determine what works for you.

St. John's Wort seems to help with the physical symptoms of PMDD, but it doesn't do much to relieve emotional symptoms like depression, anxiety, and irritability. Also, it can interact with birth control pills and reduce their effectiveness.

The FDA doesn't regulate supplements like it does medicines. Talk to your doctor before you try any complementary therapy, to make sure it's safe for you.

 
Dietary supplements like vitamin B6, calcium, and magnesium have also been studied for treating PMDD. So far, none of these supplements have been confirmed to work.
Following a healthy lifestyle can make you feel better overall. Your doctor might suggest that you:

  • Do aerobic exercises like walking or bike riding for 30 minutes at least five days a week.
  • Eat a well-balanced diet with plenty of fruits, vegetables, and whole grains.
  • Try to get seven to nine hours of sleep a night.
  • Cut back on alcohol, sugar, salt, and caffeine.
  • Don't smoke.

  • Reduce stress with relaxation techniques like deep breathing and meditation.
Everyone has a different experience with PMDD. Some people's symptoms last longer than others. In general, symptoms should improve within a couple of days after your period starts, but they may return the next month. Treatment can make PMDD symptoms more manageable and help you live better with this condition. PMDD may not be preventable because it's related to changing hormone levels.

PMDD symptoms can be severe enough to interfere with work, school, and other aspects of daily life. Women with PMDD are more likely to miss work, be less productive when they are at work, have problems in their romantic relationships, and have difficulty parenting their children.

 Some women have thoughts of self-harm or suicide, which requires immediate medical attention.

Between 70 percent and 90 percent of people who get a period have some premenstrual symptoms. Out of those, an estimated 3 to 8 percent have PMDD.

 A study published 2024 that only included people with a confirmed PMDD diagnosis found that the actual number was much lower — about 1.6 percent of menstruating women worldwide.

With PMDD, the usual disparities are reversed. Black women have the advantage of being much less likely to be diagnosed with this condition than white women. An older study found that around 2.9 percent of Black women have PMDD, compared with 4.4 percent of white women. Researchers aren't sure why this is the case.

 There haven’t been any newer published studies further investigating this disparity.
PMDD can overlap with these conditions:

  • Anxiety disorders: Feelings of intense fear or anxiety triggered by things that are not usually dangerous.
  • Somatoform disorders: Mental disorders that cause physical symptoms like pain, stomachache, shaking, or numbness.
  • Major depressive disorder: A down mood that lasts for at least two weeks and affects daily life. About half of people with PMDD also have depression.

  • Bipolar disorder: A condition that causes emotional highs and lows.
  • Thyroid disease: An overactive (hyperthyroidism) or underactive (hypothyroidism) thyroid gland.

The International Association for Premenstrual Disorders (IAPMD)

The IAPMD offers six Facebook support groups for people with PMDD, their partners, parents, and friends. These groups are available to people all over the world, and they offer a safe space for people to share experiences and learn from each other.

  • Premenstrual dysphoric disorder (PMDD) is a collection of symptoms like irritability, anger, breast tenderness, and difficulty sleeping that starts about a week before a menstrual period and can be severe enough to disrupt daily life.
  • Doctors diagnose PMDD based on a physical exam and symptoms.
  • PMDD should improve on its own within a couple of days after a period starts, but treatments like antidepressants and birth control pills can make symptoms less severe.

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