2 GPs Explain What You Need To Know About PMDD

What is PMDD?

“Premenstrual dysphoric disorder (PMDD) is a severe and often disabling extension of premenstrual syndrome. Both conditions have similar physical and emotional symptoms, but those with PMDD find the severity of their symptoms disrupts daily life and can affect their personal, social and professional lives. In short, the difference is it’s far more severe than PMS.” – Cheryl Lythgoe, GP at Benenden Health

“In terms of diagnosis, it’s all quite new and many of us may not have heard of it. It was only in 2019 that the World Health Organisation added PMDD to the International Classification of Diseases and Related Health Problems. Those suffering from PMDD may feel very angry, argumentative and out of control. It affects 3.2% of UK females who are of reproductive age, with an estimated 824,000 women struggling with this debilitating condition. Much more needs to be done to help. It’s a shocking fact that studies on erectile dysfunction outnumber studies on PMDD by a factor of five to one. This is despite the fact that 75% of women experience premenstrual symptoms, but only 19% of men suffer from ED.” – Dr Deborah Lee,  Fox Online Pharmacy

What are the defining symptoms?

“As with PMS, PMDD symptoms can start seven to ten days before your period starts, in your luteal phase (between ovulation and when your period starts). These symptoms often continue for the first few days of your cycle. It’s common for sufferers to experience irritability, anxiety, depression and feelings of hopelessness. On top of this, they may be hostile, affecting relationships and causing conflict. Those with PMDD also tend to suffer with concentration, memory problems, sleep difficulties, reduced libido and feelings of paranoia. It’s not unusual for them to have severe fatigue too, alongside palpitations and fainting. Mood disturbances are often so severe that they interfere with home, school or work life, resulting in reduced efficiency and productivity. You don’t need to have all these symptoms to be diagnosed.” – Deborah 

Given its similarity to PMS, how can you ensure correct diagnosis? 

“To help diagnose PMDD, you may be asked by your medical professional to keep a detailed symptom journal, in which you record your symptoms in combination with your menstrual cycle for at least two months. Your clinician will also take a detailed medical and lifestyle history, and may undertake a physical examination. Blood tests can also be taken to rule out any other medical problems. Diagnosis is often made from several factors, including having at least five symptoms from a diagnostic criteria list in the final week before the onset of your period. These include, but are not limited to, lethargy, change in appetite, mood swings, marked irritability, joint or muscle pain, and bloating. To help distinguish PMDD from other mood or hormonal disorders, clinicians will look for more prominent evidence of these symptoms in the final week before the onset of your period. Even if you only have a few symptoms, don’t delay seeking advice from your GP.” – Cheryl 

Are there any risk factors worth knowing about?

“The evidence isn’t clear on what causes PMDD, though the theory is that it is linked to serotonin levels. Serotonin is a brain chemical that can support mood regulation. Those who have previously struggled with anxiety or depression, and have lower levels of serotonin, may be more susceptible to PMDD.” – Cheryl 

“Women with PMDD have also been shown to have alterations in the function of the hypothalamo-pituitary axis (HPA) which is the body’s main mechanism for dealing with stress. When subjected to mental stress, PMDD sufferers may produce less cortisol than women without the condition. PMDD sufferers also have higher cortisol levels in the luteal phase of the cycle. Other risk factors include:

• Past traumatic experiences including sexual abuse.
• Cigarette smoking – current smokers have twice the risk of nonsmokers. Even a history of smoking is a risk factor.
• Obesity – the risk rises by 3% for each extra kilo of weight. The risk is significantly increased in those with a BMI of 35 and over.
• Family history – abnormal genes for 5-HT and oestrogen receptors have been identified in studies of twins.” – Deborah 

Let’s move onto treatment options – what’s available?

“Treating PMDD is challenging, and each woman is different. There is no single cure or best remedy. However, there are plenty of treatment options and they can have a positive outcome. Listen to the advice and try each treatment for three to six months at a time. Persevere and don’t give up too quickly:

• Antidepressants: The gold standard treatment for PMDD are selective serotonin reuptake inhibitors (SSRIs) such as citalopram, escitalopram, fluoxetine, paroxetine and sertraline. Good results have been obtained with the noradrenaline reuptake inhibitor venlafaxine. In contrast to taking SSRIs to treat depression, these can be taken as soon as PMDD symptoms are noticed and continued all the time symptoms are present. This means you only need to take them for a few days a month. They also have a very rapid onset of action, often within minutes, and good responses can be obtained even at a low dose. 
• The Combined Pill: Some women may be trialled on a combined contraceptive pill continuously. This means missing out on the seven-day break and taking it daily. It’s not possible to say one specific pill brand is better for PMDD than another, which is why this option may be a process.
• GnRH Agonists: Severe PMDD may necessitate the use of a GnRH inhibitor such as Zoladex, which ‘switches off’ the ovaries. This is usually prescribed for 3 to 6 months. It also works as a trial to see how you would feel without your ovaries and being plunged into menopause. In severe PMDD, removal of the ovaries (oophorectomy) is a possible solution.
• CBT: Another treatment option is cognitive behavioural therapy (CBT). This is a talking therapy, aimed at a better understanding of the condition and to equip sufferers with coping strategies.” – Deborah

Are there any non-medical treatments worth trying? 

“Lifestyle advice is important for PMDD management. For example, limiting your alcohol, increasing your movement and ensuring you have a healthy diet will generally support your body for managing any illnesses. With PMDD, peer support can also help. I recommend Mind, the National Association for Premenstrual Syndrome’s Guidelines  on premenstrual syndrome and Psycom's PMDD. Using mindfulness techniques and talking therapies can also help with the mental toll of having PMDD.

“There is a small amount of evidence to suggest that calcium carbonate and vitamin B6 may help reduce physical and psychological symptoms. While these are not medically recommended, anecdotal evidence suggests they can provide some light relief. Always ensure your clinician or pharmacist knows of any herbal or complementary therapies you are using, as these can affect prescribed medications.” – Cheryl

“As well as the above, I recommend the four, seven, eight breathing technique – this is a simple exercise. You can do it sitting, standing or lying. Breathe in using your diaphragm – this means filling your lungs by sucking your tummy in – while counting slowly to four. Then hold your breath and count slowly to seven. Then breathe out slowly to the count of eight and repeat several times. When you breathe using your diaphragm you activate the parasympathetic nervous system, which is the body’s involuntary pathway for relaxation.” – Deborah

Do you have any advice for monitoring PMDD correctly?

“If you think you might have PMDD, why not take the IAPMD quiz? You might also want to download and print out the Premenstrual Symptom Tracker, or use the Mac-PMSS-app. This lists most of the common PMS/PMDD symptoms and gives you the option to record whether or not and how severely you experienced these on each day of the month. You need to track two or three-monthly cycles and you can then take this to show your GP.

You can use Clue, Ovia Fertility and Cycle Tracker and Natural Cycles  to record your menstrual cycle. You can also keep a record of your thoughts, feelings and emotions, and record any spotting or bleeding. If you find you don’t get anywhere with your GP or things are slow, print off and take the NICE with you to your next appointment, and ask to see a gynaecologist or an endocrinologist with an interest in PMDD.” – Deborah 

Lastly, any long-term advice or further resources worth sharing?

“PMDD sufferers face many obstacles in getting a firm diagnosis, being taken seriously and being offered appropriate treatments. Many healthcare providers do not take the condition seriously enough and patients report being fobbed off or given different reasons for their symptoms. PMDD is a specialist condition that many doctors will not have had experience of managing. The patient needs to see a gynaecologist or an endocrinologist who specialises in the condition, so push for this if you feel you can. The positive to end on is that once you find an appropriate specialist, a lot can be done to improve symptoms and quality of life. It’s important to remember that symptoms stop at menopause. The National Association of Premenstrual Syndrome (NAPS) has a list of PMS/PMDD specialists here and the International Association for Premenstrual Disorders (IAPMD) runs online support groups which are free and available 24/7.” – Deborah

DISCLAIMER: Features published by SheerLuxe are not intended to treat, diagnose, cure or prevent any disease. Always seek the advice of your GP or another qualified healthcare provider for any questions you have regarding a medical condition, and before undertaking any diet, exercise or other health-related programme.