Living with Premenstrual Dysphoric Disorder: Why Your Cycle May Affect Your Mental Health

For many women, the days leading up to their period come with a mix of uncomfortable symptoms, like extreme irritability, mood swings, fatigue, and trouble concentrating. Oftentimes, these are brushed off as “just premenstrual syndrome (PMS).” However, if those symptoms prove to be debilitating, you could be suffering from premenstrual dysphoric disorder (PMDD).

PMDD is a severe, often misunderstood condition that affects an estimated 10% of women or people assigned female at birth (AFAB). [1] Many women with PMDD go undiagnosed or misdiagnosed for years, and it’s not uncommon for patients to receive treatment for anxiety or depression without addressing the cyclical nature of their symptoms.

This article will demystify PMDD and offer the understanding and validation so many women have long been denied.

What Is PMDD? How Is It Different From PMS?

Every woman would have likely experienced some type of PMS since they started their menstrual period − whether it is cramps, food cravings, fatigue, tender breasts, or mood swings. PMDD, though similar to PMS, is a more intense and disruptive condition.

Denise, who was diagnosed with PMDD at the age of 22, describes it as, “I feel like I only get one week each month where I feel like myself, the rest of the time, it’s a constant battle just to get through the days.” Women with PMDD experience severe emotional and physical symptoms that can interfere with work, school, relationships, and daily functioning. In the worst-case scenario, PMDD can sometimes trigger suicidal thoughts. (Image 1)

Causes of PMDD

PMDD is classified as a psychiatric disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). However, its root cause is biological, and not psychological. 

The luteal phase is the period between ovulation (peaking at day 14) and menstruation (usually arrive around day 28-35), when the levels of progesterone and estrogen in your body start to rise. Researchers believe that the brain of a woman with PMDD is especially sensitive to these hormonal fluctuations, especially to a hormone by-product called allopregnanolone, which normally has calming effects in the brain. In PMDD, the biological cause is abnormal sensitivity to luteinizing hormone (LH) levels and the sharp premenstrual drop, which can cause the signal to flip and bring on dysphoria instead of a calming effect. In PMDD, improper functioning of this chemical disrupts brain signaling and triggers intense mood symptoms like irritability, anxiety, and depression. The following image illustrates the hormonal fluctuations during a typical menstrual cycle: [2]

A few studies have also found women with PMDD to have lower serotonin (a neurotransmitter that regulates mood, sleep, and appetite) activity, especially during the luteal phase (day 14-28 in your cycle) when symptoms typically appear. [2]

Hormonal Sensitivity Is Behind PMDD

PMDD isn’t caused by abnormally high or low hormone levels, but rather it is the brain’s abnormal sensitivity to the menstrual cycle’s hormonal shifts that are interacting with the serotonin pathways in the brain which are associated with calmness. This is why some patients feel better when they are prescribed SSRI drugs (Selective Serotonin Reuptake Inhibitors, a class of antidepressants) during the symptomatic window, which is the luteal phase – i.e., taken only during the last week preceding the start of menstruation, and not daily dosing.

How PMDD Really Affects Life

The patient’s burden of living with PMDD often persists throughout their cycle (and is likely underestimated). Large population data link premenstrual disorders to lower quality of life and more health problems. Routine health assessments are most likely not capturing the full impact of PMDD with the female patient. [3]

Individuals at Risk of Developing PMDD

PMDD can affect any person assigned female at birth, including transgender and nonbinary individuals. However, some research suggests that white Caucasian women have a higher prevalence of PMDD than other racial groups. [4] Data on Asian women vary by setting: a Japanese community sample reported PMDD prevalence of 1.2% among adult women [14], and among visible minority women in the U.S.A., greater exposure to American culture was associated with a higher likelihood of PMDD. Other risk factors include:

• Family history of either PMS or PMDD

• Personal or family history of mood disorders like depression, anxiety, bipolar disorder, or postpartum depression

• History of trauma, adverse childhood experiences, or other stressful life events

• Cigarette smoking

Symptoms of PMDD

The symptoms of PMDD can vary from person to person. Some report feeling very sensitive to everything around them, while others experience severe depression or panic attacks. Symptoms usually begin after ovulation (around day 14), worsen in the days leading up to menstruation, and end within a few days after your period starts. 

Psychological Symptoms

• Depressed mood

• Feelings of hopelessness or worthlessness

• Increased anxiety, stress, or panic attacks

• Severe mood swings

• Emotional sensitivity

• Suicidal thoughts

• Poor self-image

• Increased sensitivity to rejection

• Increased irritability or anger that affects relationships

• Sudden sadness or tearfulness

• Loss of interest in usual activities

• Trouble concentrating or brain fog

• Feeling out of control or being emotionally overwhelmed

Physical Symptoms

• Breast tenderness or swelling

• Headaches/ migraines

• Weight gain

• Digestive issues (nausea, constipation, bloating, or diarrhea)

• Changes in appetite (binge eating, overeating, or cravings)

• Sleep disturbances (trouble sleeping or excessive sleeping)

• Fatigue, lethargy, or lack of energy

• Joint or muscle aches

• Skin inflammation and itching

• Heart palpitations

• Hot flashes

• Backache

• Cramps

• Acne

Diagnosis of PMDD

Unlike many other health conditions, PMDD can’t be diagnosed with a blood test, imaging scan, or a single doctor’s visit. Diagnosis is based on a pattern of symptoms and how much they interfere with your life.

Obstetricians-Gynecologists (OB-GYNs) are often the first point of care. They specifically help rule out conditions such as endometriosis, PCOS, fibroids, menopause, and hormone problems.

Since PMDD is associated with mental health symptoms, you will also be referred to a psychiatrist to get evaluated for mental health concerns and to ensure mood disorders aren’t responsible for your symptoms. It is best to consult reproductive psychiatrists who have expertise in mood disorders linked to the reproductive sex hormones. (You can connect with one at the International Society of Reproductive Psychiatry.)

A reproductive psychiatrist will use the criteria listed in the standard diagnostic tables (see tables 1 and 2) to diagnose PMDD and differentiate it from PMS.

A woman must experience the following to be diagnosed with PMDD:

• At least 5 of the symptoms listed in Table 2, including at least one mood-related symptom, during most cycles over the course of a year.

• Symptoms begin 7-10 days before menstruation and resolve a few days after you start bleeding.

• Symptoms cause significant distress or hinder your ability to function normally in social, work, or other situations.

• Symptoms aren’t better explained by other physical or mental health conditions or by the side effects from medications.

Since the symptoms are cyclical, your healthcare provider might ask you to keep a daily symptom journal for several months to confirm the pattern and make a proper diagnosis.

To track these PMDD symptoms, many women use a PMDD tracker—a simple daily log or table that records mood, physical symptoms, cycle dates, and day-to-day impact. Consistent tracking over several cycles helps identify the cyclical pattern of symptoms, distinguish PMDD from PMS or other conditions, and inform treatment decisions. It also lets users and clinicians see triggers, monitor what helps (medications, lifestyle changes), and review progress with clear summaries that can be shared at appointments. An example of a PMDD tracker sheet is below. 

How PMDD Is Treated

PMDD is a chronic condition that is treatable. However because every person’s experience with PMDD is different, treatment is highly personalized based on symptoms, severity, overall health, response to previous therapies, and personal preference.

Lifestyle And Behavioral Changes

• Healthy Diet – A diet rich in lean protein (poultry and fish) and complex carbohydrates (legumes, whole grains, and quinoa) helps regulate blood glucose levels and increase tryptophan availability, leading to increased serotonin production. [5]

• Regular Exercise – At least 30 minutes of daily physical activity, especially aerobic exercises like brisk walking, running, swimming, or cycling, increases serotonin and beta-endorphin levels, which may ease PMDD symptoms. [6]

• Stress Management – Stress can worsen the symptoms of PMDD in some people by keeping them stuck in negative thought loops. [7] Yoga, controlled breathing, and meditation may help, but their efficacy hasn’t been widely studied.

• Limit alcohol, caffeine, and added sugar since these can worsen symptoms and increase mood swings.

Supplements

• Calcium – For some people, up to 1,200 mg/ day of calcium supplements has been found to reduce symptoms like depression, fatigue, and appetite changes. [8]

• Vitamin B6 – Up to 80 mg/day may help with mood-related symptoms. [9}

• Magnesium – May reduce bloating, breast tenderness, and mood symptoms. [9]

• L-tryptophan – A precursor to serotonin, it can help improve mood. [10]

• Chasteberry (Vitex agnus-castus) – A few studies have shown chasteberry to be moderately effective due to its ability to bind to dopamine D2 receptors in the brain and inhibit prolactin release, a hormone that is thought to contribute to symptoms like breast tenderness and mood changes. [11]

Selective Serotonin Reuptake Inhibitors (SSRIs)

SSRIs are often considered the first-line therapeutic treatment for PMDD. These antidepressants boost serotonin levels and are prescribed to be taken either continuously throughout the month or intermittently during the luteal phase of the menstrual cycle (day 15-28) when the symptoms are present. However, SSRIs may cause side effects such as nausea, fatigue, and sexual dysfunction. [12]

Hormonal Therapies

• Combined Oral Contraceptives – Birth control pills stop ovulation and stabilize the hormonal changes, thereby easing PMDD symptoms. [13] However, some people report that these pills worsen their symptoms, so contraceptive medicines requires close monitoring.

Treatment for Symptom Management

• NSAIDs (Nonsteroidal Anti-Inflammatory Drugs) – OTC pain relievers, like Ibuprofen, aspirin, etc., can relieve symptoms like headache, breast tenderness, backache, and cramps.

• Anti-Inflammatory Medicines – May reduce physical discomfort.

• Diuretics – Help with fluid retention and bloating.

Surgery

In rare, treatment-resistant cases, surgical removal of the ovaries (bilateral oophorectomy) may be considered. This permanently stops ovulation and eliminates hormonal cycling. If both ovaries are removed, hormone replacement therapy (HRT) is necessary to reduce menopausal symptoms.

Living With PMDD

Since PMDD is both invisible and cyclical, many women face stigma in the workplace, at school, or even at home. This can delay diagnosis, lead to feelings of shame, and prevent women from getting the support they need.

Measures like joining a peer support group or being part of a community like Healthyher.Life can help you get answers and the support you need. In addition, keeping track of your cycle, scheduling demanding tasks outside your symptom window, educating partners and family members about PMDD, and keeping a self-care box of things that give you comfort, like a book, can also help.

Managing PMDD isn’t always easy, but with the right treatment plan and support system, many women find relief. If you’ve read this and think you may have the symptoms, make an appointment with your healthcare provider or contact our nurse practitioners.