PMDD: Symptoms, Diagnosis and Treatment

The short answer: PMDD, or premenstrual dysphoric disorder, is a severe, recognised condition in which mood symptoms such as anger, anxiety, depression or hopelessness build in the one to two weeks before a period and ease within a few days of it starting. It is thought to come from extra sensitivity to normal hormone changes. Doctors diagnose it from a daily symptom chart kept over at least two cycles. Antidepressants, certain contraceptive pills, CBT and lifestyle changes can help. If you have suicidal thoughts, get help now.

What PMDD is

PMDD stands for premenstrual dysphoric disorder. "Dysphoric" means a state of deep unease or distress. It is a cyclical condition: symptoms arrive in the second half of the menstrual cycle, after ovulation, and lift soon after the period begins.

It is not ordinary moodiness and it is not a weakness of character. PMDD is listed in the DSM-5, the main manual psychiatrists use to diagnose mental health conditions, where Cleveland Clinic notes it is classified as a depressive disorder. The World Health Organization's ICD-11, the international list of diseases, also includes it: its main place is in the chapter on the genitourinary system, and it is cross-listed with depressive disorders because mood symptoms are so prominent.

Cleveland Clinic estimates that PMDD affects up to 10% of people who have periods. The NHS describes it as affecting a small number of women. Either way, if you have it, you are far from alone, and treatment helps most people.

PMDD vs PMS: the key differences

PMS and PMDD share the same timing, and both can bring bloating, headaches and sore breasts. If you want the full picture of ordinary PMS, read PMS: Symptoms, Causes and What Actually Helps. For the emotional side of PMS, see PMS Mood Swings, Anxiety and Low Mood. The main difference with PMDD is severity, especially of mood symptoms.

PMDD symptoms

Symptoms vary, but they fall into three groups. Cleveland Clinic and the NHS list the following.

Mood symptoms

• Anger or irritability that feels out of proportion
• Feeling on edge, tense or overwhelmed
• Anxiety and panic attacks
• Depression, hopelessness and, for some, suicidal thoughts
• Sudden mood swings, such as crying one moment and furious the next

Thinking and energy

• Difficulty concentrating
• Tiredness and low energy
• Sleep problems, either sleeping much more or struggling to sleep

Body symptoms

• Food cravings, overeating or appetite changes
• Headaches
• Joint and muscle pain
• Bloating and breast tenderness

Many women with PMDD say the hardest part is feeling like a different person for part of every month. Arguments with a partner or in-laws, quitting a course, or pulling away from friends may all cluster in the same week. When the period comes, the fog lifts, often leaving guilt about what was said or done.

When PMDD symptoms start and stop

PMDD follows the luteal phase, the part of your cycle between ovulation and your next period. Cleveland Clinic says symptoms typically begin 10 to 14 days before a period and ease within a few days after bleeding starts. If you'd like to understand when you ovulate, read Ovulation Explained: Signs, Timing, Pain and Cervix Changes.

The symptom-free stretch after your period is just as important as the bad days. That clear "off" window is what separates PMDD from depression or anxiety that is present all month.

Cleveland Clinic notes that for some people symptoms continue until menopause, and that most people have no symptoms after menopause.

What causes PMDD

The exact cause isn't known. It seems to involve a stronger reaction to the normal rise and fall of oestrogen and progesterone after ovulation, rather than anything wrong with the hormones themselves. The NHS links PMDD to being very sensitive to hormone changes, or to certain genes inherited from parents.

Serotonin, a brain chemical that affects mood, hunger and sleep, is thought to play a part, and its levels also shift across the cycle. This is one reason antidepressants that act on serotonin can help.

Cleveland Clinic lists these risk factors:

• A personal history of anxiety or depression
• A family history of PMS, PMDD or mood disorders
• A history of trauma, abuse or very stressful events

None of these means PMDD is your fault. It is a medical condition, like migraine, that has triggers and treatments.

How PMDD is diagnosed

There is no blood test or scan for PMDD. Diagnosis is based on your history and, most importantly, a daily symptom chart.

The daily chart

The NHS and Mayo Clinic both advise tracking symptoms for at least two menstrual cycles. Each day, note your cycle day (day 1 is the first day of bleeding) and score your main symptoms. A simple scale works: 0 for none, 1 mild, 2 moderate, 3 severe. Add a note on how they affected your day. Our guide on how to calculate your next period date shows how to count cycle days.

Doing this from memory doesn't work well, because the bad weeks can feel endless and the good weeks get forgotten. A notebook by your bed or a notes app with a daily reminder is enough.

What the doctor looks for

Cleveland Clinic says a provider looks for five or more PMDD symptoms, including at least one mood symptom, that are clearly present before periods and ease afterwards. The ICD-11 adds that symptoms should have occurred in most cycles over the past year and be severe enough to cause real distress or affect daily life.

Your doctor will also ask about your mental health across the whole month, your periods, any medicines and your family history. Mayo Clinic notes that conditions that can look like PMS, such as thyroid disorders, depression and anxiety, may be checked with blood tests or mood screening.

PMDD or premenstrual worsening of another condition?

Some people have depression, anxiety or another condition that gets worse before a period but is present at other times too. This is called premenstrual exacerbation. It matters because the treatment plan is different. The ICD-11 makes this distinction: PMDD symptoms should not simply be a flare-up of another mental health condition. Your chart is what helps tell them apart.

Treatment options for PMDD

Treatment depends on your symptoms, age, whether you want to get pregnant, and what you prefer. Many women need a combination. Your doctor may suggest:

Antidepressants

Mayo Clinic describes SSRIs, a type of antidepressant, as a first-line treatment for severe PMS or PMDD. They are usually taken daily, though Mayo Clinic notes some people take them only in the two weeks before a period. Your doctor will decide which approach suits you. Don't stop an antidepressant suddenly without talking to your doctor first.

Hormonal treatment

The combined contraceptive pill stops ovulation, which may ease symptoms. Cleveland Clinic notes that pills containing a particular combination of hormones are used for PMDD. A few women find their mood worse on a new pill, so tell your doctor if that happens rather than just stopping it.

Cognitive behavioural therapy

The NHS lists CBT as a treatment for PMS and PMDD. CBT is a structured talking therapy that helps you notice and change unhelpful thinking and behaviour patterns. For PMDD, it often includes making a plan for the hard days and learning to manage anger and anxiety.

Lifestyle changes

Regular exercise, less caffeine and alcohol, steady meals and stress management help many people, though they may not be enough on their own when symptoms are severe. Cleveland Clinic suggests that vitamin B6 and magnesium may help, but the NHS notes the evidence for supplements is limited, so check with a doctor first.

Pain relief and referral

Painkillers such as paracetamol or ibuprofen can help with headaches, cramps and breast pain; check the packet or ask a pharmacist. If symptoms continue despite treatment, the NHS says you may be referred to a gynaecologist, psychiatrist or counsellor for specialist care.

Living with PMDD day to day

Treatment takes time to work, and a plan for the hard days makes a real difference.

• Mark the window: once you know your pattern, mark the likely difficult days on your calendar. Avoid scheduling big decisions, difficult conversations or family events then, where you can.
• Tell one or two people: a partner, sister or close friend who understands can step in, take over chores or simply check on you.
• Write a "future me" note: on a good day, write a few lines reminding yourself that this feeling is temporary and listing what helps.
• Protect sleep: keep regular bed and wake times, and cut chai and coffee after lunch.
• Reduce small stresses: on the days before your period, a period panty can be worn from the day you expect bleeding, so you're covered if it starts early. It has one absorbency for every flow and lasts up to 8 hours depending on flow, which takes one worry off a heavy week.

At work or college, you don't have to disclose PMDD. If it affects your performance, a doctor's letter can support a request for flexibility on the worst days.

PMDD and suicidal thoughts: getting help now

Cleveland Clinic notes that some people with PMDD become suicidal, and the NHS lists feeling suicidal as a PMDD symptom. These thoughts can arrive suddenly and feel very convincing, even if you were fine a week ago. They are a symptom of the condition, and they can be treated.

If you have thoughts of ending your life or harming yourself:

• Call Tele-MANAS, the government's free mental health helpline, on 14416
• If you are in immediate danger, call 112 or 108, or go to the nearest hospital emergency department; don't drive yourself, and ask someone to go with you
• Tell someone you trust right now, even with a single message
• Remove anything you might use to hurt yourself, or ask someone to hold onto it

If you know your risky days come before your period, make a safety plan in advance with your doctor or a trusted person. Write down the helpline numbers and who you will call.

See a doctor if

• Your premenstrual mood symptoms are affecting your work, studies or relationships
• Your daily chart shows severe symptoms that lift after your period, month after month
• Self-help hasn't helped after two or three cycles
• You have low mood or anxiety most of the month, which gets worse before your period
• You have very painful or heavy periods as well; see Dysmenorrhoea vs Menorrhagia

In India, you can start with a family doctor, gynaecologist or psychiatrist. Say clearly, "I think I might have PMDD," and bring your chart.

Frequently asked questions

Is PMDD a mental illness? It is listed as a depressive disorder in the DSM-5, and the ICD-11 lists it under conditions of the genitourinary system as well as depressive disorders. It involves both hormones and the brain. Either way, it is real and treatable.

Can PMDD be cured? There is no one-off cure, but most people get good relief with treatment. Symptoms usually stop after menopause.

Can a blood test diagnose PMDD? No. Diagnosis rests on a daily symptom chart over at least two cycles. Blood tests may be used to rule out other causes, such as thyroid problems.

Do I need to take antidepressants all month? Not always. Some people take them daily and some only in the second half of the cycle. Your doctor will advise what suits you.

Can teenagers have PMDD? Symptoms can begin any time after periods start. If a teenager has severe mood changes before her periods, especially any talk of self-harm, see a doctor promptly.

Is PMDD the same as bipolar disorder? No. Cleveland Clinic notes they share some symptoms, but PMDD symptoms follow the menstrual cycle and ease after a period starts.

Related reading

• PMS Mood Swings, Anxiety and Low Mood: Why They Happen and What Helps
• PMS: Symptoms, Causes and What Actually Helps
• The Hormones Behind Your Menstrual Cycle, Phase by Phase
• PCOS and Mental Health: Anxiety, Low Mood and Body Image

This article is for general information and doesn't replace advice from your doctor.

Sources: Cleveland Clinic: Premenstrual Dysphoric Disorder (PMDD), NHS: PMS (premenstrual syndrome), Mayo Clinic: Premenstrual syndrome, diagnosis and treatment, World Psychiatry: Innovations and changes in the ICD-11 classification of mental, behavioural and neurodevelopmental disorders