How to provide better care for patients with PMDD

“I will always remember the day I was officially diagnosed with premenstrual dysphoric disorder (PMDD). Shaking on the examination bed, I spilled out my darkest moments to my physician, describing symptoms I had been brushing away as “normal” for about two years.

These symptoms had long ago began interfering with my daily life, ranging from debilitating cramps, brain fog, irritation, lack of motivation and negative thoughts that clouded my mind for about two weeks every month. As a result, my academic and social life had taken a hit. I found myself struggling in my courses, calling in sick to work, avoiding my family and peers and spiraling for about two weeks before every period.

Discussing these symptoms with my physician was an extremely vulnerable but comfortable experience; I felt like I could finally breathe. A simple “I hear you” was exactly what I needed, as nothing compares to having your pain and emotions validated by a certified health professional.”

—Female, 21

What is PMDD?

On average, the menstrual cycle is 28 days long. The cycle is broken up into four phases: follicular, ovulating, luteal and menstrual. Each of these phases plays a role in maintaining reproductive health, but you may not be aware of the severity of symptoms that can occur in the luteal phase for about one in 20 people with uteruses and AFABs (assigned female at birth).

We’ve all heard the term “PMS” used (and misused) before. Premenstrual syndrome (PMS) refers to a combination of physical and behavioral changes that may occur before monthly menstrual cycles. PMDD is a lesser known but more severe form of PMS, defined as a gynecological-mental health diagnosis characterized by the brain’s reaction to the hormonal changes of progesterone and estrogen that occur in the luteal phase. This means that for most individuals affected by PMDD, severe mood changes occur for up to two weeks before the onset of their flow, and just like magic, symptoms end at the beginning of the menstrual phase.

PMS vs. PMDD

The difference between PMS and PMDD is that with the latter, symptoms are severe enough to interfere with daily function and quality of life. Therefore, PMDD is a serious and chronic condition that requires treatment. April is PMDD Awareness Month, and my hope is that you learn something new and see how you can contribute to PMDD awareness as a medical student, clinician, family member and friend.

One way to explain PMDD is that it is like PMS on steroids, causing cyclical mood changes and a feeling that you’re not yourself for one to two weeks, followed by a couple weeks of feeling normal before you start the cycle all over again. Imagine experiencing cramps, bloating, acne plus increased feelings of irritability, possible suicidal ideation, trouble sleeping and more. Understandably, it is a debilitating condition that many of our patients unknowingly battle. It is listed as a diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) with the following criteria:

• In the majority of menstrual cycles, at least five symptoms must be present in the final week before the onset of menses, start to improve within a few days after the onset of menses and become minimal or absent in the week post menses.
• One or more of the following symptoms must be present:
  • Marked affective lability (e.g., mood swings, feeling suddenly sad or tearful, increased sensitivity to rejection).
  • Marked irritability or anger or increased interpersonal conflicts.
  • Markedly depressed mood, feelings of hopelessness, or self-deprecating thoughts.
  • Marked anxiety, tension and/or feelings of being keyed up or on edge.
• One (or more) of the following symptoms must additionally be present to reach a total of five symptoms when combined with symptoms from Criterion B above
  • Decreased interest in usual activities.
  • Subjective difficulty in concentration.
  • Lethargy, easy fatiguability or marked lack of energy.
  • Marked change in appetite; overeating or specific food cravings.
  • Hypersomnia or insomnia.
  • A sense of being overwhelmed or out of control.
  • Physical symptoms such as breast tenderness or swelling; joint or muscle pain, a sensation of “bloating” or weight gain.
• The symptoms are associated with clinically significant distress or interference with work, school, usual social activities or relationships with others.
• The disturbance is not merely an exacerbation of the symptoms of another disorder, such as major depressive disorder, panic disorder, persistent depressive disorder (dysthymia) or a personality disorder (although it may co-occur with any of these disorders).
• Criterion A should be confirmed by prospective daily ratings during at least two symptomatic cycles (although a provisional diagnosis may be made prior to this confirmation).
• The symptoms are not attributable to the physiological effects of a substance (e.g., drug abuse, medication or other treatment) or another medical condition (e.g., hyperthyroidism).

Diagnosis and support

One of the best ways to confirm a diagnosis of PMDD is by having the patient diligently track their symptoms for at least two consecutive menstrual cycles. This can be difficult, due to the fact that these changes interfere with mood, interest and daily activities, but is crucial for the diagnosis.

As a physician, especially in the osteopathic field, you can also encourage patients to take the time to pay attention to their mind-body connection and allow them to feel reassured that there may be an underlying, biological explanation for their symptoms. Menstruating individuals often brush off their symptoms as “normal” because they may believe they are simply part of an unlucky few who experience mood changes.

Oftentimes, it is even discouraged to talk about mental health symptoms, let alone menstrual symptoms, as both these topics are considered to be “taboo.” A recent survey showed that patients, on average, wait for 12 years before obtaining a diagnosis of PMDD. This is why PMDD awareness is crucial. As physicians, we must create an environment where our patients can be completely open with us so that, in turn, we can ensure accurate diagnosis and support.

Treatment

The treatment options for PMDD range from conservative management to medications, all of which focus on increasing serotonin, a neurotransmitter involved in mood and behavior regulation. Before medication, it’s best to explore lifestyle changes such as self-care and stress management, including physical exercise, and calming activities such as yoga and meditation. Increased protein intake is also advised, as protein consumption further increases tryptophan, a precursor to serotonin.

In addition to these conservative methods, selective serotonin reuptake inhibitors (SSRIs) can greatly benefit patients. Sertraline is one of the first-line agents used either strictly during the luteal phase or daily. Other forms of treatment may include vitamin supplementation, anti-inflammatory medicines and oral contraceptives. As osteopathic medical students and physicians, our philosophy of embracing the mind-body connection can really come into play when approaching PMDD treatment.

Moving forward

With proper education and awareness, a PMDD diagnosis should no longer go under the radar. I encourage you to add PMDD to your list of differentials as an underlying cause of depression for patients of reproductive age. Until an astute physician takes the initiative to say something and dig a little deeper, a patient may not even realize that their thoughts are connected to their menstrual cycle.

Additionally, PMDD awareness can be key to normalizing “period talk” and validating our patients’ experiences. Moving forward, let us be cognizant of how we speak about menstruating individuals and their behavior. Just like any other mental health condition, there is often more than meets the eye. Yes, we may have chocolate cravings, be a little snappy, fatigued and joke that we are “just” PMS-ing. But the truth is, patients with PMDD may be facing difficult thoughts and symptoms that need to be addressed.

This article is a reflection of a medical student’s personal research and thoughts. Always seek out a health care professional if you are in need of medical advice.

Care resources

If you or someone you know is experiencing suicidal thoughts or a crisis, please reach out immediately to the Suicide Prevention Lifeline at 800-273-8255 or text HOME to the Crisis Text Line at 741741. These services are free and confidential.

• IAPMD
• Vicious Cycle PMDD
• Patient education: Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) (Beyond the Basics)

Related reading:

Raising awareness of depressed physicians in honor of Suicide Prevention Awareness Month

The DO Book Club, Feb. 2022: It’s All in the Delivery and Motherhood, Medicine & Me