When PMS Is Really Premenstrual Dysphoric Disorder And What To Do About It
We are all familiar will Premenstrual Syndrome (PMS) - what it is, when it arrives, and how it impacts our lives as women on a monthly basis. Furthermore, many of us have probably learned overtime, ways to mitigate or at minimum, deal with this time of the month to ensure that it doesn’t completely derail us. Premenstrual Dysphoric Disorder (PMDD) on the other hand, is a diagnosis you may be less familiar with- though may be experiencing, if symptoms of PMS seem to greatly interfere with your quality of life.
What is PMDD?
Premenstrual Dysphoric Disorder is a severe mood disorder characterized by many cognitive – affective symptoms that occur in a cyclical pattern on a monthly basis before menstruation.
How is PMDD Different from PMS?
While premenstrual symptoms also include a combination of mood, behavioral, and physical alterations prior to menstruation, most females report only mild discomfort that does not impede their lives. 5%-8% of women conversely experience debilitating symptoms that cause significant psychological stress and functional impairment. [1]
How do you know if your monthly suffering is more than PMS? Well, it depends upon the type of symptoms, the severity, and of course, the timing.
Symptoms of PMDD include:
Extreme mood swings
Irritability or anger
Depression, anxiety, feelings of overwhelm
Emotional sensitivity, uncontrollable crying
Difficulty concentrating, brain fog, forgetfulness
Nervousness, paranoia, heart palpitations
Feelings of hopelessness, self-deprecating and suicidal thoughts
Physical symptoms such as fatigue, appetite change, breast tenderness, and headaches
Severity:
If you experience some of these symptoms- how debilitating are they? Women with PMDD find that their symptoms are associated with significant distress, interference with work, school, usual social activities, and their relationships with others.
Timing:
Because many of these symptoms may also be signs of other psychiatric disorders, it is important to recognize the timing of your symptoms in relevance to your menstrual cycle. Symptoms of PMDD can begin to show after ovulation (day 14 of your cycle) but are generally the most prominent in the final week before your period, with symptoms disappearing in the week post menstruation.
What Causes PMDD?
While PMDD may sound like simply a heightened form of premenstrual syndrome, there is physiologically much more at play.
Several studies have essentially concluded that women who are vulnerable to and experience PMDD do not generally have abnormal levels or any other type of hormonal dysregulation. It is actually a sensitivity to normal cyclical hormonal changes that causes symptoms. This is why PMDD is often categorized as a mental health, depressive disorder and treated with antidepressants such as SSRI’s.
So why are some women more sensitive to hormonal shifts?
What we know about PMDD is that there are likely many factors at play such as:
Neurotransmitter deficiencies and imbalances: Women with PMDD exhibit a decreased sensitivity to GABA receptors [2] (due to lower levels of allopregnanolone) and experience serotonin abnormalities in the luteal (premenstrual) phase of their cycles. It is additionally observed that their symptoms are aggravated during tryptophan depletion.
Genetic Susceptibility: Studies on twins have shown that there are both inheritable traits and genetic polymorphisms that make someone more susceptible to experiencing PMDD. [2] This includes genetic variations that potentially account for neurotransmitter sensitivity to hormone fluctuations.
HPA Axis and inflammation: Though still being researched, there is some evidence that women with PMDD have higher levels of chronic stress, trauma, inflammatory cytokines, and a potentially altered HPA axis with irregular cortisol levels.
What does PMDD have to do with my Fertility?
If you believe you may have PMDD, have already been diagnosed or being treated for, and are planning on conceiving soon, you should be aware that conventional treatments for PMDD may interfere with your ability to become pregnant and may leave you more susceptible to mood disorders during and after pregnancy.
The traditional approach in treating PMDD includes SSRIs (Serotonin Reuptake Inhibitors), psychotropic agents like BZDs (Benzodiazepines) and other hormonal therapies (like birth control) that interfere with the menstrual cycle and aim to suppress ovulation.
As SSRI’s have been shown to significantly reduce the odds of conception, [3] many women choose to risk the side effects of coming off of their medication for the sake of getting pregnant. Not only will such a decision likely effect your quality of life and make your fertility journey more challenging, but it may additionally increase your chances of developing mood disorders while pregnant and postpartum.
As mentioned above, women with PMDD have exhibited lower levels of allopregnanolone in the luteal phase of their menstrual cycle. Unfortunately, low levels of this progesterone metabolite has been frequently associated with mood disorders (like depression and anxiety) during pregnancy, [4] and has recently been determined as a precursor for developing postpartum depression. [5] If you are looking for an alternative way to treat PMDD in pursuit of conception, you may want to consider some of the options mentioned below.
How To Approach Natural Healing
1. Track your symptoms:
If you haven’t already been diagnosed with PMDD but suspect this may be effecting you, start tracking your symptoms. Because PMDD affects women in a very specific stage of their cycles each month, it is necessary to keep a very accurate record of the symptoms you experience in relevance to your cycle. There are no tests for PMDD, so it is important to ensure that the timing of what you are experiencing matches with the post ovulation pattern mentioned above.
You can track you cycle, any symptoms you encounter, and the severity of these symptoms in a period tracker app (there are many). There is even an app specifically designed for women with PMDD called Me vs. PMDD.
2. Talk with your physician about 5-HTP and Gaba:
5-HTP is a chemical precursor to serotonin (produced from the amino acid tryptophan) known for its effective treatment in serotonin mediated depressive symptoms. While there just one study that has looked at 5-HTP as a mechanism and treatment for PMDD, [5] and we certainly need more, the easily accessible supplement may serve as an alternative to SSRI’s.
Women with PMDD may additionally benefit from supplementing with GABA to enhance the sensitivity of their Gaba receptors-especially in the late luteal phase of their cycle when progesterone levels dip and anxiety is more commonly experienced.
While only you with the help of your physician can decide what line of therapy is right for you, these alternative treatments may be worth exploring.
3. Make sure your mental health is in check before trying to conceive:
If you are on medication, attempting to tamper off of one, or trying any of the alternative therapies mentioned in this article to improve your symptoms, give yourself time to achieve mental stability before pregnancy. While I know there is sometimes a sense of urgency when trying to conceive, the fertility journey can be very challenging. Giving yourself this space now will save you more time in the future by decreasing the need for mental recovery down the road with a newborn on your hands.
4. Check your diet:
Diet plays an important role in managing PMDD through both reducing inflammation and increasing the availability of tryptophan, a precursor of serotonin and other neurotransmitters.
The Essentials:
A whole foods diet rich in complex carbohydrates and adequate protein that increases both tryptophan availability and serotonin levels.
Consumption of vitamin B rich foods- especially Vitamin B6 as it plays an important role in serotonin synthesis. These foods include lean meat, fish, pistachios, sunflower seeds, beans, and avocados.
Ensuring adequate levels or supplementing with calcium, vitamin D, and magnesium have all been shown to reduce the severity of both PMS and PMDD. [6,7]
The inclusion of Omega-3 fatty acids (lots of seafood) to reduce the overall inflammation associated with premenstrual disorders, and to support neurotransmission.
A reduction of sugar, sodium, and caffeine.
5. Reduce Stress and get a good nights’ sleep
Stress management techniques like meditation, yoga and breath work have all been suggested for managing PMDD and reducing inflammation along with diet.
Because PMDD often overlaps with SAD (seasonal affective disorder) due to a genetic susceptibility, women with PMDD have improvements in their mood when they are contentious about their sleep/wake cycles and work towards realigning their natural circadian rhythms [8]- which improves sleep!
While therapies targeted towards PMDD should be discussed with your healthcare provider, we hope to have provided you with some resources on where to start. If you are currently dealing with symptoms of PMDD and have tried any of these therapies, we want to hear from you! Please let us know where you are in your journey and how everything is going.
References:
1. Mishra S, Marwaha R. Premenstrual Dysphoric Disorder. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2018. http://www.ncbi.nlm.nih.gov/books/NBK532307/.
2. The Etiology of Premenstrual Dysphoric Disorder: 5 interwoven pieces. - MGH Center for Women’s Mental Health. https://womensmentalhealth.org/specialty-clinics/pms-and-pmdd/the-etiology-of-pmdd/.
3. Casilla-Lennon MM, Meltzer-Brody S, Steiner AZ. The effect of antidepressants on fertility. Am J Obstet Gynecol. 2016;215(3):314.e1-314.e5. doi:10.1016/j.ajog.2016.01.170
4. Hellgren C, Åkerud H, Skalkidou A, Bäckström T, Sundström-Poromaa I. Low Serum Allopregnanolone Is Associated with Symptoms of Depression in Late Pregnancy. Neuropsychobiology. 2014;69(3):147-153. doi:10.1159/000358838
5. Eriksson O, Wall A, Olsson U, et al. Women with Premenstrual Dysphoria Lack the Seemingly Normal Premenstrual Right-Sided Relative Dominance of 5-HTP-Derived Serotonergic Activity in the Dorsolateral Prefrontal Cortices - A Possible Cause of Disabling Mood Symptoms. PLoS ONE. 2016;11(9). doi:10.1371/journal.pone.0159538
6. Thys-Jacobs S, McMahon D, Bilezikian JP. Cyclical Changes in Calcium Metabolism across the Menstrual Cycle in Women with Premenstrual Dysphoric Disorder. J Clin Endocrinol Metab. 2007;92(8):2952-2959. doi:10.1210/jc.2006-2726
7. Fathizadeh N, Ebrahimi E, Valiani M, Tavakoli N, Yar MH. Evaluating the effect of magnesium and magnesium plus vitamin B6 supplement on the severity of premenstrual syndrome. Iran J Nurs Midwifery Res. 2010;15(Suppl1):401-405. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3208934/.
8. Shechter A, Boivin DB. Sleep, Hormones, and Circadian Rhythms throughout the Menstrual Cycle in Healthy Women and Women with Premenstrual Dysphoric Disorder. International Journal of Endocrinology.