Understanding Premenstrual Dysphoric Disorder (PMDD): 

Symptoms, Differences from Premenstrual Syndrome (PMS), and Treatment Options

Premenstrual Dysphoric Disorder (PMDD) is a severe, often-debilitating form of premenstrual syndrome (PMS). PMS is familiar to most women as are its symptoms, but PMDD is less well-known and is significantly more challenging to manage. This article explains what PMDD is, what causes it, how it differs from PMS, and describes unique treatment options.

What is PMDD?

PMDD is a chronic medical condition characterized by severe emotional and physical symptoms that typically occur in the luteal phase of the menstrual cycle, usually the week or so before menstruation. However, every woman is unique and for many who suffer from PMDD, the timing can be atypical, lasting into menstruation itself. Its symptoms seriously affect daily life, relationships, and overall well-being. Unlike PMS, which affects up to 75% of women, PMDD affects only about 3-8%.

Symptoms of PMDD

The symptoms of PMDD include:

• Emotional Symptoms:

• Severe mood swings
• Intense irritability or anger
• Feelings of hopelessness or sadness
• Anxiety or tension
• Decreased interest in usual activities
• Difficulty concentrating

• Physical Symptoms:

• Fatigue or low energy
• Changes in sleep patterns (insomnia or hypersomnia)
• Appetite changes or food cravings
• Breast tenderness or swelling
• Joint or muscle pain
• Bloating or weight gain

For a diagnosis of PMDD, these symptoms must be severe enough to interfere with daily life and must occur consistently in the luteal phase (with variations) of the menstrual cycle.

How PMDD Differs from PMS

While both PMS and PMDD are linked to the menstrual cycle, they differ significantly in their severity and their effect on life:

• Severity of Symptoms: PMDD symptoms are more severe than in PMS. Emotional and physical symptoms are debilitating and interfere with the ability to function normally.
• Emotional and Behavioral Symptoms: PMDD is characterized by prominent mood swings, irritability, increased anxiety and depression. These same symptoms are less intense and more manageable in PMS.
• Effect on Daily Life: While PMS can cause discomfort and mild disruption, PMDD can significantly impair social functioning, academic or occupational work, and important personal relations. It is difficult to maintain unaffected routine activities and responsibilities.

What Causes PMDD?

Most sources, including fine academic ones, consider the exact cause of PMDD to be unknown. For example, Johns Hopkins University Department of Medicine writes the following:

The exact cause of PMDD is not known. It may be an abnormal reaction to normal hormone changes that happen with each menstrual cycle. The hormone changes can cause a serotonin deficiency. Serotonin is a substance found naturally in the brain and intestines that narrows blood vessels and can affect mood and cause physical symptoms.

However, this speculation, which has led to the use of serotonin-increasing agents in PMDD, sometimes effective, is unlikely to be the fundamental cause. A careful search of the literature provides support for the following mechanism. To understand fully, we take a brief—and probably unexpected—detour.

Mountain Climbing, Skiing and PMDD

Falling is not the greatest fear of high mountain climbers. It is rather so-called “mountain sickness” or “altitude sickness.” It is fearful because it is not preventable, strikes often at random and is often fatal. As one climbs higher the air becomes thinner and therefore the atmospheric pressure less. Pressure inside the body decreases as well to match the lowering outside pressure, a process called pressure equilibration or equalization, but it does so at a much slower pace. Climbers heading up very high peaks in the Himalayas—K3 or Everest, for example—will stop for a few days at a sequence of base camps along the way to allow the outside and inside pressures to equilibrate. 

However, on any high climb, there are stretches where the difference between the internal and external pressure grows. When the difference grows large enough, altitude sickness can strike. What happens is the higher internal pressure “pushes” the fluid component of blood through the walls of the smallest blood vessels—capillaries. These have to be semi-permeable as it is the in and out flow of fluid through capillary walls that our tissues receive nutrients and oxygen and expel waste and carbon dioxide.

With the onset of mountain sickness, hands and feet swell from excess fluid no longer contained with the vascular system. Indeed, this swelling occurs in every tissue of the body. Most dangerously, it also occurs in the tissues of the brain. However, unlike hands, say, the brain is contained in a fixed volume container that cannot expand.

As more fluid is driven out of the brain by the severe pressure difference between the body and the thin atmosphere, the pressure inside the brain increases sharply because the volume cannot expand. It’s like a tire that is being overfilled by compressed air.  In addition to physical symptoms caused by excess fluid in other tissues, the intracranial pressure dramatically affects the neurons of the brain and the brain’s functioning. The climber begins to feel confused. As the neurons become highly excitable from the pressure, firing randomly, the climber becomes severely irritable. His thinking becomes irrational, often leading him to violently refuse help. Hallucinations can appear. The excess fluid forced into the breathing spaces of the lung begins to compromise breathing. At that same time, the internal brain pressure can start to cause the brain to be squeezed down into the opening where the spine attaches to the skull. If this proceeds any significant amount, death will ensue.

Though there probably be a struggle, the other climbers must force the sick colleague to accept an immediate intravenous injection of a powerful diuretic such as furosemide, commonly used when people develop heart failure. This makes the climber urinate large amounts quickly thereby reducing the amount of fluid in his body, especially in his brain. If he is to survive, his colleagues must carry him down as rapidly as possible to altitudes with higher atmospheric pressure.

Skiing

Something quite similar happens to avid skiers who live near a continental coast but ski in the Western mountains or the Alps. They fly in a few hours from sea-level to a mile or more above. The abrupt drop in the outside pressure—in fact, since the air inside the plane is pressurized to sea-level, the drop is immediate—creates a very mild version of altitude sickness. Until pressure equalizes in a day or two, boots are too tight from swelling, and timing and agility are slightly impaired. Most people attribute this to the decrease in oxygen, and that certainly plays a role, but mostly with respect to exercise tolerance, not nervous system function. These latter effects are due to a mild increase in intracranial pressure, leaving the skier feeling out of sorts at first less coordinated for a few days. The solution to losing a few days of good skiing at the start is the same as for altitude sickness: Take a (mild) prescription diuretic the day of the flight and for 2 days or so after. Excess fluid will be excreted, boots fit and the skiing is great.

PMDD

The same thing happens in PMS and PMDD—fluid flows out of capillaries and into surrounding tissues, including the brain. In PMS the severity is about the same as with skiing, but with PMDD noticeably more sever, but not nearly so much as in mountain sickness. But severity aside, the only difference among them is the cause, not the results: Whereas in altitude sickness, the outflow of fluid is caused by internal and external pressure, with the body equalizing the pressure difference, in PMS and PMD the outflow is caused by hormonal changes. The dramatic increase in progesterone (and less so estrogen) causes significant changes in the vasculature—most notably of course in the lining of the uterus, but to a smaller degree everywhere in the body. This is what causes the balance of inflow versus outflow from capillaries to temporarily shift in favor of outflow.

Direct Treatment

Understanding this mechanism leads to direct treatment—the same as with altitude-driven changes: The use of mild prescription diuretics during the premenstrual days.  This treatment has very few side effects and is effective for ca. 75% of PMDD sufferers. Note that although the symptoms at the end of the causal chain are psychiatric, the treatment is rather mechanical—hydraulic if you will. It also reduces swelling elsewhere and to a certain degree, pain caused by the swelling.

Managing PMDD

Managing PMDD well requires a combination of lifestyle changes, medication, and therapy. Effective treatment options include:

    Lifestyle Changes:

• Diet and Exercise: A balanced diet, reduced caffeine and sugar, and regular physical activity will alleviate some PMDD symptoms.
• Stress Management: Techniques such as mindfulness, meditation, and yoga can reduce stress and improve emotional well-being.

    Medications:

• Diuretics: Spironolactone or Hydrochlorothiazide are mild diuretics that are usually sufficient to alleviate PMS and PMDD symptoms.        
• Antidepressants: Selective serotonin reuptake inhibitors (SSRIs) are often prescribed to help manage the emotional symptoms of PMDD. They can be taken continuously or only during the luteal phase.
• Hormonal Treatments: Birth control pills, particularly those that contain drospirenone and ethinyl estradiol, can help regulate hormonal fluctuations and reduce symptoms. GnRH agonists may also be used in more severe cases.
• Nonsteroidal Anti-inflammatory Drugs (NSAIDs): These can help alleviate physical symptoms such as cramps and breast tenderness.

    Therapy:

• Cognitive Behavioral Therapy (CBT): CBT can be highly effective in managing the emotional symptoms of PMDD. It helps individuals identify and change negative thought patterns and behaviors.
• Support Groups: Joining a support group can provide emotional support and practical advice from others who understand the challenges of living with PMDD.

    Nutritional Supplements:

• Calcium: Studies have shown that calcium supplements can reduce the severity of PMDD symptoms.
• Vitamin B6 and Magnesium: These supplements may also help alleviate symptoms, although it’s important to consult with a healthcare provider before starting any new supplement regimen.

Seeking Help

If you suspect you have PMDD, it’s important to seek medical advice. Your physician can help diagnose the condition and develop a personalized treatment plan. Keeping a symptom diary for a few months can also be helpful in identifying patterns and triggers.

Conclusion

PMDD is a serious condition that requires attention and appropriate treatment. With the right combination of lifestyle changes, medication, and therapy, individuals with PMS or more severe PMDD can find relief and improve their quality of life. 

Remember, managing PMDD is a journey, and it’s important to be patient and persistent in finding what works best for you. With the right approach, you can regain control and lead a more fulfilling life.