The PMDD Puzzle: Piecing Together Effective Treatment Options
The PMDD Puzzle
Piecing Together Effective Treatment Options
Have you observed that you feel extra ragey, depressed, anxious, or irritable prior to starting your period? Maybe you feel like you’re going crazy or you feel like a totally different person that you don’t quite recognize… If this is the case, you may be struggling with Premenstrual Dysphoric Disorder (PMDD). I’ve worked with several women, primarily mothers, who have struggled with PMDD and had no idea that the symptoms they were experiencing were related to PMDD. When I educate and share about PMDD with my clients, they are able to connect the dots and consistently observe patterns in their symptoms that generally start 7-10 days leading up to menstruation. PMDD may be described as Premenstrual Syndrome (PMS) on steroids, and it is estimated that approximately 3-8% of menstruating women struggle with PMDD (1). Unfortunately, women who struggle with PMDD often get misdiagnosed as having a bipolar mood disorder (4). The physical and emotional symptoms can be challenging to make sense of and manage, and they can be so intense that they interfere with daily activities, social and interpersonal relationships, work and job satisfaction, and your self-esteem. But what exactly are these symptoms? Let’s take a look.
What are the symptoms of PMDD?
Symptoms of PMDD may include the following:
feelings of sadness or despair (and at times may include thoughts of suicide)
self-deprecation
anxiety and/or panic attacks
crying spells
irritability, anger, or rage
a lack of interest in or attention to activities and relationships
a decrease (or major plummet) in job satisfaction
fatigue and tiredness
difficulty focusing or concentrating
changes in appetite such as sugary or salty food cravings and binge eating
sleep disturbances such as hypersomnia, insomnia, or feeling restless
feeling out of control
unpleasant physical symptoms such as breast tenderness, body aches, bloating, and weight gain
In order to confirm a diagnosis of PMDD, you must experience a minimum of 5 symptoms listed above, with one of those being mood related changes (depressed, angry, anxious, anhedonia) leading up to the start of your period for at least 2 cycles.
What Causes PMDD?
It is suspected that PMDD may be related to the hormonal changes that occur throughout your menstrual cycle. More specifically, it is believed that the symptoms are triggered by the fluctuations in levels of estrogen and progesterone that occur during the luteal phase, the phase in your menstrual cycle after ovulation and before menstruation. Historically, it was attributed to an imbalance in the levels of these hormones (lower levels of progesterone or higher levels of estrogen), but it is now believed that PMDD is more closely related to a sensitivity to normal hormone fluctuations. Recent research actually points toward a cellular disorder in the brain, which results in the individual’s brain reacting severely and negatively to the normal rise and fall of hormones throughout the menstrual cycle (3). Other hormones, such as cortisol (your stress hormone), or thyroid hormones, may also contribute to the symptoms of PMDD. Oftentimes, PMDD can occur after having a baby or closer to menopause - both are significant life event that can change the way some women’s brains react to various hormones such as progesterone and estrogen (6).
The 4 Phases of the Menstrual Cycle
If you’re going to try to make sense of and understand PMDD, it is important that you begin to learn your body and your menstrual cycle. Let’s discuss the 4 stages or phases of a woman’s menstrual cycle. Typically, the menstrual cycle (all 4 stages together) lasts about 28 days, although it can vary from woman to woman - it can range from 21 days on the lower end and up to 35 days on the higher end. The menstrual cycle is divided into four phases:
The menstrual phase: This is the first phase of the menstrual cycle during which the lining of the uterus (the endometrium) is shed in the form of menstrual bleeding. This is more commonly known as your “period.” The menstrual phase typically lasts about 4-7 days and bleeding throughout may vary from a light flow, medium flow, or heavy flow.
The follicular phase: This is the second phase of the menstrual cycle during which the ovarian follicles (the small, fluid-filled sacs in the ovaries) mature. One of the follicles will eventually release an egg (ovulate) during this phase. The follicular phase typically lasts about 7-14 days. It starts with menstruation and ends with ovulation (next phase).
The ovulatory phase: This is the third phase of the menstrual cycle during which one of the ovarian follicles releases an egg (ovulates). Ovulation usually occurs around day 14 of a 28-day cycle, but it can vary depending on the length of the menstrual cycle and occur earlier or later in the menstrual cycle depending on that specific cycle. You can think of ovulation as the dividing point between your follicular phase and luteal phase.
The luteal phase: This is the fourth and final phase of the menstrual cycle during which the uterine lining begins to thicken in preparation for a potential pregnancy. If pregnancy does not occur, the uterine lining is shed during the next menstrual phase (you start your period again). A study by Crawford et. al. (2017) saw a variation in the length of the luteal phase, ranging from 7 to 19 days in women who had 28-day cycles, with an average length of 14 days. During the luteal phase, progesterone levels decrease - this is when women typically observe changes in mood, sore or tender breasts, bloating and headaches, and other PMS related symptoms. It is during the luteal phase that many women with PMDD experience the majority of their symptoms. Sensitivity to the hormonal fluctuations that occur during this phase are thought to be a major contributor to PMDD symptoms.
If we take into consideration the duration of each phase in the menstrual cycle, as well as the number of menstrual cycles throughout a woman’s life, we can see why addressing PMDD symptoms is critical.
Treatment Approaches for PMDD
There is no specific test that can assess PMDD directly, and a diagnosis is typically based off symptom history, mood tracking, and blood work/labs. The best treatment approach for PMDD may vary from person to person, and a combination of treatments may be necessary to help you manage and/or treat your symptoms. I’ve outlined 3 treatment approaches to PMDD, including functional medicine, mental health, and western medicine approaches to treatment. Oftentimes, a combination of the 3 may be needed to effectively treat PMDD.
Functional Medicine Approach to Treating PMDD
Functional medicine is a holistic approach to healthcare that focuses on identifying and addressing underlying causes of various symptoms and issues. A functional medicine doctor may address the specific imbalances or dysfunctions in the body using a combination of lifestyle modifications, nutritional interventions, and targeted supplements or medications. In the case of PMDD, a functional medicine approach may involve the following:
Various forms of testing to identify underlying imbalances or deficiencies that may be contributing to PMDD symptoms. This could include testing hormone levels during different parts of your menstrual cycle, nutrient deficiencies or food allergies/sensitivities, gut dysbiosis, or other underlying health issues.
Working with you to address any deficiencies through a combination of lifestyle changes, such as diet and exercise, and targeted supplements such as magnesium, vitamin B6, calcium, a high-quality probiotic, and Omega-3.
Providing ongoing support and guidance to help you make long-term lifestyle changes that can help to lessen or prevent future episodes of PMDD.
Mental Health Approach to Treating PMDD
Psychologists can play an important role in helping women cope with a variety of health issues, including those related to reproductive health and hormonal fluctuations. It’ll be important to work with a mental health provider who treats women and has training in women’s mental health (I strongly encourage you work specifically with a psychologist in this regards). A psychologist can help you manage the emotional symptoms of PMDD through a variety of therapies, including:
Cognitive Behavioral Therapy (CBT): The primary focus of CBT is modifying dysfunctional emotions, behaviors, and thoughts by uprooting negative beliefs or thinking errors. This type of therapy can help you identify unhelpful thoughts and learn coping skills or cognitive reframing techniques to manage negative self-talk and thinking errors that pop up (like self-blame, all-or-nothing thinking, labeling, etc.). If you’re interested in learning more about reframing techniques, you can register for my free course, 15 Days to a Better Mindset: A simple step-by-step guide for mothers to thinking thoughts that make you feel good.
Interpersonal Therapy: This type of therapy can help you improve your relationships and communication skills, which can be particularly helpful for managing PMDD related mood swings and irritability. It is a form of psychotherapy that focuses on you and your relationships with other people. The goals of IPT are to improve your interpersonal functioning, increase social support, and reduce symptom severity.
Mindfulness-based Therapies: Mindfulness approaches can help you learn to become more aware of your thoughts and emotions, and to respond to them in a more healthy and adaptive way. One example of a mindfulness based therapy approach is Acceptance and Commitment Therapy (ACT). In ACT, you learn how to reduce the impact and influence of painful thoughts and feelings while also taking action to build a life that is rich and full of meaning.
Relaxation Techniques: Stress can exacerbate PMDD symptoms, so learning relaxation techniques can be beneficial in managing the symptoms that accompany PMDD. Techniques such as deep breathing, progressive muscle relaxation, and guided imagery can help you manage stress and improve your overall emotional well-being. Psychologists can teach you these skills and how to integrate them into your life in a way that benefits you.
In addition to various therapy interventions and techniques, a psychologist can also provide emotional support and guidance as you work to make lifestyle changes, such as improving your sleep habits or increasing your physical activity, which can help you manage PMDD symptoms. It is important to note that while therapy can be a helpful part of treatment for PMDD, it is not a substitute for medical treatment.
Western Medicine Approach to Treating PMDD
When it comes to a western medicine approach in addressing symptoms of PMDD, you have a few options, including a reproductive psychiatrist, an endocrinologist, or an OB-GYN. A western medicine approach to treatment may involve a variety of pharmaceutical interventions and various labs or tests (as listed above under functional medicine approach) to help determine the underlying cause of symptoms. Pharmaceutical approaches typically include antidepressants or hormonal contraceptives, such as birth control pills.
Antidepressants: SSRI’s can be effective in managing PMDD symptoms. They work by increasing the levels of serotonin in the brain, which can help to improve your mood and reduce the symptoms of PMDD. The sensitivity to hormonal fluctuations that contribute to the symptoms of PMDD can affect the levels of neurotransmitters such as serotonin — by targeting serotonin via the use of an SSRI, some women observe improvements in their mood and a reduction in symptoms of anxiety, irritability, and depression. SSRIs are typically taken daily, either continuously or for a period of time during the menstrual cycle.
Hormonal contraceptives, such as birth control pills or patches, contain synthetic versions of the hormones estrogen and progesterone, which can help regulate the menstrual cycle and reduce the severity of PMDD symptoms by stabilizing hormonal fluctuations that occur during the menstrual cycle. Hormonal contraceptives can help with PMDD by preventing ovulation. This means that the hormonal fluctuations that occur during the menstrual cycle, and which can contribute to PMDD symptoms, are minimized. Additionally, hormonal contraceptives can help stabilize the levels of estrogen and progesterone in the body, which can reduce symptoms such as bloating, breast tenderness, and mood changes. It is important to note that some women have observed an increase in symptoms when on birth control, so it is necessary that you work closely with a provider that you trust, feel comfortable with, and one who does not dismiss your symptoms.
PMDD can significantly impact the quality of life for many women; however, there are a variety of treatment options available to help you manage the symptoms of PMDD. Every woman's experience with PMDD is unique, so it's important to work with a healthcare provider to develop a personalized and comprehensive treatment plan that meets their individual needs and preferences. With proper care and treatment management, women with PMDD can improve their quality of life - it may not be easy, you may have to advocate for yourself often, and you may have to try several treatment approaches, but it is possible. Be kind and gracious with yourself as you piece together treatment options that work for you.
Sincerely,
Dr. Alice Pickering, Psy.D., CCTS-I
References:
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
Crawford NM, Pritchard DA, Herring AH, Steiner AZ. Prospective evaluation of luteal phase length and natural fertility. Fertil Steril. 2017;107(3):749-755. doi:10.1016/j.fertnstert.2016.11.022
Dubey N, Hoffman JF, Schuebel K, Yuan Q, Martinez PE, Nieman LK, Rubinow DR, Schmidt PJ, Goldman D. The ESC/E(Z) complex, an intrinsic cellular molecular pathway differentially responsive to ovarian steroids in Premenstrual Dysphoric Disorder, Molecular Psychiatry, January 3, 2016, doi.org/10.1038/mp.2016.229