What Causes Premenstrual Dysphoric Disorder and How to Treat It?

Premenstrual syndrome (PMS) is a recurrent syndrome that occurs in the luteal phase, the 12 days right before menses. It is a condition characterized by physical, psychological, and behavioral changes that are severe enough to cause deterioration of interpersonal relationships and normal activity. Premenstrual symptoms include breast tenderness, abdominal bloating, backache, cramping, nausea, anxiety, depression, poor concentration, irritability, and headache. Premenstrual dysphoric disorder (PMDD) is considered a severe form of PMS.

What is PMDD?

Up to 10% of women have severe PMS symptoms or PMDD. Both are similar disorders but vary distinctly by the severity of their symptoms and how they impact women every month.

Defined by physical, psychological, emotional, and behavioral symptoms two weeks before menses, 80% of women experience mild to moderate symptoms premenstrually from time to time. However, 3 to 8% meet the criteria for PMDD, the severest form of the condition that substantially impairs daily living and requires medication or other therapies to control.

It is more common in the third and fourth decades of life. Genetics plays a large role in the development of PMDD in women whose mothers were afflicted.

Both conditions can worsen during perimenopause because the menstrual cycle varies as not every cycle is ovulatory. This means that hormone fluctuations can vary widely. As estrogen levels fall, progesterone, the hormone mainly responsible for the moodiness associated with PMS, increases.

PMDD consists of mood swings, anxiety, irritability, and even anger that occur throughout the two weeks before menses begins. The key emotional symptoms are mood swings, frequent crying, sensitivity to other people’s opinions, fear of rejection, irritability, anger and personal arguments, depression, difficulty concentrating, feeling overwhelmed or out of control, hopeless feeling, or poor self-esteem, anxiety, feeling edgy.

Lack of energy, fatigue, appetite changes, food cravings, and physical symptoms such as changes in sleep, breast tenderness, swelling, or bloating are more symptoms of PMDD.

Diagnosing PMDD

A. According to the clinical criteria, as established by the Diagnostic and Statistical Manual of Mental Disorders, for a PMDD diagnosis, at least five of the 11 specified symptoms must be present in the two weeks before menses in most months each year with at least one of the symptoms being either (1), (2), (3), or (4):

  • Severely depressed mood, feelings of hopelessness, or self-defeating thoughts.
  • Severe anxiety or tension.
  • Feeling sad or tearful suddenly.
  • Persistent and severe anger or more arguments with others.
  • Decreased interest in daily activities.
  • Difficulty concentrating.
  • Lethargy, fatigue.
  • Change in appetite, overeating, or specific food cravings.
  • Excessive sleep or inability to sleep.
  • Feeling overwhelmed or out of control.
  • Other physical symptoms, such as breast tenderness or swelling, headaches, joint or muscle aches, bloat, or weight gain.

B. The disturbance must significantly interfere with work, school, or social activities and relationships with others.

C. The problem is not due to another psychological disorder, such as major depressive disorder, panic disorder, bipolar disorder, or a personality disorder

D. The criteria A, B, and C must be present for two consecutive cycles.


The exact cause of PMDD is unknown, but the major theories are ovarian hormone fluctuations, serotonin changes, psychological dispositions, and sociocultural, cognitive, and social learning theories.

The hormone hypothesis suggests that the ovarian hormones estrogen and progesterone are out of balance in PMDD with a relative progesterone deficiency. However, in PMS patients from the 1960s who were treated with progesterone suppositories, research results were inconclusive, probably due to suboptimal therapy or other study design problems. Since PMDD is similar to other serotonin deficiency syndromes such as anxiety and depression, researchers believe it represents a pathological interaction between serotonin and ovarian hormones. In patients with PMDD, there are lower levels of serotonin in circulating blood and reduced platelet uptake of serotonin.

Likewise, cortisol levels are higher in the premenstrual phase in PMDD, yet lower levels occur during mental stress. Other neurotransmitter systems that have been implicated in PMDD are opioid, adrenergic, and gamma-aminobutyric acid (GABA) systems.

The adrenal, hypothalamic, pituitary, and ovarian interactions are implicated in the cause of PMDD. But one distinct pathway has not been elucidated, which is the case with all diseases; all diseases, disorders, and conditions are multifactorial. Interestingly, menopause and ovarian removal result in the resolution of PMS and PMDD, which makes the biochemical changes from ovarian hormonal fluctuations the most plausible basis for the disorder.

Risk Factors

Risk factors for PMDD include the following:

  • Personal history of depression, bipolar, or anxiety.
  • A family history of mood disorder.
  • Premenstrual mood changes or depression.
  • History of sexual abuse.
  • Past, present, or current domestic violence.


  • Increase fiber. Bloating is due to slower GI transit during the cycle after ovulation when progesterone levels are high, so increasing fruits and vegetables or taking a fiber supplement can help like glucomannan, as well as maintain hydration. Exercise is good for bloating, and avoid gas-producing foods like beans or take an enzyme supplement like Gas X or Beano.
  • Avoid salty foods, exercise, and increase hydration, as swelling results from water retention.
  • Consider birth control. Headaches can be hormonal, and migraines, known as menstrual migraines, often respond to birth control pills and suppress the period altogether.
  • Medication. Moodiness worsens premenstrually as do mood disorder symptoms. Medications are the mainstay of treatment and include SSRIs or selective serotonin reuptake inhibitors such as Prozac (fluoxetine), Zoloft (sertraline), Paxil (paroxetine), and Celexa (citalopram). Drugs to suppress ovarian hormone production, such as birth control pills, progesterone, and antiandrogens such as Danazol, as well as NSAIDs, may be useful for symptoms of PMDD.

Other dietary or herbal supplements for PMS management include omega-3 fatty acids, ginkgo, chaste berry tree, evening primrose oil, and crocus sativus. As cannabidiol (CBD) becomes more popular for anxiety, depression, neurological disorders, chronic inflammation, and chronic pain syndromes, its role in PMDD may become more popular. Researchers haven't studied CBD for PMDD, but given its promise in similar ‘mood’ disorders, a trial of CBD may be a promising option. Especially since it is deemed safe, it may be an option if other remedies are not successful.

Lifestyle changes such as frequent and small meals with complex carbohydrates, avoidance of caffeine, salt, and fat can be helpful in PMDD. Regular exercise, stopping smoking, avoiding alcohol, regular sleep, stress reduction, meditation, yoga, light therapy, cognitive behavioral therapy, and Vitamin B, E, and calcium carbonate can be helpful for PMDD.

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