Three in four women experience premenstrual physical or mood changes, but for women suffering from premenstrual dysphoric disorder (PMDD) the monthly symptoms are more than just annoying or uncomfortable – they affect the ability to work, impact on their relationships and increase their risk of suicide.

While premenstrual syndrome (PMS) is well-known, affecting at least 75% of women, PMDD is a more severe form, recognised as a clinical mental health condition and affecting approximately 5% of women.

Some describe feeling as if a switch has been flicked to turn them into a different person in the week before their menstrual period, feeling out of control and responding to events that wouldn’t usually upset them with extremes of anger, tears or even violent behaviour. Others shift from energetic extroverts to withdrawn, unable to function in their normal daily life, and depressed to the point of contemplating or attempting suicide.

The combination of physical discomfort with the extreme mood shifts and behaviour changes caused by PMDD impact just as severely on a woman’s quality of life, ability to function and years lost to ill-health as other, more widely recognised, major mental health disorders such as depression, said Dr Bavi Vythilingum, member of the South African Society of Psychiatrists (SASOP).

In Women’s Month of August, SASOP aims to raise awareness of women’s mental health and the importance of early, correct and effective treatment to minimise risks of more serious mental health problems developing later in life.

“Hormone levels fluctuate through women’s different life stages, from the onset of menstruation to the reproductive or child-bearing years, to the changes during and after pregnancy, through to menopause. Hormones affect brain function, and this makes women particularly vulnerable to mental health challenges arising from these physical changes,” Dr Vythilingum said.

She said that although PMDD affects a relatively small percentage of women, it is important to raise awareness of the condition as it is not well understood and is frequently misdiagnosed, mistaken for depression or bipolar disorder, or “it is brushed off as being ‘just hormonal’ and women are told there is nothing wrong with them”.

“However, the correct treatment, which is specific to PMDD and not the same as treatment for conditions such as depression, can dramatically improve the lives of women who go through the monthly cycle of severe, even suicidal, symptoms,” she said.

While PMS can cause sadness, tearfulness, irritability and anxiety, in women with PMDD these symptoms are extreme, preventing them from carrying on with daily life, disrupting their relationships and causing intense feelings of depression and hopelessness, to the extent that more than a third of women with PMDD have attempted suicide.

Dr Vythilingum said women with PMDD have normal hormone levels but are unusually sensitive to the normal changes in oestrogen and progesterone levels that occur through the menstrual cycle, affecting the brain chemistry that controls moods, emotions and sense of well-being.

PMDD can affect women at any age or life stage. Stress and childhood trauma, especially sexual trauma, are risk factors for developing PMDD, as well as a personal or family history of anxiety and depression, PMS or postnatal depression.

Breakthroughs in medical research have shown that the high sensitivity that some women have to the normal hormonal fluctuations throughout life is biological and influenced by genetics.

“The latest research shows that there is a biological basis for PMDD, that the disorder is related to abnormal metabolism of hormones causing mood disruptions. This is an assurance for women living with PMDD that their condition can’t simply be brushed off as imaginary or hysterical, and it opens the door to more effective treatment,” Dr Vythilingum said.

The key difference between PMDD and other mental health conditions is that PMDD is cyclical – women feel fine and are able to function as usual, except in the one to two weeks before menstruation, and the symptoms disappear once menstruation starts.

PMDD adds extreme and debilitating mental distress to the typical physical symptoms of PMS such as bloating, breast tenderness, headaches and muscle or joint aches and pains, fatigue, difficulty sleeping and food cravings.

The mental symptoms include extreme anxiety, irritability or anger; distinct mood swings, deep sadness or despair, lack of interest in things the woman usually enjoys, panic attacks and difficulty thinking or focusing.

Dr Vythilingum said that PMDD is highly treatable and treatment could include selective serotonin reuptake inhibitor (SSRI) anti-depressants to remedy mood and emotional symptoms and difficulties with sleeping and concentrating. Depending on the woman’s overall mental health, anti-depressants can be taken daily or only in the days between ovulation and the start of her menstrual period.

Birth-control pills can also aid in controlling hormone levels as well as relieving physical aches and pains, while nutritional supplements are also helpful, especially 1200mg of calcium daily, as well as vitamin B6, magnesium and Omega 3 and certain herbal remedies. She advised consulting with one’s doctor on the most appropriate supplements.

Healthy lifestyle changes can also improve PMDD symptoms, she said, especially regular exercise, cutting back on caffeine, stopping smoking and avoiding alcohol.

“Getting enough sleep and using relaxation techniques such as mindfulness, meditation and yoga, may also help. Avoid stressful and emotional triggers, such as arguments over financial issues or relationship problems, whenever possible,” Dr Vythilingum advised.

For women whose PMS symptoms are extreme and depression symptoms most marked in the one to two weeks before their period and disappear with the onset of menstruation, she advises consulting a medical practitioner with experience in both mental health and women’s health – ideally a psychiatrist, or their GP or gynaecologist.

REFERENCES

Office on Women’s Health, United States Department of Health and Human Services. https://www.womenshealth.gov/menstrual-cycle/premenstrual-syndrome

PMDD is classified as a depressive disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), published by the American Psychiatric Association.

Halbreich U, et al. The prevalence, impairment, impact, and burden of premenstrual dysphoric disorder (PMS/PMDD). 2003. Psychoneuroendocrinology Journal.  https://pubmed.ncbi.nlm.nih.gov/12892987/

Jen-Hui Chan, et al. Premenstrual dysphoric symptoms and lifetime suicide experiences in patients with mood disorder. 2021. Journal of General Hospital Psychiatry. https://pubmed.ncbi.nlm.nih.gov/33965699/

EurekAlert! American Association for the Advancement of Science. Sex hormone-sensitive gene complex linked to premenstrual mood disorder. 2017. News release on peer-reviewed publication by US National Institutes of Health (NIH). https://www.eurekalert.org/news-releases/842617