This Overlooked Condition Makes Women Combative, Irritable, and Often Suicidal
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When Laine Y. was 13 years old, she got her first period. By the next year, she started having cramps so severe she would struggle to breathe. By 17, the emotional highs and lows were almost unbearable: She'd tear apart her room in a fit of rage, then slump on the floor and cry for hours. She'd be inconsolable over getting a 97 on a chemistry test. The next day, Laine would get her period and suddenly she’d feel elated, ready to plan a picnic and enjoy the afternoon.
She didn't know what was going on exactly. But she knew enough to write in her diary at 17, "If I kill myself, it will be because of my period."
Laine went to therapy. She went to her annual gynecology check-ups. No one ever asked if her moods were different around her period, and it never occurred to the young adult to point it out.
It would be a few years before Laine felt her moods begin to rein in — she got into a serious relationship and started taking birth control, though at the time she just attributed the balance to the stability of having a good partner.
It’d be another few years, with Laine now in her mid-20s, that a gynecologist at Planned Parenthood would finally put a name to her suffering: She had premenstrual dysphoric disorder, or PMDD, a condition that causes severe irritability, depression, or anxiety in the days before your period when your hormone levels fall after ovulation.
Her story sounds extreme — but it’s alarmingly common. Emily H., now 35 and living in St. Louis, Missouri, said her teenage years were spent battling thoughts about worthlessness and contemplating suicide. Whenever those extreme feelings would crop up, the next day, her period would start. She went to therapy, but got no answers. It wasn't until 2016, when Emily was 31, that she went to a new ob-gyn who asked and recognized immediately that Emily was suffering PMDD. Emily started birth control, and, she tells InStyle, the bad thoughts went away all together.
Up to 8% of women experience PMDD. That’s about the same as clinical anxiety — but PMDD sufferers often go years without getting the correct diagnosis. If you struggle with extreme mood changes right before your period, here’s what you need to know.
What exactly is PMDD?
“PMDD has been billed as a more severe PMS, but that’s really a false equivalent,” says Carly Snyder, M.D., a New York-based reproductive psychiatrist and director of Women’s Health for Family Health Associates. For starters, PMS is incredibly common, with up to 90% of women having experienced it. PMDD only affects some 3 to 8% of menstruating women.
PMDD is actually a type of depression — one that’s defined by symptoms exclusively coming on the week or so before menstruation, known as the luteal phase. The symptoms end promptly once the bleeding starts.
There are 11 possible symptoms tied to PMDD, and women must have at least five to be diagnosed over the course of a year— but only for one week of the month. The concerns range from mood-related to physical.
- Mood swings
- Irritability, anger, or increased interpersonal conflicts
- Depressed mood, feelings of hopelessness, or self-deprecating thoughts
- Anxiety, tension, and/or feelings of being on edge
- Decreased interest in usual activities
- Difficulty concentrating
- Marked lack of energy
- Changes in appetite
- Excessive sleepiness or insomnia
- A sense of being overwhelmed or out of control
- Physical symptoms such as breast tenderness or swelling, joint or muscle pain, or bloating
Many women report having low energy, poor motivation, and apathy — their desire to work out is suddenly out the window. Their appetites often increase, and a lot of people report either trouble sleeping or constant fatigue and excess sleep.
But Dr. Snyder says usually the women she sees are plagued most by irritability and a low frustration tolerance for the several days before their period. “They’re easily angered, quick to yell at others, and very short-fused,” she explains. While a woman may be calm and in control of her emotions and responses for three weeks, for that fourth week, she’s tearful, anxious, quickly hostile, and generally feels like “a mess,” Dr. Snyder describes.
That combination affects their life so much — from relationships, to work, to children — that they end up in her office, seeking answers.
Why is it overlooked and under-diagnosed?
There are a lot of reasons PMDD is so overlooked, Dr. Snyder says. For starters, it wasn’t even recognized as an official problem until 2013, when it was added to the DSM (that’s the Diagnostic and Statistical Manual of Mental Disorders, which is a kind of encyclopedia of mental health diagnoses). And even then, some docs were resistant to using the label because they felt it enabled society to further stigmatize women as emotionally unstable monthly, she adds.
Then, because the symptoms run the gamut and don’t look the same from person to person, it’s also hard to diagnose.
Mostly, though, people have written off all pre-menstrual symptoms as run-of-the-mill PMS. The latter is defined by the same symptoms, but much more mild cases. In fact, 80% of PMS sufferers say it doesn't really affect their daily functioning, according to a study in American Family Physician.
“Many physicians do not fully appreciate the magnitude of the impact that PMDD can have on a woman’s life — how much her mood can change for the days prior to her period, how different her behavior may be, how powerless a woman can feel as a result,” says Dr. Snyder.
What causes PMDD?
Calling PMDD a type of depression is a bit misleading. While depression is largely due to an imbalance of neurotransmitters, PMDD isn't because of any asymmetry. It’s actually the result of your body abnormally responding to the (very normal) hormonal changes that happen during the luteal phase (the window between ovulation and menstruation) of your period, Dr. Snyder says.
We don't quite know why women with PMDD react differently to the natural cycle of hormones. But one prevailing thought is that your central nervous system (or CNS, which controls your fight-or-flight and rest-and-digest modes) is more sensitive to certain categories of hormones, including female sex hormones like pregnenolone, progesterone, and estradiol. This dominos down to put certain receptors (namely that for the neurotransmitter GABA) on overdrive, increasing your fight-or-flight response and not responding to balancing metabolites like allopregnanolone (ALLO), which would otherwise act as an anti-anxiety chemical, or sedative. This creates erratic moods and increases things like stress and anxiety.
What’s more, women with PMDD see a quicker drop in progesterone during their luteal phase than normal. Since their CNS is more sensitive to these changes, this may create a hormonal withdrawal that prompts certain symptoms like moodiness, irritability, and anxiety, reports a 2019 study in the Journal of Affective Disorders.
Who’s likely to have it?
PMDD can affect women at any menstruating age, from a first period through menopause. If you already suffer a mood or anxiety disorder, have polycystic ovarian syndrome (PCOS), have a family history of PMDD, or are exposed to chronic stress in your 20s to 30s, you're more likely to develop PMDD, says a recent meta-analysis in the Neurobiology of Stress.
Additionally, experiencing abuse as a child — emotional, physical, or sexual — increases your chances of developing the disorder (as well as other mood issues like major depression). That’s probably because you become less sensitive to the calming metabolite ALLO after repeated or chronic stress.
What can help alleviate PMDD symptoms?
Researchers are currently developing the first drug to specifically combat PMDD, called Sepranolone. If that pans out, sufferers would have a more targeted solution for their pains. But clinical trials are still in the early stages, and we wouldn’t see Sepranolone on the market until 2022 at best.
Until then, the two most well-proven and widely used treatments are prescriptions: birth control and antidepressants.
But like any condition with torturous symptoms and a history of being overlooked, people with PMDD are willing to try most any alternative remedy to fix their symptoms — or minimize the destruction they can cause.
“I’ve heard of women spending thousands of dollars monthly on supplements with limited evidence supporting any benefit; sequestering themselves alone for days at a time premenstrually; forgoing vacations to instead call in sick leading up to their period — the list is sadly endless,” Dr. Snyder says.
But there are some non-pharmaceutical solutions that do hold cred.
“I often find that there are significant and meaningful lifestyle changes that can reduce and eliminate these symptoms, bringing the diverse functions and sensations of the body back into balance,” says Eden Fromberg, M.D., founder and director of Holistic Gynecology New York.
Here, nine remedies for PMDD that science says might help.
Hormonal contraceptives have been shown to help improve the mental health of PMDD sufferers without any common side effects, according to a 2019 study review out of Stanford University. It’s one of the most popular and effective ways of helping PMDD sufferers. That’s because it stops ovulation, and overriding the body’s natural hormonal fluctuations improves — or ideally alleviates — PMDD symptoms, Dr. Snyder explains.
Selective serotonin reuptake inhibitors (SSRIs), which increase your brain's production of the happiness hormone serotonin, are considered the first line of treatment, according to a 2019 study review in The Medical Clinics of North America.
Which is probably why when Jamie C., a 44-year-old in Lancaster, Pennsylvania, first mentioned her increased irritability, combativeness, and short-temper right before her period, her therapist suggested Prozac. Jamie wasn't ready to make the leap into pharmaceuticals. But when all the herbs and supplements she had heard about didn't work and her condition had deteriorated, she agreed to start taking Lexapro.
“SSRIs are incredibly beneficial for the treatment of PMDD,” Dr. Snyder says. Many women who don’t suffer other forms of depression practice intermittent dosing — they only take their antidepressant during their luteal phase (on average, this portion of your menstrual cycle lasts 10 to 14 days) when they’re symptomatic. “They feel nearly instantly better — it’s truly miraculous,” she adds.
It's definitely not for everyone — some of the other women we spoke to, like Deb in Massachusetts, felt like Celexa (another popular SSRI) helped soften her symptoms but caused other side effects, including weight gain, lowered sex drive, and orgasm suppression that she wasn't down with.
But for someone like Jamie, the transformation was wildly helpful. "I no longer write 'I hate everyone and everything,' in the chart where I track my moods. Instead, I write, 'a little annoyed with everything today,' which is HUGE," she says.
Cognitive Behavioral Therapy
When PMDD sufferers were given eight weeks of therapist-guided virtual cognitive behavioral therapy (CBT), they saw improvements in symptoms and everyday wellbeing immediately. What's more, their symptoms were still being well-controlled six months later, reports a 2019 study in Psychotherapy and Psychosomatics. CBT helps re-write the way you process and react to situations, emotions, and thoughts.
When 33-year-old Deb, living in Massachusetts, felt her antidepressants were causing too many side effects, she traded them for Dialectical Behavior Therapy (DBT), a form of CBT, to help control her moods and aches. "[With DBT] you learn how to live with a greater degree of mindful awareness, and how to tackle issues in life with more skill and less emotional pain. With DBT, I still have all the same symptoms, but my experience of them is much less intense, and everything feels so much more bearable," she says. In other words, CBT teaches women to cope on their own, which helps lower levels of perceived stress.
Herbs and Vitamins
Women with PMDD experienced fewer symptoms and had a greater quality of life when they had been taking a micronutrient formula daily for three menstrual cycles, reports a recent preliminary study in The Journal of Alternative and Complementary Medicine. Researchers speculate it's thanks to the anti-inflammatory effect of vitamins and minerals, which may help with mental health issues like depression and anxiety. Their formula was high in vitamins A, C, D, and E; B12, biotin, calcium, phosphorus, and potassium.
Essential Fatty Acids
Research shows that essential fatty acids (EFAs) are especially helpful for the mood changes and irritability of PMDD, says Dr. Fromberg. Getting more omega-3s can help reduce inflammation and alleviate some of the chemical cascades that come before the luteal phase and potentially contribute to discomfort, says a 2018 study in the Journal of Psychosomatic Obstetrics & Gynecology.
Dr. Fromberg recommends Gamma Linolenic Acid (GLA), which is made from evening primrose oil, black currant seed oil, and borage oil and helps modulate prostaglandin, a hormone that regulates inflammation.
A 2016 study in the Journal of Caring Sciences found calcium and B6 together helped control PMS symptoms — which could help with some of the overlapping symptoms that also affect sufferers of PMDD.
“Vitamin B6 has positive effects on hormones including adrenal stress, supporting progesterone as it declines during the last week of the menstrual cycle, and helps with estrogen detoxification pathways in the liver,” Dr. Fromberg says. “Vitamin B6 also positively affects neurotransmitter production, blocks histamine, and can work in synergy with EFAs to reduce symptoms of PMDD.”
The research on taking chasteberry for PMDD symptoms is mixed, but some meta-analyses have marked chasteberry as a safe and effective treatment for the disorder. Dr. Fromberg recommends the herb to help increase the production of luteinizing hormones (a special kind of hormone that helps trigger ovulation), in turn boosting progesterone levels.
FWIW, Dr. Snyder warns chasteberry does come with some risks, including headaches, nausea, and potentially playing with the effectiveness of birth control. And you should skip the herb if you also have polycystic ovarian syndrome (PCOS), Dr. Fromberg warns, since it drives your already-elevated luteinizing hormones even higher.
A 2018 study review out of Australia found that acupuncture and acupressure (anywhere from seven to 28 sessions) helped improve the physical and psychological symptoms of PMDD. Some studies suggest it may help improve symptoms by as much as 50%.
“Acupuncture can help balance hormones, reduce stress, and reduce inflammation,” says Gabrielle Francis, naturopathic doctor and acupuncturist in New York. During a session, you drop into a very deep and meditative state, so sessions during your luteal phase (typically 10-14 days before your period starts) can also be helpful for simply helping you relax.
It sounds so simple and perhaps obvious, but adding nurturing activities to your daily life — especially during the luteal phase of your menstrual cycle — can add up to a foundation of relief. “Exercise, more time in nature, improving my diet — none of these things make my symptoms go away, but all of these help a little,” says Deb. Her favorite cure-all: a long, hot bath.
Dr. Fromberg agrees it's super important to bolster your internal resources instead of just looking for external fixes. “Movement and breathing in particular are some of the most important interventions for PMDD, as they increase blood flow and oxygenation to the tissues, increase lymphatic drainage and metabolism, and treat the system as a whole,” she adds.