Ask Dr. Annie K.
“I have been struggling with anxiety and depression throughout most of my life. However, the past few months I have started to notice that these feelings get a lot worse right before and during my period. During my period I feel like I am at my very lowest – depressed, hopeless and anxious to the point where leaving the house is difficult for me. I did some research and think I might have PMDD. I know starting birth control might be able to help these symptoms but I’ve had terrible experiences with birth control in the past and don’t want to mess with my emotions/hormones even more. What can I do? Any advice on how to deal with this? I’m really struggling. “
Thank you to the anonymous reader for asking this critical question.
First of all, YOU ARE NOT ALONE. At least 90% of women report unpleasant physical or psychological premenstrual symptoms. For most women it is mild and tolerable. There is a subset of women that suffer terribly. Symptoms are so disabling that they cause a significant disruption in their lives.
What is Premenstrual Dysphoric Disorder (PMDD)?
PMDD is a more severe form of Premenstrual Syndrome (PMS). Mood disturbance begins 1-2 weeks prior to the onset of menstruation. It affects 3-8% of women and usually starts during a woman’s twenties. This chart highlights the differences between PMS and PMDD:
What are the symptoms?
How does a typical month look for PMDD sufferers?
What else could it be?
Mood disorders can worsen during the premenstrual period and may mimic PMDD. In that case, the term premenstrual exacerbation (PME) is a more accurate diagnosis. In fact, 40% of women who seek treatment for PMDD actually have PME.
What is the treatment?
Non-pharmacological treatment
- Monthly mood charting
- Lifestyle modifications – decrease caffeine and sodium intake, regular aerobic exercise
- Nutritional supplements – a large clinical trial found that 1200mg of calcium/day is beneficial. Other studies show B6 (50-100mg/day) and Magnesium (200-360mg/day) can relieve symptoms.
- Herbal remedies – nothing definitive, more research is needed. The front runners are chasteberry (vitus agnus castus fruit extract) and black cohosh.
- Light therapy – 10,000 Lux, similar to lights for seasonal affective disorder are being explored as a treatment
- Cognitive Behavioral Therapy (CBT) – essential. A recent study showed CBT was as effective in treating PMDD as Fluoxetine (Prozac) 20mg/day.
Pharmacologic treatment
Selective serotonin reuptake inhibitors (SSRIs) are first-line treatment for premenstrual mood disorders. There are several options for dosing:
- daily continuous all month
- luteal phase only (2 weeks before menstruation)
- continuous with increased dose in luteal phase
Women with PME benefit most from continuous treatment with luteal phase increase in dose.
Benzodiazepines are helpful for premenstrual anxiety. They should be prescribed very cautiously and for limited periods only.
Oral contraceptives (OCP) suppress ovulation and can eliminate premenstrual symptoms. Continuous treatment, rather than cyclical ( 21 days active/7 days placebo) works best for PMDD patients. OCP must be prescribed cautiously, weighing the risks and benefits. Some women should not take OCPs – women with history of blood clots, smokers, and women over 35 years of age or older. Depression is common with OCPs, vigilance is required when prescribing OCPs to women with history of depression.
In Summary…
I recommend lifestyle changes such as diet, exercise and stress management for all women. No risk and known benefit!
Premenstrual suffering is documented in medical literature since 1931. PMDD was added to the DSM in 2013. It is a legitimate diagnosis that should not be ignored. Physicians who think it is not real are out of touch. Find a psychiatrist who is knowledgeable about reproductive psychiatry. If you feel you are not being heard, find a new doctor. Look for a medical center that specializes in women’s health – they may offer a comprehensive one-stop shop approach.
PMDD is biology, not a behavioral choice.
Start with lifestyle changes and go from there. Get the help that you deserve.
Thank you reader for asking Dr. Annie K. By asking questions, you help others :)).
