Premenstrual dysphoric disorder (PMDD)

PMDD is generally thought to be an extreme form of PMS (premenstrual syndrome). Upwards of 75% of women have some physical and/or emotional symptoms before their periods that could be considered PMS. For most women, PMS symptoms cause only mild to moderate discomfort and require little or no treatment. Far fewer women, perhaps 3% to 8%, have severe disabling, disruptive premenstrual symptoms that include depression, anxiety and irritability. These women have a treatable medical disorder known as premenstrual dysphoric disorder or PMDD. Do I have premenstrual dysphoric disorder?
While most women have some premenstrual discomfort, far fewer have the severe and disruptive symptoms that make up PMDD. Far fewer doesn’t mean rare since PMDD is present in about 5% of menstruating women. How can you tell if you suffer PMDD? The first step is to take our brief screener. While a screener cannot replace diagnosis by a qualified clinician, it can help you identify the presence of symptoms. If the screener suggests you are experiencing symptoms of PMDD, we strongly encourage you to seek help. We can probably give you a better idea if you have PMDD if you continue on in this section. To make a diagnosis for sure however, requires evaluation by a trained clinician.


What are the symptoms of pmdd?

There are no laboratory tests that can diagnose PMDD, so measuring blood levels of estrogen or progesterone or anything else will not provide a diagnosis. The diagnosis of PMDD is based on the regular presence of certain clinical symptoms for part of each menstrual cycle. More specifically, here are the symptoms that make up the diagnosis of PMDD.

All of the symptoms need not be present and they may vary from month to month. At least 5 are required to make the diagnosis, including at least one of the first four.*

1. Very depressed mood, feeling hopeless
2. Marked anxiety, tension, edginess
3. Sudden mood shifts (crying easily, extreme sensitivity)
4. Persistent, marked irritability, anger, increased conflicts
5. Loss of interest in usual activities work, school, socializing
6. Difficulty concentrating and staying focused
7. Fatigue, tiredness, loss of energy
8. Marked appetite change, overeating, food cravings
9. Insomnia (difficulty sleeping) or sleeping too much
10. Feeling out of control or overwhelmed
11. Physical symptoms such as weight gain, bloating, breast tenderness or swelling, headache, and muscle or joint aches and pains

*Adapted from Diagnostic and Statistical manual of Mental Disorders, Fourth Edition, Text Revision, 1994 with permission from the American Psychiatric Association
How is pmdd diagnosed?

There is more to making the diagnosis of PMDD than just the symptoms. For example, the symptoms must be linked to the menstrual cycle — appear in the premenstrual phase, improve or disappear when menses begins or shortly thereafter and be absent in the week following menses. Also, if the symptoms are relatively mild the diagnosis is not made. The premenstrual symptoms have to be severe enough to interfere markedly with relationships, work, school, or social activities.

In a nutshell, here is what is necessary to diagnose PMDD — severe symptoms linked predictably to the premenstrual phase of the cycle.


Why is a medical/psychiatric history and physical examination necessary?

Sometimes symptoms of another medical or psychiatric disorder can be confused with those of PMDD. Sometimes symptoms of an unrelated medical or psychiatric disorder may get worse during the premenstrual phase of the cycle, and this may be difficult to distinguish from PMDD. Sometimes a woman will have both PMDD and another medical or psychiatric disorder. For all these reasons, a complete history and physical examination make good sense.

What else will the doctor or nurse practitioner want to know?

Be sure to tell the doctor about any and all medical and emotional problems you might have. Don’t leave anything out. Also be sure the doctor knows about all medications you are taking. This includes prescription and over-the-counter medications, as well as nutritional and herbal supplements. A doctor will also want to know about your diet and whether you smoke, drink alcohol, use street drugs or caffeine. You will quite likely be asked about your family history. This may seem like a lot of detail, but a comprehensive evaluation is the best way to get the right diagnosis and the most appropriate treatment.

Why can’t you just measure my hormone levels and make the diagnosis?

Believe it or not, despite many research studies that have examined female hormone levels (like estrogen and progesterone) during the menstrual cycle in women with PMDD and in those without the disorder, no meaningful differences were found. Measuring levels of female hormone in blood or urine cannot diagnose PMDD.

Can other laboratory tests diagnose PMDD?

No. While some laboratory tests may be necessary to exclude other illnesses that could be confused with PMDD, there are simply no laboratory tests that can diagnose PMDD.

Why is keeping a daily record of symptoms necessary to make a diagnosis of PMDD?

A daily symptom diary kept over at least two cycles may not always be necessary to diagnose PMDD. However, it is the best way to confirm the diagnosis based on the type and severity of symptoms and their presence or absence across the various phases of the menstrual cycle. Surprisingly often, women who think they have PMDD learn through the use of a daily symptom diary that such is not the case.

Can other conditions be confused with PMDD?

You bet. Symptoms of unrelated medical or psychiatric disorders may vary in severity over time or even follow a cyclic pattern but one that is not linked to the menstrual cycle in the same way as PMDD. Sometimes symptoms of an unrelated disorder may worsen during the premenstrual phase of the cycle (premenstrual magnification) and be confused with PMDD. Remember that the symptoms of PMDD are gone completely during the week after menses.


How common is pmdd?

There are different types of PMDD, but remember that for the diagnosis to be PMDD, symptoms must be absent during the week following menses. Here are some examples:

Symptoms begin at ovulation (mid-cycle) and worsen gradually as menses approaches and end shortly after menses begins
Symptoms begin during the week before onset of menses and end shortly thereafter
Symptoms appear briefly at ovulation (mid-cycle), disappear for a few days and then return as menstruation approaches
Symptoms begin at ovulation, worsen and persist until menses ends
The symptoms of PMDD may differ from woman to woman. For example, one woman may experience anger and irritability, difficulty concentrating, overeating, insomnia, and feeling out of control while another woman might complain of depression, anxiety, loss of interest, fatigue, and sleeping too much.

Some women may have a medical or psychiatric illness that comes and goes. Unless it is linked to the phases of the menstrual cycle, it is not PMDD.

Also, some women may have other medical or psychiatric conditions that worsen during the premenstrual phase, so sometimes it is difficult to know if PMDD is also present as a separate disorder.

The main point: If you think you might have PMDD be sure to read through our section on how it is diagnosed and consider an evaluation by a qualified professional. Visit the ‘do I have it?’ section


How is PMDD treated?

Over the years, many treatments have been used for premenstrual symptoms, for premenstrual syndrome (PMS), and most recently for premenstrual dysphoric disorder (PMDD). Until recently, few of these treatments were evaluated in carefully designed research studies and even fewer were shown to be effective. There are now three medications (fluoxetine , paroxetine controlled-release and sertraline ) that have been approved by the United States Food and Drug Administration (FDA) for treating PMDD. Nonetheless, many treatments of less well established value remain in widespread use and some women find them to be quite satisfactory. When we discuss treatments for PMDD here, we’ll base our comments on the best available research data, the opinions of experienced clinicians, and a generous sprinkling of common sense.

There are 3 broad approaches to treating PMDD. While most experts recommend a combination of all 3, there have been no scientific studies to determine if combination treatment is really the best approach. It is likely that the best approach or combination of approaches will vary from woman to woman based on things like symptom severity and which symptoms are most troublesome.

Here are the 3 approaches with some examples of each:

Medications – including antidepressants, antianxiety drugs, analgesics, hormones and diuretics.
Psychobehavioral – including exercise and psychotherapies (cognitive-behavioral, coping skills training, relaxation).
Nutritional – including diet modification, vitamins, minerals and herbal preparations.


Helpful links and resources

American Psychiatric Association
1400 K Street NW
Washington, DC 20005
(202) 682-6000

The American Psychiatric Association is a medical specialty society with over 40,500 U.S. and international physician members. Free publications on mental disorders and their treatment are available online.

Anxiety Disorders Association of America
8730 Georgia Avenue
Suite 600
Silver Spring, MD 20910
(240) 485-1001

The Anxiety Disorders Association of America promotes the prevention and cure of anxiety disorders and works to improve the lives of all people who suffer from them. The organization provides information, resources and referrals online.

Center for Women’s Mental Health
Massachusetts General Hospital
55 Fruit Street
Boston, MA 02114
(617) 724-2933

Provides critical up-to-date information on PMS and PMDD with the goal of providing women with information to make informed decisions about their care.

Depression and Bipolar Support Alliance
730 N. Franklin St
Suite 501
Chicago, IL 60610
(312) 642-0049

The Depression and Bipolar Support Alliance works to educate patients, families, professionals, and the public concerning the nature and treatment of depressive and manic-depressive illness. The organization fosters self-help groups.

Madison Institute of Medicine, Inc
7617 Mineral Point Road
Suite 300
Madison, WI 53717
(608) 827-2470

Madison Institute of Medicine has comprehensive collections of literature on specific mental health topics: lithium, bipolar disorder treatment and obsessive compulsive disorder. It also publishes patient guides on these and other mental health topics.

Mental Help Net
570 Metro Place North
Dublin, OH 43017
(614) 764-0143

The goal of Mental Help Net is to provide an easy-to-use, friendly resource to access all the mental health topics on the Internet.

National Alliance for the Mentally Ill
Colonial Place Three
2107 Wilson Blvd, Suite 300
Arlington, VA 22201
(703) 524-7600

The National Alliance for the Mentally Ill focuses on support to persons with serious brain disorders and to their families. NAMI has over 1,000 state and local affiliates and has an online bookstore.

National Institute of Mental Health
6001 Executive Blvd, Rm. 8184
MSC 9663
Bethesda, MD 20892
(301) 443-4513

The National Institute of Mental Health works to diminish the burden of mental illness through research. Free publications may be ordered online.

National Library of Medicine
8600 Rockville Pike
Bethesda, MD 20894
(888) 346-3656

The National Library of Medicine provides online health information and library services. Free access and online searching of the world’s largest medical library, MEDLINE-PubMed, is available on this site.

National Self-Help Clearinghouse
City University of New York
365 5th Avenue, Suite 3300
New York, NY 10016
(212) 817-1822

The National Self-Help Clearinghouse facilitates access to self-help groups and works to increase the awareness of the importance of mutual support.

National Women’s Health Information Center
1828 L Street NW
Suite 625
Washington, DC 20036
(202) 223-8224

National Women’s Health Information Center is a service of the Dept of Health and Human Services. A wide variety of women’s health-related articles are online and the site is a gateway to a vast array of federal and other women’s health information.

PMS Access: National Women’s Health Hotline
1289 Deming Way
Madison, WI 53717
(800) 558-7046

Established in 1985, PMS Access provides information packets on PMS, as well as menopause, natural hormone replacement therapy and other important women’s health concerns. Information on these topics is also provided online.

Sarafem (fluoxetine)
Eli Lilly and Company
Lilly Corporate Center
Indianapolis, IN 46285
(800) 545-5979

A patient information resource on premenstrual dysphoric disorder and on Sarafem (fluoxetine).

Women’s Health Resource Center
3119 43rd Ave
Edmonton AB
Canada, T6T 1C7
(780) 468-9633

Resource Center with information on PMS and PMDD. Additionally contact information is given for Canadian organizations and individuals knowledgeable on the treatment of these disorders.

Zoloft (sertraline) for PMDD
Pfizer Pharmaceutical, Inc.
235 East 42nd Street
New York, NY 10017
(800) 438-1985

A patient information resource on premenstrual dysphoric disorder and on Zoloft (sertraline).


Drs. John Greist, James Jefferson and David Katzelnick are recognized nationally and internationally for their contributions to medical research focused primarily on the psychopharmacology of mood and anxiety disorders, behavior therapy, computer applications in clinical medicine and population-based effectiveness studies.

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