Premenstrual Dysphoric Disorder


Premenstrual dysphoric disorder (PMDD) is a condition marked by severe depression, irritability, and tension before menstruation. These symptoms are more severe than those seen with premenstrual syndrome (PMS).

Causes, incidence, and risk factors

The causes of PMS and PMDD have not been identified, although social, cultural, biological, and psychological factors all appear to be involved. Researchers estimate that PMDD affects between 3% and 8% of women in their reproductive years.

Major depression is very common with PMDD, although PMDD can occur in women who do NOT have a history of major depression.

Studies have found that women who have seasonal affective disorder (SAD), a form of depression characterized by annual episodes of depression during fall or winter that improve in the spring or summer, are likely to also have PMDD.


The symptoms of PMDD are similar to those of PMS, but they are generally more severe and debilitating. Symptoms occur during the last week of most menstrual cycles and usually improve within a few days after the period starts.

Five or more of the following symptoms must be present:

Feeling of sadness or hopelessness, possible suicidal thoughts
Feelings of tension or anxiety
Panic attacks
Mood swings marked by periods of teariness
Persistent irritability or anger that affects other people
Disinterest in daily activities and relationships
Trouble concentrating
Fatigue or low energy
Food cravings or binge eating
Sleep disturbances
Feeling out of control
Physical symptoms, such as bloating, breast tenderness, headaches, and joint or muscle pain
Signs and tests

There are no physical examination findings or lab tests specific to the diagnosis of PMDD. A complete history, physical examination (including a pelvic exam), and psychiatric evaluation should be conducted to rule out other potential conditions.

Keeping a calendar or diary of symptoms can help women identify the most troublesome symptoms and the times they are likely to occur. This information may help the health care provider diagnose PMDD and determine the appropriate treatment.


Women with PMDD may be helped by the following:

Regular exercise 3 to 5 times per week
Adequate rest
A balanced diet (with increased whole grains, vegetables, fruit, and decreased or no salt, sugar, alcohol, and caffeine)
In addition, it is important to keep a diary or calendar to record the type, severity, and duration of symptoms.

Selective serotonin-reuptake inhibitors (SSRIs) are antidepressant drugs that can treat PMDD. SSRIs include fluoxetine (Prozac, Sarafem), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), and citalopram (Celexa).

SSRIs can relieve physical symptoms, irritability, and tension. In fact, SSRIs appear to relieve PMS-related depression much faster than major depression. Women with PMDD, but without major depression, need only take SSRIs during the 14-day premenstrual period. This approach, called intermittent treatment, causes fewer side effects than when SSRIs are used to treat major depression.

Nutritional supplements — such as vitamin B6, calcium, and magnesium — may be recommended. Pain relievers such as aspirin or ibuprofen may be prescribed for headache, backache, menstrual cramping and breast tenderness. Diuretics may be useful for women who experience significant weight gain due to fluid retention.

Expectations (prognosis)

After proper diagnosis and treatment, most women with PMDD find that their symptoms go away or drop to tolerable levels.


PMDD symptoms may become severe enough that they interfere with a woman’s daily life. Women with depression may have worse symptoms during the second half of their cycle and may require medication adjustments.

As many as 10% of women who report PMS symptoms, particularly those with PMDD, have had suicidal thoughts. The incidence of suicide in women with depression is significantly higher during the latter half of the menstrual cycle.

PMDD may be associated with eating disorders and smoking.

Calling your health care provider

Call 911 immediately if you are having suicidal thoughts.

Call for an appointment with your health care provider if:

PMS symptoms do not improve with self-treatment
PMS symptoms are interfering with your daily life

Update Date: 4/8/2003

Updated by: A.D.A.M. editorial.

A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare Commission ( URAC’s accreditation program is the first of its kind, requiring compliance with 53 standards of quality and accountability, verified by independent audit. A.D.A.M. is among the first to achieve this important distinction for online health information and services. Learn more about A.D.A.M.’s editorial process. A.D.A.M. is also a founding member of Hi-Ethics ( and subscribes to the principles of the Health on the Net Foundation (



PMS has become a household word and the brunt of many jokes. According to a recent survey, many women remain unaware of its more severe form, premenstrual dysphoric disorder or PMDD. Among 500 women recently surveyed, 8 out of 10 did not know that severe premenstrual problems have been officially classified as PMDD, nor did they know that such problems can be diagnosed and treated. Even more disturbing is that the one in 4 respondents who described their premenstrual symptoms as strong or severe were among those unaware of PMDD.

œWe™ve got to educate women that they do not have to tolerate debilitating premenstrual symptoms,? said Phyllis Greenberger, MSW, Executive Director of the Society for Women™s Health Research, which commissioned the Yankelovich Partners survey (sponsored by a grant from Eli Lilly, manufacturers of Prozac). œWomen have a right to know if what they are experiencing month to month is actually PMDD, and how to get help.?

What is PMDD?
PMDD stands for Premenstrual Dysphoric Disorder. It is the acronym for the more severe form of PMS (Premenstrual Syndrome). Like PMS, PMDD occurs the week before the onset of menstruation and disappears a few days after. PMDD is characterized by severe monthly mood swings and physical symptoms that interfere with everyday life, especially a woman™s relationships with her family and friends. PMDD symptoms go far beyond what are considered manageable or normal premenstrual symptoms.

PMDD is a combination of symptoms that may include irritability, depressed mood, anxiety, sleep disturbance, difficulty concentrating, angry outbursts, breast tenderness and bloating. The diagnostic criteria emphasize symptoms of depressed mood, anxiety, mood swings or irritability. The condition affects up to one in 20 American women who have regular menstrual periods.

What is the Difference Between PMS and PMDD?
The physical symptom list is identical for PMS and PMDD; while the emotional symptoms are similar, they are significantly more serious with PMDD. In PMDD, the criteria focus on the mood rather than the physical symptoms. With PMS, sadness or mild depression is not uncommon. With PMDD, however, significant depression and hopelessness may occur; in extreme cases, women may feel like killing themselves or others. Attributing suicidal or homicidal feelings to œit™s just PMS? is inappropriate; these feelings must be taken as seriously as they are in anyone else and should be promptly brought to the attention of mental health professionals.

Women who have a history of depression are at increased risk for PMDD. Similarly, women who have had PMDD are at increased risk for depression after menopause. In simplest terms, the difference between PMS and PMDD can be likened to the difference between a mild headache and a migraine.

While nearly all of the women in the survey reported experiencing premenstrual symptoms in the last 12 months, nearly half (45 percent) have never discussed PMS with their doctors. Even among women with strong or severe symptoms, more than one out of four (27 percent) had never talked with their doctors about PMS, despite the fact that most in this group reported that the symptoms interfere with their daily activities.

When asked about their reluctance to seek medical treatment even if they thought they had PMDD, nine of every 10 respondents who would not seek treatment said that they could cope with their problems on their own, and about one of every four felt their doctors would not take their complaints seriously if they did bring it up.

PMDD has recently been listed as an official psychiatric diagnosis. The fear of this stigma may contribute to women™s reluctance to discuss it with their doctors. œI frequently work with patients who have waited years to ask a doctor about premenstrual problems or have been turned away by their health care provider when they tried to discuss symptoms,? said Jean Endicott, Ph.D., Director of the Premenstrual Evaluation Unit at Columbia Presbyterian Medical Center. œThey fear becoming the target of jokes or that seeking help is a sign of weakness. Informing women and providers about diagnosing and treating PMDD helps clear the way to effective medical care.?

Survey respondents reporting strong or severe symptoms revealed the classic PMDD features of impaired social functioning and predominant mood symptoms. Two out of three women (67 percent) with moderate, strong or severe symptoms reported interference with their daily activities. One third of these women said they find their mood changes, not their physical symptoms, to be most bothersome.

The survey also found that women with strong or severe premenstrual symptoms were five times as likely as those with moderate symptoms (26 percent vs. 5 percent) to experience these symptoms every month. A key part of the PMDD diagnosis is determining whether symptoms have occurred during most cycles of the past year and are clearly documented for at least two consecutive menstrual cycles.

When asked what they would do if they thought they had PMDD, two out of three women (66 percent) in the survey said they would most likely get information from their obstetrician or gynecologist, as opposed to consulting friends or using Internet resources. This is encouraging, according to Dr. Endicott, because the American College of Obstetricians and Gynecologists (ACOG) issued treatment guidelines for premenstrual symptoms earlier this year. It recommended the newer form of anti-depressant medications called œSSRIs? (selective serotonin reuptake inhibitors) as the preferred method for treating symptoms associated with PMDD.




How do you know if you really have PMS or PMDD? If you think you may, start keeping a PMS Symptom Diary. List the dates of your period, and which symptoms you have (and their severity) on the 10 days preceding, as well as following, your period. After tracking your symptoms for at least 2 cycles, bring this diary with you to consult your physician, along with a list of all medications you are taking (including prescriptions, over-the-counter medications, herbs, vitamins, and supplements). Your doctor will give you a complete history and physical exam to rule out other possibilities (such as hypothyroidism, hypoglycemia or depression); no specific physical findings or tests can confirm the diagnosis of PMS.

If you think you have PMS or PMDD, take Dr. Donnica™s Decisionnaireâ„¢. Check off all the points that apply to you and take this list with you when you consult your physician.

Are you having relationship difficulties with your spouse, family members, or coworkers?
Are you getting enough sleep (do you awake feeling refreshed?)?
Do you get 20 minutes of aerobic exercise 3-4 times per week?
Do you drink alcoholic beverages?
Is your diet high in red meat, salty foods or sugar?
Do you have mood swings or crying jags in the 10 days before your period?
Do you actually gain weight the few days before your period (that goes away when you™ve finished)?
__ Are you on birth control pills?

Treatment of PMDD:
For general PMS relief, your doctor may recommend birth control pills or switching to another pill if you already take one. Other prescription medical interventions will depend upon the types of symptoms that most affect you. For example, if you are affected by bloating and weight gain, your doctor may prescribe a certain type of diuretic (sprionolactone) to help your body eliminate the excess water. If severe breast tenderness is a major complaint, birth control pills are often recommended. If this is insufficient, your doctor may prescribe a medication called bromocriptine to lower your levels of prolactin (a hormone linked to breast tenderness) or an androgen called Danazol®. For dysmenorrhea (painful periods), prescription prostaglandin inhibitors such as Naprosyn® or Ponstel® can be very effective if over-the-counter non-steroidal anti-inflammatory drugs such as Motrin® or Advil® were not sufficient.

If you have severe PMS symptoms that interfere with your responsibilities or relationships, or if you tell your physician that you just feel out of control on those days, s/he may suggest that you try one of several prescription medications for PMDD symptoms. The choices are diverse and represent two major classes of anti-depressant medications: the selective serotonin reuptake inhibitors (SSRI™s) and the tricyclic antidepressants. The SSRI™s include medicines such as Prozac®, Effexor®, and Zoloft®. They are generally well tolerated, work quickly, and reduce or eliminate disturbing emotional symptoms for many women, often at doses significantly lower than those required to treat depression. A recent study showed that this type of antidepressant medication worked significantly better for the treatment of PMS than the tricyclics, although tricyclics (e.g. Pamelor®, Elavil®) have a role in treating women with severe insomnia or those with combined depression and PMS.

There are many advocates for œnatural? progesterone therapy for PMS. However, to date, multiple controlled clinical trials of progesterone in several dosage forms has failed to show any benefit for the treatment of physical or emotional symptoms of PMS.

In addition to conventional therapies, many women with PMS report that they have been helped by modalities such as biofeedback, relaxation techniques, acupuncture, and massage. My general approach to these types of therapies is that if you find something that works for you — great. For many patients, simple stress-reduction techniques such as taking long, hot baths or meditation are also helpful.

Dr. Donnica™s Top Ten Tips for PMS Management:
Discuss your situation with your physician. Work together to develop a comprehensive treatment plan. Follow it!
If you smoke, quit.
Practice stress management: many of the symptoms of PMS are unpredictable and emotionally draining. This can be very stressful and can exacerbate your condition.
Regular exercise may reduce your risk of PMS altogether; exercising once you have symptoms (even though you may not feel like it) will reduce the symptoms you experience for that cycle.
Take a daily, non-prescription multi-vitamin; discuss any other supplement needs with your physician.
Be sure to get an adequate daily intake of calcium (1,200 mg/day).
Eat a well balanced diet; don™t skip meals.
Reduce intake of caffeine, alcohol, refined sugar, and salt.
Enlist the support and understanding of friends and loved ones.
Try to get regular, sufficient sleep.
Important Questions to Ask Your Physician if You Think You Have PMS or PMDD:
Should I be taking any dietary supplements?
Are there any other illnesses that could be causing my symptoms?
Should I be evaluated for other conditions such as low blood sugar, under-active thyroid, or depression?
Could this be related to any medications I might be taking (including birth control pills)?
Do I have PMS or PMDD?
Could my symptoms be related to perimenopause?
Am I a candidate for prescription drug therapy for this condition?
What medicines should I be taking to combat PMS?
Can PMDD be Prevented?
Because doctors are not exactly sure what causes PMS or PMDD, there is currently no proven prevention. However, you may be able to alleviate some symptoms by leading a healthier lifestyle or changing other medications.

There is no cure, per se, for PMS other than menopause. As discussed above, there are many strategies for effective management, and many interventions, which may decrease the symptoms significantly. Whatever your choice of therapy, remember that you™re not committed to that choice for life! The other good news about PMS unlike other recurrent conditions is that you won™t have it for life: PMS ends with menopause if it hasn™t already disappeared after age 40 (although many of the symptoms of perimenopause are very similar to having PMS). You and your physician will monitor your progress and your comfort level with your treatment plan. If there are factors that change — including your level of satisfaction — discuss this with your physician.

What Men Should Know About PMS and PMDD:
The main thing that men need to know about PMS or PMDD is that jokes about PMS may be hazardous to your health! In all seriousness, PMS is serious and PMDD is very serious. Be supportive and understanding; but most of all, be thankful that you don™t have to go through these symptoms every month.

Created: 11/28/2000 – Donnica Moore, M.D.
Copyright © 2000

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