What is premenstrual dysphoric disorder

Rare severe form of PMS raises need for greater awareness and sensitivity

Thursday, August 27 2020

Premenstrual dysphoric disorder (PMDD) is a rare yet potentially debilitating disorder linked to a woman’s monthly menstrual cycle. An estimated two to five percent of menstruating women report symptoms meeting the diagnostic criteria of this condition at some point during their lives.

A psychiatrist and a gynaecologist share their perspectives on this women’s health issue, and explain how it differs from the more commonly-known premenstrual syndrome (PMS).

“PMDD can affect various aspects of a woman’s life, including family, social, and occupational functioning, however, as with other mood disorders, a significant concern is the potential for women with PMDD to develop suicidal thoughts if they find it difficult to cope with its impact on their lives,” says Dr Lavinia Lumu, a psychiatrist who practises at Akeso Randburg - Crescent Clinic.

She says that this is in contrast to PMS, which about half of women experience at some time between puberty and menopause. “Traditionally, there has been social stigma attached to menstruation, as this was considered a private or taboo subject. As PMDD is usually diagnosed through women self-reporting their symptoms, it is possible that this stigma could have resulted in fewer women seeking assistance for it,” she points out.

Symptoms of PMDD

According to Dr Lumu, to reach a diagnosis of PMDD, a woman should experience a set of five symptoms from the potential range of symptoms listed below. These specifically begin to develop the week before the menstrual period and ease within several days from the onset of menstruation. A diagnosis may be reached when these occur for at least two consecutive monthly cycles in the same year, where other causes have been ruled out.

One of the set of five symptoms should be from the potential symptoms listed directly below:

  • Mood swings
  • Marked irritability or anger
  • Markedly depressed mood
  • Noticeable anxiety and tension.

In addition, the woman should also have another four symptoms, either from the list above, or from the following list:

  • Decreased interest in usual activities
  • Difficulties in concentrating
  • Lethargy and marked lack of energy
  • Marked change in appetite (e.g. overeating or specific food cravings)
  • Insomnia or oversleeping
  • Feeling overwhelmed or ‘out of control’
  • Physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of ‘bloating’ or weight gain.

Although each PMDD sufferer’s experience is unique, some women have described the experience of going through PMDD as ‘feeling like a prisoner in my own body’, ‘very debilitating’, ‘a battle to survive those days, but my family expects that life must continue as usual’.
Some describe acute anxiety, while some have reported uncharacteristic feelings or outbursts of rage, for instance: ‘I feel so angry that at the time that I don’t care what I say or who I say it to. I feel so upset and I even have suicidal thoughts but when the PMDD passes, I feel content and positive again as usual’.

Reaching a diagnosis

“In my practice I’ve met a few women who thought they may have premenstrual dysphoric disorder, however, in most cases the symptoms were attributable to other causes,” adds Dr Marabe Simon Mothiba, a gynaecologist who practices at Netcare Pholoso Hospital in Polokwane.

Dr Mothiba explains that it is essential to consider each woman’s symptoms in the context of her medical and family history, combined with a physical examination and more specific tests that may be required, in order to reach a diagnosis.

“Thyroid disorders are a relatively common possible cause of symptoms such as these, and we would need to exclude thyroid problems and other conditions or factors that might account for the difficulties the woman is experiencing. We ask the patient about the severity of her symptoms, any medications she might be taking, and also explore whether there may be other underlying issues. By exclusion, we reach a diagnosis of PMDD or another underlying medical disorder,” he explains.

Causes of PMDD

Dr Lumu adds that PMDD causes could include genetic factors, psychosocial factors such as stress, and sensitivity to reproductive hormones. “The timing of symptoms of PMDD suggests that hormonal fluctuation plays a key role yet, paradoxically, women with PMDD cannot be distinguished from asymptomatic women in terms of peripheral ovarian hormone levels. Instead, recent research suggests that women with PMDD have an altered or heightened sensitivity to normal hormonal fluctuations, particularly oestrogen and progesterone.”

Although PMDD represents an extreme, Dr Mothiba points out that there are certain physiological effects associated with a woman’s monthly cycle. “These commonly include a drop in serotonin levels around two weeks after the onset of menstruation. Serotonin is sometimes referred to as the ‘happy hormone’ because it appears to have a role in regulating our moods, although it also supports other complex functions for both men and women,” he says. 

Treatment options

“Once a PMDD diagnosis is reached, the management of the condition depends on the severity and the women’s individual circumstances. We start with the more conservative treatment options appropriate to the woman’s condition and circumstances, and where the symptoms are relatively mild, increased exercise can be very helpful,” notes Dr Mothiba.

For patients with more severe symptoms, a multi-disciplinary team, including a gynaecologist and a psychiatrist, supported by other healthcare professionals where needed, adopt a holistic approach to treating this complex condition.

According to Dr Lumu, this may involve antidepressant medicines, such as selective serotonin reuptake inhibitors (SSRIs), prescribed by a psychiatrist. “It appears that SSRIs are helpful with treating anxiety symptoms of PMDD, and psychotherapy can complement this by equipping the woman with cognitive-behavioural coping strategies for long-term resilience during such times. If the woman is not planning a pregnancy, hormonal treatments may be recommended if SSRIs do not offer relief.”

Support from partners and families

Dr Mothiba says that the support of a woman’s partner and family is valuable to those who may be experiencing either PMDD or the more common and milder PMS.

“It must be emphasised that women’s abilities are generally not impaired by their menstrual cycle but it is important that we should acknowledge that menstruation does affect some women in a more profound way,” he says.

“I have sat down with younger patients and explained, ‘PMDD is not something anyone chooses, it’s biological’. Parents and partners should not underestimate how much their support means, and how helpful it can be for women and girls to talk these things through, if they wish to, and be heard with sensitivity and understanding,” Dr Mothiba concludes.


Issued by:           MNA on behalf of Netcare Pholoso Hospital and Akeso Crescent Clinic
Contact:               Martina Nicholson, Graeme Swinney, Meggan Saville and Estene Lotriet-Vorster
Telephone:        (011) 469 3016
Email:                   [email protected], [email protected], [email protected] or [email protected]