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Is Extremely Bad PMS Normal?

Premenstrual dysphoric disorder vs. PMS vs. clinical depression
PHOTO: Katie Buckleitner

The (incredibly sexist) joke about premenstrual syndrome (colloquially PMS) is that it drives people to do mean, crazy things. But if you've ever had PMS yourself, you understand. There are few things more disorienting than watching your body inflate every month with water retention, or having agonizing headaches for a week just because your period is coming. So yeah, maybe it makes you a little mean. But wouldn't anyone who feels like shit half of every month be mean, too? (Yes.)

A small percentage of people who menstruate feel this even more, and have something called premenstrual dysphoric disorder (PMDD), which is essentially an extreme version of PMS that comes with symptoms similar to clinical depression. Like PMS, PMDD is tied to the menstrual cycle. But unlike PMS, PMDD is severe enough that it has a negative effect on your school/work life, your personal life, and your general ability to function in the two weeks before your period starts.

Two specialists, Dr. Shari Lusskin, a clinical professor of psychiatry, obstetrics, gynecology, and reproductive science at Mount Sinai's Icahn School of Medicine, and Dr. Alexandra Sacks, a reproductive psychiatrist in New York City, explained what makes PMDD so bad, and what a doctor looks for when diagnosing it.

What causes PMDD

Like most disorders related to women's health, doctors aren't yet totally sure what causes PMDD, though Sacks said it's certainly something researchers are interested in. The leading theory is that it's rooted in a sensitivity to the natural hormone fluctuations that occur during the menstrual cycle.

"In women who have PMDD, the hormone changes in their menstrual cycle may impact their serotonin levels, which is a chemical in the brain that your brain cells use to regulate all sorts of physical, emotional, and behavioral experiences but includes mood, attention, sleep, [and] pain," Sacks said.

Per the theory, your hormones and brain are connected by a system called the hypothalamic-pitutiary-gonadal axis, and through this system, hormonal fluctuations produced by the ovaries (part of a normal menstrual cycle) impact the hypothalamus and pituitary areas of the brain, which impacts mood. Sacks clarified that women with PMDD don't necessarily have high or low levels of hormones or any physical problems with their ovaries—it's more a matter of how sensitive your body is to the levels of hormones present.

PMDD vs. regular PMS

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According to a 2018 study in Clinical Obstetrics and Gynecology, about three to eight percent of menstruating women meet the diagnostic criteria for PMDD. It was added to the DSM-5, a handbook used by medical professionals to diagnose mental health disorders, in 2013. "This gave it much greater legitimacy for the millions of women who were suffering worldwide," Sacks said. "And it just speaks to the importance of how much more research is needed in the field of women's mental health."

Lusskin said "up to 80 percent of women have premenstrual syndrome" and experience mood and body changes (like bloating and breast tenderness). "But they don't meet the criteria for PMDD, which is defined as having at least thirty percent worsening—you have to have a significant decrease in mood with a substantial impact on functioning."

The symptoms for PMDD are similar to those of PMS, but more severe. Sacks said to officially diagnose someone with PMDD, a doctor will look for five or more combined emotional, physical, and behavior symptoms. These are things like mood swings, anxiety, a feeling of hopelessness, trouble concentrating, change in appetite, trouble sleeping or oversleeping, breast tenderness or swelling, bloating, et cetera. And they should be severe enough that they impact your day-to-day function when you're experiencing them.

PMDD vs. clinical depression

If the symptoms of PMDD look familiar it's because they are. Part of what makes PMDD tricky to diagnose is that it so closely resembles other mental disorders, particularly clinical depression and anxiety. Lusskin said the key difference between PMDD and general mood disorders is that PMDD is linked to the menstrual cycle and symptoms don't persist all month long. For a PMDD diagnosis as opposed to clinical depression, doctors look for symptoms that start around the time of ovulation (about two weeks after the first day of your period) and subside shortly after your next period starts, according to Lusskin.

To identify a pattern, Lusskin said your doctor will ask you to track your symptoms in real time instead of retrospectively, when it's easy to point at any symptoms you were having and blame them for the period that you know showed up three days later. What the doctor is looking to rule out is symptoms that last all month long but get worse around the time of your period, which would technically be something more like depression or panic disorder than PMDD.

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Sacks said the doctor will look for symptoms that accompanied every menstrual cycle for the past year, but may only ask you to track symptoms for two months in a row before making a diagnosis and starting treatment. They'll also ask about medical history (to rule out other mood disorders) and ask about any recent changes in birth control.

"You really want to see this as a pattern in your life not impacted by anything else—not other conditions or medications," Sacks said. If it seems that your symptoms only started showing up or got worse around the time you switched birth control medication, your doctor will offer the option of switching to a different contraceptive before diagnosing with PMDD.

Treating PMDD

Even though the symptoms are similar, differentiating between PMDD and depression or PMS is important because the treatment options are subjective to each condition. Like depression, PMDD is also often treated with an SSRI. But unlike depression, a doctor might suggest you only take an SSRI during the two weeks of the month that your symptoms appear for PMDD, while someone with depression takes an SSRI continuously.

There's also a difference in how quickly the SSRI kicks into action. "SSRIs have a quick onset of action for PMDD, within one to two days," Lusskin said. "Whereas it takes up to six or eight weeks to get a response for depression." The research on this is still being conducted, but medical professionals believe this quick action has something to do with the fact that SSRIs can impact how progesterone and estrogen impact mood. Researchers believe PMDD is a hormonal sensitivity, so this would make sense.

It may also help to level out hormonal fluctuations. Another common treatment option is to prescribe the birth control pill Yaz, which has been shown in clinical studies to reduce symptoms of PMDD because, unlike most other contraceptives, it contains drospirenone (a synthetic version of the hormone progesterone). Yaz also targets another hormone that works as a diuretic and therefore helps to reduce some of the physical symptoms of PMDD, like water retention that causes bloating.

Sacks added that your doctor may also suggest talk therapy and lifestyle approaches, like increasing exercise, decreasing alcohol and drug use, decreasing caffeine and sugar intake, and just generally eating and acting healthfully (which feels incredibly counterintuitive when you're depressed, but c'est la vie).

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The important thing about the treatment for PMDD is that it's highly individualized. While there isn't a cure, per say, treatment can help some women feel much more "normal" leading up to their period, so to speak. Which is just to say that, if you think you're experiencing PMDD, you should absolutely bring it up with your doctor. Whether it's PMDD or something else (like depression or another mood disorder) there's almost certainly something that can be done to help you feel less "meh."

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This article originally appeared on Cosmopolitan.com. Minor edits have been made by the Cosmo.ph editors.