Updated: Apr 5
You may have heard of a condition called PMDD, or premenstrual dysphoric disorder which is a more severe form of PMS impacting the mood. PMDD has a diagnostic criteria according to the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders), with symptoms appearing the week before menstruation, and lifting within a few days of your period. (These symptoms are minimal or absent in the weeks following your period).
PMDD is defined as having at least 5 of the following 11 symptoms (including at least 1 in the first 4 listed) present in most menstrual cycles in the past year:
Marked affective lability (e.g., mood swings; feeling suddenly sad or tearful, or increased sensitivity to rejection)
Marked irritability or anger or increased interpersonal conflicts
Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts
Marked anxiety, tension, and/or feelings of being keyed up or on edge
Decreased interest in usual activities (e.g. work, school, friends, hobbies)
Difficulty in concentration
Lethargy or marked lack of energy
Marked change in appetite; overeating; or specific food cravings
Hypersomnia or insomnia
A sense of being overwhelmed or out of control
Physical symptoms such as breast tenderness or swelling, joint or muscle pain, sensation of bloating, or weight gain
These symptoms are associated with clinically significant distress or interference with work, school, usual social activities, or relationships with others (e.g., avoidance of social activities; decreased productivity and efficiency at work, school, or home).
Conventional treatment of PMDD is typically a combination of an antidepressant (SSRI) medication and hormonal birth control. Although I do agree that in some cases this will make a significant positive impact, neither of these treatments address the root cause and are not necessarily a long-term solution. What if we could first understand why the hormonal changes through your menstrual cycle are causing such extreme symptoms?
Areas to investigate for root cause treatment:
As in most hormonal conditions, there is not one single cause of PMDD and there are often stacking factors. Here is a starting list of factors that can be investigated. Please note: these factors also apply with PMS in general, where the causes may be similar but the intensity of symptoms differ.
Progesterone levels: Progesterone is produced in the second half of the menstrual cycle (luteal phase), and low production of progesterone, an early decline in hormone levels, or sensitivity to changes in progesterone is often a significant part of PMDD.
Other hormone imbalances: Estrogen dominance, imbalance in androgen levels, and irregular ovulation can also contribute to mood changes, and can be diagnosed through hormone testing.
Nutrients deficiencies: Deficiencies in vitamin B12, iron, magnesium, zinc, vitamin D and vitamin A can impact mood and neurotransmitter production. These deficiencies may be from diet choices, or due to problems with absorption.
Significant life stress: When stress levels are chronically high, or there is a history of trauma, the normal ebb and flow of emotions around menstruation can be significantly amplified. Taking a close look at stress hormone patterns can help to re-regulate the mood and hormones.
Thyroid imbalance: Thyroid issues seem to be epidemic in women, ranging from mild ‘subclinical hypothyroidism’ to fully overt thyroid dysfunction. A significant symptom of underactive thyroid is depression, along with fatigue and other signs such as dry skin, hair loss, constipation, feeling cold, poor concentration and feeling unrefreshed from sleep. A full thyroid assessment is recommended in all cases of PMDD.
Methylation problems: A process called methylation which impacts cellular levels of vitamin B12 and folate can impact overall neurotransmitter levels and hormone balance. Assessment through personal genetics may be indicated to support overall mood, and hormone metabolism. Methylation issues tend to be amplified with a vegetarian or vegan diet due to lower intake of B-vitamins.
Histamine intolerance: A new understanding of PMS and PMDD comes from my colleague Dr. Lara Briden, who shares that histamine intolerance causes anxiety, headaches, fatigue, brain fog, insomnia, and breast tenderness. Histamine levels rise and fall along with estrogen, so they peak just before ovulation, and again the week before menstruation. If you also have breast pain, menstrual pain, migraines that are relieved by antihistamines, anxiety at ovulation, this is another avenue to investigate (read Dr. Lara Briden’s article here).
Depending on other health factors (ex. example weight gain, allergies, migraines, menstrual pain, nutrition), family history, menstrual history and stress levels, the next step is to do lab testing to confirm some of the layers. Testing could include:
Bloodwork for hormones: Day 21 estrogen, progesterone
Bloodwork for a full thyroid panel (including free T3, free T4 and thyroid antibodies)
DUTCH urine test for estrogen metabolites, progesterone and androgen levels
Bloodwork or saliva panel for adrenal hormones (cortisol and DHEA)
Nutrients we can accurately test for with bloodwork: iron, vitamin B12, vitamin D, magnesium, zinc
Personal genetics to look at methylation pathways, issues processing nutrients, and detox pathways
Putting it all together:
If your mood changes are severe before your period, you’re not alone. There are many potential causes for PMDD that contribute to debilitating premenstrual depression and anxiety. The key is to test and assess first – learn where the imbalances are and then treat them systematically. In most cases, there are several layers rather than one primary cause: for example subclinical hypothyroidism, cortisol imbalance and low progesterone; or histamine intolerance compounded by nutrient deficiencies.
There is hope for PMDD, and through our detective work together we can determine the root cause(s), and make a positive impact on your overall health and well-being.