Understanding and Treating Premenstrual Dysphoric Disorder (PMDD): Diagnosis, Causes, and Management Strategies

This episode, hosted by psychiatrist Dr. Tracey Marks, provides a comprehensive overview of Premenstrual Dysphoric Disorder (PMDD), distinguishing it from the more common Premenstrual Syndrome (PMS). Addressing a viewer's question about differentiating PMDD from Bipolar II, Dr. Marks explains that PMS affects about 80% of women with mild to moderate mood changes, while PMDD is a severe form impacting 3-8% of women, characterized by drastic emotional and physical symptoms. PMDD was officially recognized as a diagnosis in the DSM-5 in 2013, requiring at least five out of eleven specific symptoms to manifest the week before menstruation, improve within days of the period starting, and become minimal or absent the week after.

A key distinction highlighted is the cyclical nature of PMDD symptoms, which strictly resolve post-menstruation, unlike the more persistent mood fluctuations seen in conditions like Bipolar II. The underlying physiological cause of PMDD is attributed to a rapid drop in progesterone during the luteal phase. Progesterone is converted into allopregnanolone, a hormone that binds to GABA-A receptors, similar to alcohol and benzodiazepines, thereby decreasing anxiety and depression. For women sensitive to this hormonal drop, the experience can be akin to withdrawing from Xanax or alcohol, explaining the intense and debilitating symptoms.

For diagnosis, Dr. Marks recommends keeping a daily symptom diary for two months, suggesting tools like the official Daily Record of Severity of Problems or her adapted diary. Treatment options include Selective Serotonin Reuptake Inhibitors (SSRIs) such as paroxetine, sertraline, and fluoxetine, which are FDA-approved and can be taken intermittently (7-10 days before menstruation) or continuously. SSRIs work faster for PMDD by accelerating the conversion of progesterone to allopregnanolone. Hormonal treatments, specifically the combination birth control pill drospirenone and ethinyl estradiol (Yaz), are also FDA-approved. A more drastic option, Leuprolide, induces medical menopause by shutting down estrogen and progesterone. Non-pharmacological interventions include diet modifications (eliminating caffeine, sugar, nicotine, alcohol, minimizing sodium), lifestyle changes (7-9 hours of sleep, regular exercise), and nutritional supplements like calcium, vitamin B6 (with caution for dosage), magnesium, and vitamin E. Herbal remedies such as agnus-castus fruit extract (chasteberry) and ginkgo biloba are also mentioned.

The episode underscores the critical importance of accurate diagnosis to ensure appropriate treatment and avoid mislabeling conditions. It emphasizes the profound impact PMDD can have on a woman's quality of life and highlights that effective management can lead to significant improvement. By detailing the physiological mechanisms linking hormonal fluctuations to mental health, the discussion illustrates the intricate interplay between endocrinology and psychiatry, offering a nuanced approach to understanding and treating cyclical mood disorders.

"PMDD stands for premenstrual dysphoric disorder, and this is not to be confused with premenstrual syndrome, or PMS."

"PMDD is a severe form of PMS. It's almost like turning into a werewolf when the full moon rises."

"PMDD became an official diagnosis in 2013 with the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders."

"You must have five of them the week before your period starts. Then the symptoms start to improve just within days of starting your period. Then they become minimal or absent the week after your period."

"Progesterone is converted to another hormone called allopregnanolone. allopregnanolone binds to GABA-A receptors. This is the same receptor that alcohol and benzodiazepines like Xanax bind to."

"So for women who are sensitive to this drop, what you can experience can be similar to withdrawing from Xanax or alcohol, which is a terrible feeling."

"The main medication treatment is SSRIs, or selective serotonin reuptake inhibitors."

"You would start taking the medication seven to 10 days before your menstrual period is supposed to start. You can stop taking it after your period starts, which is called intermittent dosing."

"Paroxetine, sertraline, and fluoxetine are all FDA-approved for PMDD to take intermittently or daily."

"A more drastic approach though is to use a medication called Leuprolide. This medication shuts down your estrogen and progesterone. And this effectively is a medical menopause."

"You don't want take more than 100 milligrams though, because higher doses can cause peripheral neuropathy, and this can feel like burning, pain, or even weakness in your hands and feet."

"There are some herbal remedies that have been shown in studies to be helpful and this would be agnus-castus fruit extract, also known as chasteberry, and ginkgo biloba."