PMDD or “Premenstrual Dysphoric Disorder” is a relatively recent re-classification of women who experience significant mood changes in the weeks leading up to their menstrual cycle. Certainly in some cases, adding ways to label and classify patients doesn’t translate to better treatment. In this case, reorganizing women with PMDD appropriately may not only lead to better treatment, but may actually honour the severity of the challenges these women face each month.

Women with PMDD are different. We witness them face significant changes in the two weeks leading up to their period (the luteal phase). Their hormones and brain chemistry are different, their experience of pain is different, and (of course) as a result, their treatment should be different. Women with PMDD experience significant mood changes, tearfulness and sensitivity, food cravings, relationship conflict and difficulty concentrating. Their symptoms impact their quality of life, work and relationships(1), often leading to lost work days or social withdrawal. As if the emotional symptoms weren’t enough, these women also experience physical symptoms including breast tenderness and bloating (but not menstrual cramps, which happen for a different reason altogether).

The unique feature of PMDD that separates it from depression, or other mood disorders is the distinct shift a woman experiences the moment her period starts, with the week after menses often being the “best” week of the month. Women often note that they feel there are “two versions” of themselves. The anxious, depressed and debilitated version before her period, and the calmer, more confident and happy version that arrives after her period.

Physician surveys in the United States show that less than 20% of doctors use menstrual symptom tracking, (required for accurate diagnosis)(2). Meaning that many women are not being accurately evaluated in the first place, and are left under-supported and untreated.

Pathways including the serotonin system (responsible for mood, and the common target for antidepressants) have been implicated, which explains the conventional prescription of SSRI based antidepressants. Interestingly women with PMDD may not have different sex hormone levels (estrogen and progesterone) than women without PMDD, but may be more sensitive to the monthly fluctuation of these hormones instead(1). Conventionally options including the birth control pill, or other ovulation-blocking protocols are being explored to stop the daily change in hormones.

Estrogen influences the brain’s serotonin reception (responsible for happiness, craving control) and progesterone is a precursor for GABA-like neuro-compounds (responsible for calming anxiety). Women with PMDD are more sensitive to the ups and downs of hormones through the month, leaving them feeling vulnerable in the week prior to menses when female sex hormones begin to plummet.

The diagnosis for PMDD is made by having women assess the following symptoms over the last year of her menstrual cycle:

  • Markedly depressed mood, feelings of hopelessness, or self-deprecating thoughts
  • Marked anxiety, tension, feelings of being “keyed up” or “on edge”
  • Marked affective lability (eg, feeling suddenly sad or tearful or experiencing 
increased sensitivity to rejection)
  • Persistent and marked anger or irritability or increased interpersonal conflicts
  • Decreased interest in usual activities (eg, work, school, friends, and hobbies)
  • Difficulty in concentrating
  • Lethargy, easy fatigability, or marked lack of energy
  • Marked change in appetite, overeating, or specific food cravings
  • Oversleeping or insomnia
  • A sense of being overwhelmed or out of control
  • Other physical symptoms, such as breast tenderness or swelling, headaches, 
joint or muscle pain, a sensation of bloating, or weight gain

The symptoms have to have occurred in at least 6 of the last 12 months, and significantly impact work, school or social functioning.

A diagnosis alone can help women get on the right track for improving her symptoms, and exploring the individualized options for improving mood and regulating the monthly fluctuations in symptoms. Working with an ND can help women investigate the hormonal, neurological or physical symptoms associated with PMDD, and can offer safe, effective treatment options.


  1. Hantsoo L, Epperson CN. Premenstrual Dysphoric Disorder: Epidemiology and Treatment. Curr Psychiatry Rep. 2015 Nov;17(11):87.
  2. Craner JR, Sigmon ST, McGillicuddy ML. Does a disconnect occur between research and practice for premenstrual dysphoric disorder (PMDD) diagnostic procedures? Women Health. 2014;54(3):232–44.