Many women experience a worsening of mood symptoms in the second half of their menstrual cycle, between the time of ovulation and menstruation. For some this is an unpleasant experience and for others it can be cripplingly severe.
Mild premenstrual symptoms affect perhaps 75 – 80% of women. Premenstrual Dysphoric Disorder (PMDD) is the more severe form of the condition that affects only about 5 to 10% of women.
It is not clear why some women develop PMDD and others do not. There does not appear to be a relationship between the pattern of changes in estrogen and progesterone hormones throughout the menstrual cycle (the nature of these changes or their magnitude) and the severity of mood symptoms. Rather it seems that the difference may have to do with the sensitivity of the brain to the cyclic changes in hormones that occur normally in the menstrual cycle.
The most common symptoms of premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) are fatigue, bloating, irritability, and anxiety. Other symptoms include the following –
- Sadness, hopelessness, or feelings of worthlessness
- Tension, anxiety, or “edginess”
- Variable moods with frequent tearfulness
- Persistent irritability, anger, and conflict with family, coworkers, or friends
- Decreased interest in usual activities
- Difficulty concentrating
- Fatigue, lethargy, or lack of energy
- Changes in appetite, which may include binge eating or craving certain foods
- Excessive sleeping or difficulty sleeping
- Feelings of being overwhelmed or out of control
- Breast tenderness or swelling, headaches, joint or muscle pain, weight gain
In general, the things that help mood symptoms overall tend to improve premenstrual mood symptoms.
The foundation of treatment of premenstrual mood symptoms is a mood chart that also tracks the menstrual cycle because there is significant variation among women with regard to the time course of symptoms and the response of mood symptoms to interventions.
A mood chart also makes it possible to distinguish between women who have ongoing depression that is worsened in the premenstrual period, and women whose depression is limited to the period before menses. Women with ongoing depression should receive aggressive treatment for that depression, and usually if there depression resolves so too does the premenstrual worsening of depression. Only women whose depression is confined to the period before menses are considered to have PMDD.
Several natural treatments have been shown to improve symptoms in women with PMDD. Usually they are effective on their own for women with milder forms of PMS and PMDD. But it is worth starting with these treatments since they do not have side effects and may boost the effectiveness of prescription medications.
- Exercise can help to reduce stress, tension, anxiety, and depression. We generally recommend a goal of 30 minutes of aerobic exercise at least 5 days a week.
- Mindfulness meditation has also been shown to be effective in reducing premenstrual symptoms. Other relaxation techniques may be helpful including progressive muscle relaxation, self-hypnosis, and biofeedback.
- Vitamin and mineral supplements – Vitamin B6 (up to 100 mg/day) might have a small benefit for women with mild PMS. No more than 100 mg of vitamin B6 should be taken per day.
Selective serotonin reuptake inhibitors (SSRIs) – SSRIs are a highly effective treatment for the symptoms of PMS and PMDD. Studies showed that SSRIs reduced the symptoms of PMDD significantly compared with placebo; between 60 and 75 percent of women with PMDD improve with an SSRI. It may not be necessary to take the medication every day. Taking the SSRI only during the second half of the menstrual cycle may be sufficient.SSRIs should be taken for at least two menstrual cycles to measure their benefit. About 15 percent of women do not experience relief with these drugs after two cycles, in which case an alternative treatment is recommended.
Birth control pills — Some women with PMS or PMDD get relief from their symptoms when they take a birth control pill.
The pill can be taken continuously to avoid having a menstrual period. To do this, the woman takes all of the active pills in a pack and then opens a new pack; the placebo pills are discarded. In theory, taking the pill continuously prevents the usual cyclical hormone changes that could affect mood.
There are also oral contraceptive formulations that are designed to reduce the frequency of menstruation to once every three months, this is almost certainly safer than taking active pills continuously, and probably less safe than monthly cycle contraceptives.
Of the monthly cycle contraceptives , those containing drospirenone are probably most effective, in part because there is a shorter pill free interval of four days rather than seven days with these formulations. In the United States, one birth control pill (Yaz) is approved for the treatment of PMDD. Yaz contains 24 tablets of 20 mcg ethinyl estradiol and 3 mg drospirenone.However, there are some concerns that women who start Yaz might be at higher risk for blood clots in the legs and lungs (but the absolute risk of having a blood clot is very, very low).
Gonadotropin-releasing hormone agonists — Gonadotropin-releasing hormone (GnRH) agonists (eg, leuprolide acetate or Lupron) are a type of medication that causes the ovaries to temporarily stop making estrogen and progesterone. This causes a temporary menopause and improves the physical symptoms (eg, bloating) and irritability caused by PMS and PMDD. However, the medication results in extremely low estrogen levels, which causes severe hot flashes and bone loss over time. Therefore, in addition to the GnRH medicine, women are treated with low doses of estrogen and progesterone to treat the hot flashes, and to prevent bone loss. Although this treatment is very effective, it is complicated and expensive, and is only used if other treatments do not work.
Ineffective treatments — Several treatments are of no proven benefit in relieving the symptoms of PMS. These treatments include progesterone, other antidepressant drugs (tricyclic antidepressants and monoamine oxidase inhibitors), and lithium. There is also no proven benefit of several popular dietary supplements, including evening primrose oil, essential free fatty acids, and ginkgo biloba.