For many women, the days leading up to their period can be fraught with unwelcome physical and psychological symptoms.
Fluid retention, mood changes, weight gain, breast tenderness and swelling -- these are just a few of the unpleasant features that can be associated with the menstrual cycle.
Premenstrual Syndrome (PMS) is so prevalent in women that research shows around 90 percent of women experience at least one symptom of PMS every month and around 50 percent of women identify with having several symptoms.
However, a significant number of menstruating women, between five to eight percent, experience much more severe symptoms during this time -- a condition that is now recognised as Premenstrual Dysphoric Disorder, also known as PMDD.
The psychological symptoms of the disorder can be so debilitating that PMDD was recognised as a depressive disorder in the fifth edition of the Diagnostic And Statistical Manual of Mood Disorders (DSM-5), published by the American Psychiatric Association in 2013.
"I see often the worst cases. It's not unusual for a woman [with PMDD] to come in with a partner, to sit down and start weeping, and say 'I want everything out. I want my uterus, tubes and ovaries out.'" Director of the WHRIA and Associate Professor of Reproductive Endocrinology at UNSW John Eden told HuffPost Australia.
"That's often the opening line, that's how desperate they are. It's devastating for many, many women. It's affecting their relationships severely. Many women find it's difficult, if not impossible, to work. It's really, really destructive."
So what exactly is PMDD? Why are some women more likely to experience it than others, and what treatments are available?
What Causes Premenstrual Dysphoric Disorder?
The short answer is, we don't know definitively. However, experts have been able to determine that there are several key factors involved.
"We certainly don't have the whole picture. It's definitely a brain syndrome. Earlier this year [the US National Institutes of Health and the University of North Carolina] found a gene for PMDD. It was clear that these women had a vulnerability that other women didn't have," Eden told HuffPost Australia.
"Clearly there's a brain component, they have a particular mood centre that seems to react to the cycle in an abnormal way," Eden said.
Eden explained that a woman's menstrual cycle typically become less regular as they move into their late 30s and 40s. While typically peaks and troughs of estrogen remain the same month-on-month between 20 and 25, as a woman ages her cycle becomes more erratic. This means estrogen levels vary dramatically, setting off the mood centre.
"And then you have what I call the black box, which is everything else in life. Living in a so called post-modern life -- too busy, too tired, too much on your plate. All that stuff, greatly emphasises the problem as well."
"So there we have the triad, this particular type of mood centre and probably genetic vulnerability, the cycle getting much more variable as women go from their 30s towards 50. And the black box, all the other stresses in your life, good or bad," Eden said.
What Are The Symptoms of PMDD?
"Many of the women I would see would have severe breast pain, headaches, fluid retention and abdominal bloatedness. And that can vary from mild, moderate to severe. From the psychological side, it's symptoms such as depression, anxiety, rage, anger and confusion," Eden said.
Sydney based Dr Brad McKay agreed that many of the physical symptoms of PMS are present for PMDD sufferers, though sometimes exacerbated in the latter. He explained that the mood symptoms are really what highlight PMDD, citing symptoms such as feeling really depressed or suicidal, feeling irritable, anxious or stressed out and having a very short fuse.
"Some people feel out of it or confused, they want to... hide away from society. Some people get really angry or have outbursts at their partner or significant others," McKay added.
Eden explained that the feelings of depression can become so intense during this time that patients will share that they experience suicidal ideation.
"Many women actually feel suicidal. The only thing keeping them going is knowing that it won't last forever. They stop and say to themselves, 'Only two more days and it will be over'. And there's often degrees of these. We're talking about the severe cases, which is what PMDD is about."
When Does PMDD Typically Occur?
Though it can happen at any age, PMDD is more likely to occur in women who are in their mid-to-late 30s, continuing through their 40s until they reach menopause.
The commonest pattern is typically to get worse from a woman's mid-late 30s and really getting bad through their 40s
"It certainly can happen at any age, but the commonest pattern is typically to get worse from the mid-to-late 30s and really get bad through the 40s. The menopause transition is horrible and when their cycle finally stops, they're cured."
Eden explained that there is also a strong link between post-natal depression and PMDD, with women suffering from post-natal depression sometimes finding that this transforms into PMDD once their menstrual cycle returns.
How Long Does PMDD Last?
To understand the onset and length of PMDD symptoms, it's useful to understand how the days of the cycle are counted. Day one is considered the first day of menstrual bleeding, and menstrual cycle is typically counted as 28 days.
"So (PMDD symptoms are) normally starting around day 21 of the cycle. But it can happen around four to 10 days before the period begins," McKay said. Eden agreed that typically the symptoms appear seven to 14 days before menstrual bleeding begins.
McKay explained that symptoms of PMDD typically begin around four to 10 days before a woman's period begins. Though women may feel totally fine before this time in their menstrual cycle, when they enter into this pre-period phase, they will find the physical and psychological symptoms of PMDD can be debilitating.
Once their period starts, sometimes it's like that switch is flipped off and people will go back to normal again straight away.
What differentiates PMDD from other depressive disorders is that the symptoms generally subside on the first day of menstrual bleeding.
"Once their period starts, sometimes it's like that switch is flipped off and people will go back to normal again straight away. There are other women (where it) may take two to four days," McKay said.
Will A Pre-Existing Depressive Disorder Make You More Likely To Experience PMDD?
Although there is a strong link between women experiencing post-natal depression and then going on to develop PMDD, typically women are not more likely to experience PMDD just because they have already suffered, or suffer, from a different depressive disorder.
"We see depression and PMDD as being quite separate entities. I have had a number of (PMDD) patients who aren't depressed, they're normally absolutely fine," said McKay.
"I've seen quite a few patients where they have been misdiagnosed as bipolar disorder, because with bipolar you're swinging between highs and lows. But unless you take a careful menstrual history, you may not pick up that it's related to the menstrual month,"
However, PMDD can be misdiagnosed as other depressive disorders due to the severe mood changes that are associated with the former.
"I've seen quite a few patients where they have been misdiagnosed as bipolar disorder, because with bipolar you're swinging between highs and lows. But unless you take a careful menstrual history, you may not pick up that it's related to the menstrual month," Eden said.
What Are The Treatments For PMDD?
Natural Remedies and Lifestyle Changes
If you are experiencing extreme distress, the first port of call should be your doctor. However, Eden and McKay also recommended a number of lifestyle changes that can have a positive impact on lessening PMDD symptoms.
- Regular exercise -- such as running or cycling -- to boost mood.
- Eating a low salt diet and lots of fruit and vegetables.
- Eating small meals throughout the day to avoid bloating.
- Reducing caffeine and alcohol.
- Relaxation techniques -- including meditation.
- Natural herbal remedies Premular (vitex agnus-castus) and Vitamin B6.
- Magnesium, Calcium and Vitamin E also work for some women.
Eden and Mckay both recommended speaking to your doctor about SSRI anti-depressants -- these are prescription drugs -- but studies have shown low doses to be an effective treatment for PMDD.
"Fluoxetine seems to be our best anti-depressant," Eden said, while McKay recommended Fluoxetine and Sertraline.
The most unique element of this form of treatment is that the SSRIs do not neccessarily need to be taken for the whole month. Eden said that some women use menstrual tracking apps in order to track their cycle, which means they can identify the date their symptoms are likely to begin and start taking their SSRIs several days before.
However, some women may have side effects, such as nausea, which mean it is better for them to take the SSRI every day of the month.
Another drug therapy that has shown to be useful for PMDD is certain brands of the contraceptive pill.
"The standard contraceptive pills tend to be bad, but there are two pills that some women with PMDD do tolerate very well and seems to help them -- Yaz and Zoely. It's probably seven out of 10 women that find that one of these two pill will be quite helpful," Eden said.
It's important to note that while removal of the uterus tubes and ovaries is an extreme measure that your doctor is likley only to consider once you have tried all other natural and drug therapies. Even then, typically doctors will trial women on drugs that temporarily pause the menstrual cycle.
"There is a class of drugs in Australia that actually switch off the cycle. The most commonly used are Zoladex and Synryl. They turn off the clock that regulates the menstrual cycle. So while a woman is on these medicines, it's a bit like the menopause. When you stop the medicine, the cycle comes back.
"What we typically do, is give (women) a trial, Zoladex is a monthly injection (if they get hot flushes we often give them an estrogen patch to go with that), which the GP can supervise, and we actually turn off the cycle for 6 months. Say they have been on that for 4-5 months and then they are cured, no symptoms, feeling wonderful, they usually come back in tears of joy," Eden said.
Once this trial has proven successful, your doctor is more likely to be able to recommend you for surgery that removes the uterus tubes and ovaries.
What Should You Do If You Think You May Have PMDD?
"If they are in desperate need, they should go and see their doctor straight away," McKay said.
"If they have a bit more time up their sleeve, keeping a mood diary and a period diary can be really helpful, because then we can see patterns and make sure that the moods that is happening are in conjunction with the periods, and then we can get a plan of attack."
If women still have questions or do not feel their needs are being met by their GP, they can ask to be referred to a gyneacologist. It's also extremely important to recognise that many women are going through the same experiences and seeking help is not a sign of weakness.
"Often people will try to decrease down their stress and relax, they're doing everything in their power to keep things under control and they're still having troubles, so they feel that they're a failure because they're not managing their mood.
"It's really important for women to know that this is a really common thing. Some women because of their genes, their family history and their life circumstances may not be able fix it using their own strength, so it's important to have a doctor on board and to get that assistance when needed," McKay said.