Premenstrual dysphoric disorder (PMDD) is the most severe form of premenstrual syndrome (PMS). It is characterized by physical and behavioral symptoms that occur repeatedly in the late luteal phase of the menstrual cycle, usually beginning the week before menstruation and resolving a few days after menstruation. These symptoms cause significant distress or interference with daily activities and are not caused by an underlying psychiatric condition.^[1] Anger, irritability, depression, and internal tension are especially prominent symptoms. PMDD is a chronic condition, typically beginning in the adolescent years and continuing until the menopause transition, and requires an individualized approach to treatment.^[2]

People with PMDD report a wide variety of physical, behavioral, emotional, and cognitive symptoms; usually, the behavioral and emotional symptoms are the most prominent.^[3] Some common symptoms include irritability, mood swings, depression, anxiety, fatigue, body aches, and bloating. These symptoms are severe enough to cause serious distress or interference with daily activities and only occur during the late luteal and very early follicular phases of the menstrual cycle. Symptoms tend to be at their worst 3 to 4 days before through 3 days after menstruation.^[4]

Additional symptoms include:

• Difficulty concentrating and decreased interest in usual activities
• Excessive sleepiness or difficulty sleeping
• Changes in appetite, including food cravings and binge eating
• Feelings of being overwhelmed or out of control
• Breast tenderness
• Headaches
• Joint or muscle pain
• Hot flashes
• Cramps, constipation, nausea, or vomiting
• Fluid retention, including swelling and periodic weight gain

PMDD is diagnosed based on a history of severe, cyclic PMDD symptoms that are not caused by an underlying condition. To meet the PMDD criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), there must be at least 5 specific PMDD symptoms present, one of which must be a key major mood symptom, and these symptoms must both cause significant distress or interference with daily activities and occur during the late luteal phase of most menstrual cycles over the previous year.^[6] Prospective documentation using a validated questionnaire for at least two symptomatic cycles is also required.^[1]

Additional tests, like laboratory tests, a pelvic exam, and imaging, are not necessary for a PMDD diagnosis, but they are used to rule out other conditions that cause similar symptoms.

Medical treatments for PMDD focus on relieving symptoms, usually by increasing the availability of serotonin in the brain or by suppressing cyclic changes in sex hormones. Selective serotonin reuptake inhibitors (SSRIs) have the best evidence for efficacy and are the main medication used to treat PMDD. They can be taken continuously, only during the luteal phase, or at the time of symptom onset through the first few days of menstruation. Symptoms should improve by the first menstrual cycle following SSRI treatment.^[7] Serotonin-norepinephrine reuptake inhibitors (SNRIs) may also be used.^[8] For people who desire contraception, a combined estrogen-progestin oral contraceptive can be prescribed, although oral contraceptives may not decrease depressive symptoms.^[9]

Gonadotropin-releasing hormone (GnRH) agonists in combination with low doses of estrogen and progesterone are reserved for people who do not respond to the aforementioned treatments. When all other therapies have failed and symptoms are debilitating, surgical removal of the ovaries may be considered.^[10]

A number of supplements, such as myo-inositol, calcium, vitamin E, vitamin D, St. John's Wort, saffron, magnesium, fish oil, curcumin, vitamin B6, vitex agnus-castus (chaste tree), and evening primrose oil, have been studied for premenstrual symptoms.^[11][12] Most are only effective for mild to moderate symptoms, when used in combination with other therapies, or to correct nutritional deficiencies.^[3] In fact, compared to PMS, there are few trials specific to supplements for PMDD. Chaste tree is perhaps the most well-studied, and although some trials find that it reduces PMDD symptoms, the quality of available evidence is low^[13], and it may not be as effective for psychological symptoms as antidepressants.^[14]

There is little data to support a strong relationship between diet and PMDD. However, dietary patterns that emphasize eating a variety of whole foods (e.g., fruits, vegetables, nuts), while reducing the intake of ultraprocessed foods, salt, caffeine, and alcohol, are associated with a lower risk of premenstrual symptoms.^[15][16] Diets rich in calcium, zinc, magnesium, and B vitamins may also reduce the risk of PMS.^[16][17] Whether this data applies to PMDD is unclear, but adopting a healthful diet is unlikely to worsen the condition and could provide benefits.

Because PMDD strongly affects psychosocial health, certain therapeutic interventions can improve quality of life, promote positive coping skills, and decrease feelings of depression, anxiety, and distress. Cognitive behavioral therapy,^[18] couple-based cognitive behavioral therapy,^[19] and mindfulness-based therapies^[20] can all benefit people with PMDD. Additionally, acupuncture and acupressure may improve the symptoms of PMDD when compared to sham treatment, but more research specific to PMDD is needed.^[21] This is also true of exercise, which can reduce the severity of PMS and is thus encouraged for PMDD management as well.^[22]

The exact cause of PMDD is unknown, but it is believed to be an abnormal response to the natural hormonal fluctuations that occur throughout the menstrual cycle.^[23] It is important to note that PMDD is not caused by irregular blood levels of estrogen, progesterone, or progesterone metabolites (like allopregnanolone). The cyclic changes in sex hormones between people with and without PMDD are similar.^[3][24]

Rather, in people with PMDD, the brain is highly sensitive to the hormonal shifts in the luteal phase, especially the rise in allopregnanolone, provoking an aberrant neurotransmitter response that negatively affects emotional regulation.^[25][26][12] The opioid, GABA, and serotonin systems have all been implicated in the pathology of PMDD, but the serotonin system appears to be the most important (likely underlying the effectiveness of SSRIs for many people with PMDD).