Do I have PMS? PMDD?

Discussions of premenstrual syndrome (PMS) cannot ignore the fact that it's partly a social construct, used in popular culture to explain women's increased emotionality--whether it be sadness or anger or anxiety--when it's "that time of the month." But for some women, the symptoms are much more severe than what is typically portrayed. As one woman wrote, "Every month I battle a monster. I gird myself with a healthful diet and a couple of pills, but the personality switch comes, like a lamp switched on, three weeks into my menstrual cycle. If most women get a little bloated, a little cranky, maybe a little confused, I swell an entire dress size and try to ban my husband from any room I'm in. Deciding what to eat for dinner so overwhelms me that I've broken down crying in the frozen food aisle."

In the psychiatric community, PMS's severe manifestation is called premenstrual dysphoric disorder (PMDD). The diagnosis is made using the following criteria from the DSM-5: 

It's a bit wordy, so here's a brief summary: PMDD is diagnosed by 1) the presence of at least 5 symptoms in the luteal phase of the cycle (including at least 1 mood symptom like irritability or mood swings), 2) the symptoms must be confirmed by prospectively monitoring at least 2 cycles, and 3) the symptoms must interfere with the woman's work, relationships, or other activities.

The American College of Obstetrics and Gynecology has a slightly different way of describing this condition, using the phrase "moderate to severe PMS" (rather than PMDD) and the diagnostic criteria of at least one psychological or physical symptom that causes significant impairment and is confirmed by prospective ratings.  Approximately 5-8% of women with hormonal cycles would be classified as having moderate to severe PMS, or PMDD.

The etiology of PMDD is unclear. Given the cyclicity of symptoms, it's long been thought to be related to the ovarian cycle, a brief overview of which is below:

There are 2 main phases--the follicular phase, and the luteal phase. In the follicular phase, an egg follicle in the ovary prepares to release an egg; this phase terminates with ovulation. During the luteal phase, the corpus luteum develops from the ovarian follicle and produces progesterone and estrogen. As you can see from the chart, estrogen levels peak prior to ovulation (while there is a smaller peak during the luteal phase), and progesterone levels rise significantly during the luteal phase. It's thought that the fluctuations in hormone levels--rather than a hormonal imbalance--may trigger PMS or PMDD symptoms, and that some women are more sensitive to these fluctuations than others.

However, hormones like estrogen and progesterone are not the full story; in fact, research has shown that the neurotransmitter serotonin modulates, or dampens, the impact of sex steroids on behavior, while sex steroids also affect serotonin transmission in the brain. We will be discussing the treatment of PMDD in a later post.