In this article, discover the key causes and hormonal drivers of PMDD, as well as the conventional treatments for PMDD and the FUTURE WOMAN approach to PMDD which includes hormone testing, and recommendations for supplementation, diet, lifestyle and hormone therapy.
What is PMDD and what are the symptoms?
Premenstrual dysphoric disorder (PMDD) is a premenstrual and mood disorder that occurs during the luteal phase (second half) of the menstrual cycle. Symptoms are alleviated after the menstrual bleed and in the first half of the cycle (follicular phase).
Common symptoms of PMDD include depression, insomnia and headaches.
PMDD encompasses both psychological and physical symptoms that lie at the more severe end of the continuum of premenstrual disorders.
How is PMDD diagnosed?
Diagnosis of PMDD involves following a diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders or DSM.
What causes or contributes to PMDD?
The underlying cause of PMDD may have more to do with women’s reaction to hormonal fluctuations than the hormone levels themselves. While research has shown that unopposed estrogen (low progesterone and high estrogen) can play a role in PMDD, not everyone with PMDD will have high estrogen and low progesterone. In fact, PMDD is better characterised as an abnormal response to the hormonal fluctuations of estrogen and progesterone.
Other contributing factors include an altered serotonin pathway, altered sensitivity of GABA (our calming neurotransmitter), and an imbalance in allopregnanolone.
Genetics could also be a contributing factor – women with PMDD are more likely to have variants on genes related to their seratonin receptors and transporter genes.
Serotonin pathways in PMDD
It is theorised that those with PMDD suffer from exaggerated drops in serotonin. This is due to the close connection of the serotonergic pathway with reproductive hormones such as estrogen. When estrogen drops in the second half of the cycle, so too does serotonin. This can cause drastic changes in mood.
Allopregnanolone and GABA in PMDD
Allopregnanelone is a metabolite of the hormone progesterone. One of its roles is as a modulator of our calming brain neurotransmitter GABA. GABA has a sedative and anti-anxiety effect on the brain. It is theorised that women with PMDD have an abnormal response to allopregnanolone and GABA, thus resulting in mood changes in the second half of their cycle.
Conventional treatment for PMDD
What are some of the conventional options for treatment of PMDD in the UK?
- SSRIs – This stands for selective serotonin reuptake inhibitors. SSRIs are a type of antidepressant, and the only type of antidepressant that has shown promising research for PMDD as it can reduce the exaggerated drop in serotonin that is common in PMDD. This is often one of the options that your GP will suggest first. Research supports the use of SSRIs continuously across the cycle as well as just for use during the luteal phase for PMDD.
- The oral contraceptive pill – Your GP is also likely to suggest the oral contraceptive pill for PMDD. The oral contraceptive pill essentially mimics menopause by supressing ovarian and hormonal function. Research has found that the oral contraceptive pill with combined progestins and estrogen may be superior to a placebo for PMDD (although the placebo also accounted for a large improvement in PMDD). Although the OCP may help some with PMDD, research is mixed on its effectiveness.
- Cognitive behavioral therapy – Another common suggestion from your GP may be Cognitive Behavioral Therapy (CBT). CBT and talk therapy has been shown to be supportive for managing symptoms of PMDD.
Treatment of PMDD: The FUTURE WOMAN approach
At FUTURE WOMAN we opt for a more personalised approach to your PMDD treatment, which includes testing, identifying the root cause of your PMDD and tailoring your PMDD plan to your test results and unique symptoms.
Step 1: Testing your hormones with PMDD
The most important part of determining the best PMDD treatment for you, is to test your hormones. This is always where we begin at FUTURE WOMAN. Testing helps to determine the root cause of your hormone imbalance and will reveal your individual hormone picture.
As mentioned above, the underlying cause of PMDD is an abnormal reaction to hormonal fluctuations of progesterone and estrogen, typically presenting as low progesterone and high estrogen in the luteal phase. As a result, we always look to test your estrogen and progesterone levels, ideally across your entire menstrual cycle, as well as a few other key markers:
- Estrogen – Test your overall estrogen levels is important in PMDD. This is for a number of different reasons, but one of the important reasons is due to the fact that estrogen is connected and intertwined with serotonin. When there is a withdrawal or lowering of estrogen there is an associated lower level of 5HTP (precursor to serotonin) in the blood which is linked to lower mood and worsening of PMDD symptoms. Estrogen is available in all of our FUTURE WOMAN hormone tests but you can map estrogen across the entire menstrual cycle with our Advanced + Hormone test. This may be useful in identifying if there are any dramatic fluctuations in estrogen causing your symptoms.
- Progesterone – One of the main hypotheses of the cause of PMDD is an over sensitivity of the fluctuations between progesterone and estrogen. This is why it is very important to understand what is happening to progesterone in relation to estrogen. All our FUTURE WOMAN tests include progesterone and we test 5-7 days after ovulation to capture the most accurate reading. As with estrogen, our Advanced + Hormone test may be useful in identifying if there are any dramatic fluctuations in progesterone during the luteal phase causing your symptoms.
- Cortisol and Adrenaline– If you are suffering from PMDD it is vital to test your stress hormones and HPA axis response in our Advanced hormone test and Advanced + hormone test. This is because in PMDD there is HPA axis dysregulation which can lead to increased sympathetic response in the luteal phase of the cycle (worsening of PMDD symptoms). Typically those with PMDD have lower cortisol levels due to HPA axis dysregulation.
- Dopamine – In our Advanced Hormone test and Advanced + Hormone test we look at certain neurotransmitters including dopamine. Dopamine is one of our feel good neurotransmitters, linked to the reward system in our brain. Research has shown the connection between dopamine and our hormones, in particular to aspects such as mood and working memory. In particular estrogen is a dopamine modulator and in PMDD, estrogen may overreact or not act appropriately to neurotransmitters causing symptoms such as low mood, poor concentration and memory.
- Brain and gut inflammation – In our Advanced Hormone test and Advanced + Hormone test we also look at markers called Indican (a marker for gut inflammation) and Quinolinate (a marker for neuro inflammation). Inflammation in the body can contribute to a worsening of mental health, including depression associated with PMDD. Generalised inflammation can also cause an imbalance in neurotransmitters which can worsen PMDD for many women.
By looking at your hormonal markers, stress hormones and the HPA axis in our Advanced Hormone test and Advanced + Hormone test we can gain a much better understanding of what is at the root cause of your symptoms. This is all crucial information as it can help to dictate which treatment options are then right for you.
Step 2: Personalised treatment for PMDD
Our personalised protocols for PMDD at FUTURE WOMAN will vary depending on your results and unique symptoms and timing of symptoms. But here are a few examples of protocols we might recommend.
- Supporting healthy allopregnenalone levels – In order to support GABA in the brain it is important to support and block the 5 alpha reductase pathway as this pathway can cause higher allopregnenalone and therefore disrupt GABA which can lead to mood changes. Supplements like zinc and green tea are helpful here. All our hormone tests test progesterone metabolites so we can see which is your preferred pathway for your progesterone metabolism (the alpha or beta pathway).
- Stress support – If the HPA or HPO axis (the communication pathway from the brain to the adrenal and ovaries) is out of balance due to stress, this can increase the sympathetic nervous system response in the luteal phase and worsen symptoms of PMDD. Therefore stress management through diet and lifestyle changes are key.
- Support serotonergic pathways – Supporting serotonin levels is an important part of balancing mood in PMDD. Certain supplements and herbs can be very beneficial here such as l-tryptophan, saffron and rhodiola. These supplements and herbs must be prescribed by a FUTURE WOMAN practitioner to ensure they are right for you.
Key takeaways for our approach to PMDD treatment:
- Your PMDD treatment should be personalised to you and your unique hormonal picture.
- Testing your hormones is the best place to start. A full cycle map of estrogen and progesterone with our Advanced + Hormone test can be helpful for PMDD.
- Your personalised protocol may include support for allopregnenalone, stress support and support for your serotonergic pathways.
If you are struggling with PMS or PMDD then reach out to our team and book in a FREE 15 minute consultation to discuss which testing or consultation support may be best for you. Click HERE to find out more.
Schmidt PJ, Nieman LK, Danaceau MA, Adams LF, Rubinow DR. Differential behavioral effects of gonadal steroids in women with and in those without premenstrual syndrome. N Engl J Med. 1998 Jan 22;338(4):209-16. doi: 10.1056/NEJM199801223380401. PMID: 9435325. https://pubmed.ncbi.nlm.nih.gov/9435325/
Hantsoo, L., & Epperson, C. N. (2015). Premenstrual Dysphoric Disorder: Epidemiology and Treatment. Current psychiatry reports, 17(11), 87. https://doi.org/10.1007/s11920-015-0628-3
Hofmeister, S., & Bodden, S. (2016). Premenstrual Syndrome and Premenstrual Dysphoric Disorder. American family physician, 94(3), 236–240.
Lanza di Scalea, T., & Pearlstein, T. (2019). Premenstrual Dysphoric Disorder. The Medical clinics of North America, 103(4), 613–628. https://doi.org/10.1016/j.mcna.2019.02.007
Lopez, L. M., Kaptein, A. A., & Helmerhorst, F. M. (2012). Oral contraceptives containing drospirenone for premenstrual syndrome. The Cochrane database of systematic reviews, (2), CD006586. https://doi.org/10.1002/14651858.CD006586.pub4
Marjoribanks, J., Brown, J., O’Brien, P. M., & Wyatt, K. (2013). Selective serotonin reuptake inhibitors for premenstrual syndrome. The Cochrane database of systematic reviews, 2013(6), CD001396. https://doi.org/10.1002/14651858.CD001396.pub3
Pearlstein, T. B., Bachmann, G. A., Zacur, H. A., & Yonkers, K. A. (2005). Treatment of premenstrual dysphoric disorder with a new drospirenone-containing oral contraceptive formulation. Contraception, 72(6), 414–421. https://doi.org/10.1016/j.contraception.2005.08.021
Reid RL. Premenstrual Dysphoric Disorder (Formerly Premenstrual Syndrome) [Updated 2017 Jan 23]. In: Feingold KR, Anawalt B, Boyce A, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-. Table 1, Diagnostic Criteria for Premenstrual Dysphoric Disorder (PMDD) Available from: https://www.ncbi.nlm.nih.gov/books/NBK279045/table/premenstrual-syndrom.table1diag/
Steiner, M., & Li, T. (2013). Luteal phase and symptom-onset dosing of SSRIs/SNRIs in the treatment of premenstrual dysphoria: clinical evidence and rationale. CNS drugs, 27(8), 583–589. https://doi.org/10.1007/s40263-013-0069-7