If a human being could actually combust, you are pretty sure you’re about to. Your mind is racing. You can’t focus on this project. Everything feels like too much. You’re not sure what you ever actually saw in your partner. You’re sleeping terribly. You’re pretty sure no one would even care if you disappeared.
Your world could indeed be falling apart, or you could be about to start your period.
The internet is full of memes playing on this idea. They’re often framed with an air of teasing, implying that if women could just hold on a hot second, this sky-is-falling perception would pass. The most grating ones are those that offer a smug eyebrow raise to the men who are ‘dealing’ with these hysterical women. Leave some chocolate on her pillow and then hide, they warn.
Long before memes, though, the world was already chiding women for their premenstrual mood changes. We see medical writings back from the 1800s where physicians were noticing correlations between the menstrual cycle and mental health, starting to make reference to “menstrual insanity.” By the early to mid 20th century ‘premenstrual tension syndrome’ was being discussed, but mostly focusing on physical symptoms like bloating and breast tenderness. It wasn’t until later in the 20th century that clinicians were finally taking note that some women seemed to have significant emotion-related changes prior to their period.
When Premenstrual Dysphoric Disorder (PMDD) was finally added to our psychiatric diagnostic manual in 2013, it marked a significant shift in recognizing just how debilitating some of these symptoms could be for a portion of women. But even today, many women still don’t know that PMDD exists, much less whether what they experience fits into this framework.
Let’s talk about what’s happening in PMDD and how it might look different from more common premenstrual changes. We’ll also talk about how we can use this information not to pathologize the experience, but to help us recognize and relieve its most challenging symptoms.
What’s Happening in PMDD
I don’t know about you, but despite being a woman for a decently long time now, I often feel like I missed a class somewhere on our basic biology. So let’s start with a quick overview of what’s happening, particularly hormonally, over the course of our menstrual cycle.
We’ll start with the follicular phase, which is the time during and shortly after the bleeding part of the cycle. At the start of your period, you have relatively low estrogen and progesterone. As your period winds down and in the days after, estrogen is rising steadily and progesterone remains low. Estrogen is a hormone that enhances the neurotransmitters you often hear about, like serotonin, dopamine, and acetylcholine. More estrogen means that we tend to feel better, more energized, and sharper cognitively. Research shows that our verbal memory, motivation, and executive functioning are all improved during this phase.
During the ovulatory phase of the cycle, estrogen is peaking and so is testosterone. This combination means that we tend to feel the most energized, sociable, and confident, as well as have the highest libido. Importantly, we also tend to feel strongest in our motivation and emotion regulation at this point. We tend to do the best on cognitive tasks here too. It feels like a good time to be alive.
The luteal phase, following ovulation, is where things tend to get tricky. Progesterone starts to rise and estrogen fluctuates, followed by both hormones declining sharply by the end of this phase. Progesterone acts on GABA receptors and has a calming and anti-anxiety effect, meaning that when it falls dramatically toward the end of the cycle – assuming no pregnancy – we can feel like we are heading off an emotional cliff. The fluctuation and then drop in estrogen can mean problems as well.
Most women will experience some notable shifts during this time. They report feeling more fatigued and having a lower mood. They feel somewhat less able to cope with stressors and more sensitive to perceived social rejection. Many will say that they feel less cognitively clear, which has some biological backing. There’s some evidence of decreased working memory, attention, and processing speed during this time period.
For women with ADHD, this can be a particularly challenging time and many people report a worsening of their symptoms during this phase. This makes perfect sense when considering the neurobiology at play. While more studies are needed, emerging evidence shows worsening brain fog and executive functioning, meaning impaired organization and sustained attention. It also means, for some women, greater impulsivity and reactivity.
When Shifts Become Debilitating
It’s a delicate dance to talk about the changes that happen over the course of the menstrual cycle given there’s a clear misogynistic history of using this information to try to prove some defect. And indeed, these hormonal fluctuations are not inherently a problem. In fact, I find them to be evidence of an amazingly dynamic and responsive system.
And at the very same time, some individuals will experience much more difficult and impacting effects of these fluctuations. The difference in who have more extreme effects does not seem related to the amount of the hormones themselves, but rather to the sensitivity to the fluctuations.
I’ve talked before about how mental health conditions often come down to the degree of sensitivity to changes that we see starting in infancy, and it appears that PMDD may be another example of this. This means that some women have a greater susceptibility to the otherwise “normal” changes that are happening in the body during the menstrual cycle.
Women with this sensitivity who are predisposed to PMDD might see any or all of the following:
Significant increases in anxiety and agitation
How it feels: You’re overstimulated and overwhelmed. You’re imagining worst case scenarios and nothing feels reassuring that it will all be okay. You feel like you’re existing on the edge and your body just can’t feel settled.
Mood and emotion instability
How it feels: Your mood feels all over the place. You felt fine an hour ago and now it feels like everything has gone to hell. You’re snapping at your partner and you can’t believe you just said that to your sister. You feel frustrated and angry with yourself for being this dysregulated but you don’t know how to feel more settled.
Problems focusing, remembering, and planning
How it feels: It feels like your brain just took a vacation, which is a problem because you still have so much to accomplish. You can’t seem to focus on anything and trying just makes you feel more agitated. Your mind feels foggy and like it can’t hold on to things. You just want to give up.
Increased sensitivity to rejection
How it feels: You’re convinced that everyone is annoyed with you. Or maybe it’s worse and they don’t even think about you at all. Your emotions feel so dependent on how each interaction goes. You feel down on yourself and like you just want to hide.
Feeling sad and unmotivated
How it feels: Nothing feels like it can possibly get better, so it’s hard to gather the energy to try. You feel a sense of hopelessness and maybe helplessness too. And then you feel guilty for feeling this way.
Of course, the experience of PMDD is as individual as the people experiencing it, but overall it’s marked by severe forms of these internal experiences that create disruption in your life and ability to function how you normally might.
How to Distinguish Between Depression, PMS, and PMDD
It might sound obvious, but more generalized depression lacks the cyclical nature of PMDD. That said, women with baseline anxiety or depression symptoms may have PMDD if they see a significant increase in their symptoms during the luteal phase of their cycle. Major Depressive Disorder and PMDD actually frequently co-occur, and up to 70% of women with PMDD having or having had another mental health disorder at some point in their lives.
More commonly, women wonder if their experience of PMS is actually PMDD. In casual conversation, the lines are often blurred. And even in clinical discussions, less adept providers can fail to recognize PMDD.
PMS is thought to impact about 75% of women and tends to be described with more focus on its physical symptoms – like bloating, headaches, and appetite changes. It can be significant in its impact as well, but compared to PMDD, PMS tends to be less debilitating and more able to be managed with interventions for comfort.
PMDD, on the other hand, creats significant distress and impairment for those suffering. Women will report difficulty managing the demands of work, struggles parenting, or impacts on their close relationships. Sometimes those effects will have enduring impact and lead to more depressed feelings throughout their cycle too.
At its worst, PMDD can result in women feeling so emotionally untethered and hopeless that suicide feels like the only way out. 72% of women with PMDD will experience suicidal thoughts. The intensity of the feelings during this phase make it hard for some women to feel like a different path is possible. It’s vital that we take the increased risk seriously, as research shows that the luteal phase is the most likely time for suicide to be planned, as well as completed.
Interventions that Can Help
Given the impact of symptoms and the significant risks that PMDD presents, intervention is important. Women experiencing PMDD are often prescribed SSRI medication either throughout their cycle or to be taken in the days leading up to their period. Some women who take an SSRI daily are prescribed an increased dose during this window. Some individuals are prescribed certain oral contraceptives to help address the hormone fluctuations occurring. Talking with a prescriber is, of course, the best way to determine if one of those approaches could be helpful.
Psychotherapy can also be an incredibly valuable process for those experiencing PMDD. Therapy can help offer a space to hold the difficulty and complexity of this condition, but also can offer tools for managing the emotion dysregulation, cognitive burden, and relational challenges that come with PMDD.
Understanding how one’s body and mind are shifting during the menstrual cycle and the vulnerabilities of that can be powerful knowledge. Making a few of the following shifts around the luteal phase can be useful for some:
- Avoiding particularly stressful interpersonal interactions
- If possible, structuring work to ease demands during this time
- Reducing stimulation and exertion and getting extra rest
- Engaging in extra body-based soothing practices, such as walks, breathwork, gentle yoga, or massage
- Eliminating alcohol or other substances that could contribute to poor sleep, mood changes, and impulsivity
- Journaling or art-making to have containers for increased intensity of feeling
When to Seek Support
If you suspect that PMDD may be at play for you, talk to a provider, particularly one that has knowledge of the impact of reproductive hormones on mental health. That could be a psychiatrist or therapist with perinatal or women’s health experience, or a primary care or gynecologist. They will often have you track your symptoms to evaluate any fluctuations based on your menstrual cycle and other factors. Importantly, if you experience your concerns as dismissed, follow up with someone else until you feel heard and your symptoms thoughtfully assessed. PMDD can often be well managed when you have the right team of support.
