Is It PMDD or an Exacerbation of a Mood Disorder?

If you struggle with significant symptoms before your monthly period, it can mean a variety of things. Premenstrual syndrome (PMS) is very common among women of reproductive age. Perhaps you may also be dealing with Premenstrual Dysphoric Disorder or PMDD, which is a lot more debilitating than PMS. Still, others may be undergoing a condition known as premenstrual exacerbation (PME). 

PME is a term used to refer to premenstrual mood worsening among those who suffer from a primary mood disorder. A lot of times, PME may mimic PMDD and it’s not uncommon for women to get a wrong diagnosis.

What are the symptoms of PMDD?

The official diagnostic criteria for PMDD requires at least five of the following symptoms to be present during most menstrual cycles. These symptoms usually manifest a week before the onset of your period. The symptoms must be minimal and completely subside one week after your period ends.

1. Mood swings, sudden sadness and/or tearfulness
2. Increased irritability, anger and sensitivity towards rejection
3. Increased conflicts with those around you
4. Depressed mood, feelings of hopelessness, low thoughts about yourself
5. Increased anxiety and tension or feeling on edge

In addition to the above, one or more of the following symptoms must also be present for a more accurate diagnosis of PMDD:

1. Hypersomnia or insomnia
2. Decreased interest in usual activities
3. Difficulty concentrating
4. Significant fatigue and lethargy
5. Change in appetite, food cravings, and overeating
6. Feeling overwhelmed or out of control
7. Physical symptoms such as breast tenderness, fluid retention, bloating, weight gain, muscle and joint pain.

Mood disorders and how to differentiate between PMDD and PME

If you have a mood disorder such as anxiety or depression, the luteal phase (second half of your menstrual cycle) is going to be quite a fragile period. Oftentimes, PMDD can be misdiagnosed due to a failure to rule out premenstrual exacerbation of a primary condition associated with your mood. For example, if you are overly anxious and life becomes overwhelming and difficult a week before your period starts, you might seek help to alleviate your symptoms. It wouldn’t be surprising if you get diagnosed with PMDD even if you don’t really have it!. 

A more feasible approach would be to track your symptoms for at least two months. A thorough psychological and psychiatric evaluation should also be conducted to rule out any other conditions. If the premenstrual symptoms persist for two months AFTER treating the mood disorder, then a PMDD diagnosis would be more viable.

Have a look at the flow chart below so you can work through your symptoms systematically.

Hormones and your mood

I also want to shed some light on the involvement of specific neurotransmitters or brain chemicals. For instance, progesterone and its metabolite allopregnanolone increase during the luteal phase (second half of the cycle after ovulation). Then, they reduce significantly when bleeding commences at the start of your period.

The rapid drop of hormones causes changes to the GABA receptors in your nervous system. GABA is a brain chemical and neurotransmitter which makes you feel calm, centred, and relaxed. It opposes feelings of stress, anxiety, and fear. The changes in the GABA receptors at this point in the cycle is thought to play a role in PMDD aetiology.

Allopregnanolone, the progesterone metabolite, is also a positive modulator of GABA receptors. This means that it can increase the activity of GABA receptors in the nervous system. Lower levels of allopregnanolone can produce depressive and anxiety-like symptoms.

Estradiol, the most potent form of estrogen, also exerts an effect on mood and serotonin expression. Serotonin is one of our major 'feel-good' brain chemicals. The many symptoms experienced during the luteal phase of our menstrual cycle can be correlated to altered serotonin metabolism. Estrogen can positively influence serotonin transporter genes and low estrogen can cause a decline of this gene expression. 

In PMDD, women experience serotonin abnormalities which are especially apparent late in the luteal phase when estrogen has declined. It has been demonstrated that at this point in the cycle, women with PMDD have a deficiency in 5-HT, which is a direct precursor of serotonin.

Treating PMMD

Conventional treatment of PMDD involves using medication that allows serotonin to elicit its action longer in the nervous system and preventing it from getting reabsorbed. From a naturopathic perspective, we can incorporate dietary and lifestyle factors along with herbal and nutritional medicines that help boost our natural serotonin production.

REFERENCES:

Liisa Hantsoo, C. Neill Epperson. Allopregnanolone in Premenstrual Dysphoric Disorder (PMDD): Evidence for Dysregulated Sensitivity to GABA-A Receptor Modulating Neuroactive Steroids Across the Menstrual Cycle. Neurobiology of Stress. Vol. 12, May 2020, 100213.
https://www.sciencedirect.com/science/article/pii/S2352289520300035

Sahruh Turkmen, Torbjorn Backstrom, Goran Wahlstrom, Lotta Andreen, and Inga-Maj Johansson. Tolerance to allopregnanolone with focus on the GABA-A receptor. Br J Pharmacol. 2011 Jan; 162(2): 311–327.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3031054/

Asensio, J.A., Cáceres, A.R.R., Pelegrina, L.T. et al. Allopregnanolone alters follicular and luteal dynamics during the estrous cycle. Reproductive Biology and Endocrinology 16, 35 (2018).
https://rbej.biomedcentral.com/articles/10.1186/s12958-018-0353-y