While many are familiar with premenstrual syndrome (PMS), another chronic condition that impacts 3-9% of women is premenstrual dysphoric disorder (PMDD), which is much more severe. In the United States, women with PMDD average 6.4 days of severe symptoms and functional impairment per menstrual cycle - severe enough to impact the ability to function well in daily life.
While typical symptoms associated with PMS, such as cramping, bloating, and breast tenderness, can be present in PMDD, symptoms can also extend to mental health (like anxiety or depression). They can seriously interfere with the quality of life. A complementary and integrative medicine approach to PMDD involves taking a deeper look at underlying dysfunction that may be contributing to PMDD and creating a personalized, holistic treatment plan to help reduce symptom severity and prevent the continuation of symptoms each month.
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What is PMDD?
Premenstrual Dysphoric Disorder, PMDD, is a more severe and intense form of premenstrual syndrome (PMS) that causes severe physical and emotional symptoms in the week or two just prior to your period. While some symptoms may overlap with typical PMS symptoms, the severity, frequency, and duration differentiate PMDD from PMS. PMDD causes significant distress and functional impairment to those afflicted, often interfering with the ability to maintain their daily lives, work, and relationships.
Obtaining a PMDD diagnosis can be difficult, as there is currently no single lab or diagnostic test to confirm the condition. Currently, a set of criteria must be met in order to be diagnosed with PMDD.
The current diagnostic criteria state that symptoms must not be caused or exaggerated by another condition, symptoms must significantly interfere with the ability to function in work, social, or other situations, and symptoms must be present in the majority of the menstrual cycles over the course of the year. Additionally, five or more of the following symptoms must be present: depression, anger or irritability, lack of interest in hobbies or passions, mood swings, appetite changes, insomnia or sleep disturbances, trouble concentrating or brain fog, feeling overwhelmed or out of control, or physical symptoms like bloating, headaches, and breast tenderness.
PMDD Symptoms
While some of the symptoms that are traditionally associated with PMS, like breast tenderness, bloating, and irritability, may be present, there is a multitude of other PMDD symptoms that can be quite severe in nature. These may include:
- Anger or extreme irritability
- Feeling overwhelmed or tense and "on edge"
- Depression or suicidal ideation
- Fatigue
- Difficulty concentrating
- Headaches or migraines
- Insomnia
- Mood swings
- Anxiety
- Food cravings, binge eating, or changes in appetite
- A markedly decreased interest in usual activities, like work, school, or seeing friends
Symptoms tend to appear a week or even two weeks just before the start of your period and typically go away within the first few days of your period.
What Causes PMDD?
Several potential underlying factors can contribute to PMDD, though the exact cause is unknown.
Risk factors for developing PMDD include a history of past traumatic events, a history of anxiety, cigarette smoking, obesity, and having certain genes related to the metabolism of serotonin.
Hormone Imbalances
Hormone fluctuations through the menstrual cycle likely contribute to PMS and PMDD symptom appearance and severity. Studies show that when women get pregnant or go through menopause, these symptoms often stop, supporting the idea that the cyclical nature of reproductive hormones contributes to PMDD.
Since the gut microbiome is also linked to disorders involving female sex hormones, gut health likely also plays a role in the hormone imbalances linked to PMDD. A permeable gut may play a role in recirculating estrogen levels that may amplify symptoms.
Women with PMDD also appear to have hypothalamic-pituitary-adrenal (HPA) axis dysfunction and an altered cortisol awakening response (CAR), indicating that the endocrine dysfunction goes beyond just ovarian function in these more severe cases. Additionally, pain signaling via hormone pathways like the hypothalamic-pituitary-ovarian axis may also be increased in women with PMDD, demonstrating the complexity of various hormone networks in this condition.
Progesterone and Allopregnanolone
Progesterone and its metabolite, allopregnanolone, typically rise in the luteal phase of the menstrual cycle. In women with PMDD, the temporary rise and then the drop in levels of these metabolites may be associated with the onset of these symptoms. Studies have shown that some women even see a reduction in core PMDD symptoms when taking an inhibitor that prevents allopregnanolone formation. Whether this connection is due to a hypersensitivity to allopregnanolone is yet to be determined, but it may be a factor in when symptoms appear.
Interestingly, the levels of a brain neurotransmitter called GABA have also been found to rise in women with PMDD during the luteal phase but not in women without the conditions. Allopregnanolone binds to GABA receptors, increasing GABA levels as it does so. It's possible that the rise in GABA also contributes to symptom development during the luteal phase.
Estradiol-Serotonin Connection
It's been found that there is decreased production and a general deficiency in blood serotonin in women with PMDD, and it's possible that the drop in serotonin that occurs as estrogen decreases in the luteal phase may play a large role in the timing of PMDD symptoms. Research has also suggested that genetic polymorphisms in serotonin receptors may be part of the bigger picture of the estrogen-serotonin connection in PMDD.
Vitamin and Mineral Deficiencies
Several micronutrients, including calcium, magnesium, and certain B vitamins, have been linked to improving PMS and PMDD symptoms when supplemented. It's possible that women with PMDD have a higher need for certain micronutrients or that a deficiency may impact them more severely.
Endocrine Disruptors
Endocrine disruptors are chemicals that can interact or mimic hormonal actions in the body, interfering with natural hormone production and the function of the endocrine system. Some have been linked to changes to hormone production and development in both men and women, and one study even found that reducing endocrine-disrupting chemicals decreased symptom severity in women with PMS or PMDD. High exposure to these chemicals - like dioxin or Bisphenol A (BPA) - may play a role in symptom severity for women with PMDD.
Genetic Polymorphisms
While genes aren't everything when it comes to PMDD, some women with the condition may have certain polymorphisms that make them more sensitive to fluctuations in estrogen and progesterone in the sense that they hyper-respond even to minute changes in hormone levels.
Functional Medicine Labs to Test for Root Cause of PMDD
Functional lab tests can be utilized to help practitioners understand the root causes of PMDD. The following are great functional medicine lab options:
Comprehensive Stool Test
Evaluating the function and health of the gut microbiome can help determine if inflammation, dysbiosis, or increased gut permeability may be contributing to poor hormone metabolism and elimination.
Comprehensive Female Hormone Testing
It's clear that PMDD likely has a hormonal component in its etiology and development of symptoms. Because PMDD symptoms change with hormone fluctuations, comprehensive testing like the DUTCH Cycle Mapping can provide more insight than a standard blood test into the changes in hormone levels occurring over the menstrual cycle. Cycle mapping also looks at the rhythm of cortisol production over the course of a day, which can help a patient better understand what other hormone fluctuations may be contributing to their symptoms.
Neurotransmitter Evaluation
Since studies have linked neurotransmitters like serotonin and GABA as potential contributors to PMDD, as well as the fact that the condition often presents with depression, anxiety, and other mental health-based symptoms, a neurotransmitter evaluation can help provide clarity on possible deficiencies or alterations in neurotransmitters that may be correlated with certain PMDD symptoms.
Micronutrient Test
Evaluating levels of vitamins and minerals in PMDD patients can help provide a more personalized approach to supplementation and dietary interventions, especially with various micronutrients linked to PMS and PMDD symptoms. A micronutrient panel clearly shows any missing pieces from one's diet.
Endocrine Disruptors and Toxic Burden
Evaluating possible environmental toxins through a toxic burden test can be helpful for those with PMDD to help personalize a holistic treatment plan that includes reducing exposure to endocrine-disrupting chemicals in case these are contributing to symptoms.
Conventional Treatment for PMDD
Typically, the main conventional approach to treating PMDD is with the use of selective serotonin reuptake inhibitors (SSRIs) and hormonal birth control aimed at alleviating symptoms. However, both approaches come with a fairly high non-response rate of 40%, meaning not everyone will gain relief from the medications.
Complementary and Integrative Medicine Treatment for PMDD
Complementary and integrative medicine treatments may help manage PMDD symptoms alongside conventional medical treatments. Here are some options to consider:
Integrative Nutrition for PMDD
A nutrient-dense diet that's rich in vitamins and minerals can help ensure that women with PMDD get important micronutrients to help maintain healthy hormone function and minimize symptoms. Increasing protein intake while reducing refined sugar, alcohol, and caffeine is also recommended by the Mayo Clinic.
Supplements and Herbs for PMDD
There are several supplements that integrative practitioners may use to help with a holistic treatment plan for PMDD. Here are the most common:
Omega-3 Fish Oil
Omega-3 supplementation may help reduce the mental health-based symptoms of PMDD, like depression, anxiety, and lack of concentration, while also reducing overall inflammation often linked to physical discomfort. The longer the adherence to a regular intake of omega-3 supplements, the better the results. Omega-3s have also been shown to improve the balance in the gut microbiome, specifically influencing the gut-brain axis, which is a communication system in the body between robust microbiota and the brain. This also links to healthy neurotransmitter production. The detoxification of various endocrine-disrupting chemicals can also be enhanced with the intake of fish oil, meaning this supplement choice affects multiple causes of PMDD.
Calcium, Vitamin B6, Magnesium, L-Tryptophan
The combination of supplements recommended by the Mayo Clinic includes calcium, vitamin B6, magnesium, and L-Tryptophan, due to their impacts on sex hormone metabolism and the production of neurotransmitters like serotonin.
Comprehensive MultiMineral/Multivitamin
In one study comparing the effectiveness of vitamin B6 with broad-spectrum micronutrient supplements, the broad-spectrum vitamin was superior in reducing symptom severity of PMDD, underlining the importance of adequate vitamin and mineral intake.
Inositol
Inositol is a compound important for blood sugar regulation and hormone production. It's been found to be effective at reducing depression and anxiety symptoms, particularly in women with PMDD.
Evening Primrose Oil
Evening Primrose Oil (EPO) has been shown to be effective at reducing various PMDD symptoms, though it typically can take at least 4-6 months to see the benefits. So, compliance is important if your practitioner recommends it.
Mind-Body Therapies for PMDD
Mind-Body practices can be a helpful part of an integrative treatment plan for PMDD to help manage and reduce stress and support overall well-being. In particular, massage therapy is an effective adjunct therapy for women with PMDD, helping to reduce pain, water retention, and the overall subjective feeling of distress.
Additionally, mindfulness-based cognitive therapy to help identify uncomfortable feelings and experiences and respond mindfully can be helpful for those with PMDD. This method of therapy can help to alleviate the frustrations that accompany fluctuating symptom severity and the out-of-control feelings that can be present.
Acupuncture of PMDD
Regular acupuncture sessions as part of an integrative treatment plan have been found to reduce PMDD symptoms by 50% or more without any adverse effects.
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Summary
Premenstrual dysphoric disorder (PMDD) is a complex chronic condition that is a much more severe form of PMS. Its etiology is likely multifactorial in nature, and its effects can seriously impact a woman's quality of life and ability to go about her normal routine. A functional medicine approach can help identify contributing areas of dysfunction, like poor gut health or hormonal imbalance, and functional medicine lab work can provide insight into more personalized forms of treatment to help alleviate symptoms.
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