PMDD vs. PMS: Episodes, Intensity, Mental Health

Premenstrual dysphoric disorder (PMDD) and premenstrual syndrome (PMS) are two conditions linked to the menstrual cycle. Both cause many of the same symptoms, such as fatigue, mood changes, and bloating. However, PMDD causes a more severe emotional response that can disrupt your daily life and affect how you relate to others.

Knowing whether your symptoms occur from PMDD, PMS, or another health concern is key to getting the right treatment and feeling better. There are no formal tests to diagnose PMS or PMDD. Instead, you may have to track symptoms daily for at least two menstrual cycles to determine the cause of your problems.

PMDD vs. PMS: What’s Different?

Premenstrual dysphoric disorder and premenstrual syndrome are easily confused because they share many physical and emotional symptoms. If you have symptoms that fluctuate with your menstrual cycle, you may wonder if you have PMDD or PMS. Here is how these conditions compare.

Severity of Mental Health Effects

The severity of mental health effects differs between PMDD and PMS. PMDD is a hormone-based mood disorder that occurs when your brain has a negative reaction to the monthly rise and fall of estrogen and progesterone levels.

The mental health effects of PMDD can interfere with your normal work, social, or home activities. These mental health effects can be so severe that people with PMDD have an increased risk of suicide and suicidal behavior.

A diagnosis of PMDD involves at least five symptoms that start in the final week before the start of your menstrual period and improve within a few days of the onset of bleeding. These criteria include the following:

One or more of the following symptoms:

• Mood/emotional changes that include mood swings, sudden feelings of sadness or tearfulness, or increased sensitivity to rejection
• Marked irritability, anger, or increased interpersonal conflicts
• Marked depressed feelings of hopelessness, worthlessness, or depressed mood
• Marked anxiety, tension, and/or feelings of being on edge

Plus, one or more of the following symptoms to reach a total of five symptoms combined with four symptoms from the first list:

• Decreased interest in usual activities
• Brain fog or difficulty concentrating or focusing
• Being easily fatigued or having marked low energy
• Significant changes in appetite, food cravings, binge eating, or overeating
• Feeling overwhelmed or out of control
• Insomnia (trouble falling asleep or staying asleep) or hypersomnia (excessive sleepiness)
• Physical symptoms such as joint pain or muscle pain, breast tenderness or swelling, bloating, or unintended weight gain

While these symptoms can also occur in PMS, they tend to happen at a much less intense level. For example, PMS can trigger feelings of mood changes and feelings of depression. However, the depression that occurs in PMDD can be so pronounced that you may have thoughts of self-harm or suicide.

The mental health effects of PMS can include:

• Appetite changes or food cravings
• Changes in sexual desire
• Depression, feelings of sadness, or crying spells
• Feeling tired
• Irritability or angry outbursts
• Mood swings
• Sleep problems (sleeping too much or too little)
• Tension or anxiety
• Trouble with concentration or memory

Timing Before Period and Symptom Duration

While symptoms differ for everyone, a menstrual cycle consists of two phases based on an average 28-day cycle, as follows:

• The follicular phase begins on day 1, when menstrual bleeding starts, and ends on day 13. Hormones direct the ovary to produce an egg to release and the uterine lining to develop to support a possible pregnancy. Ovulation (the release of the egg from your ovaries) usually occurs around day 14.
• The luteal phase occurs from days 15 to 28 when the follicle that released the egg increases progesterone levels for pregnancy or degrades if fertilization does not occur. If pregnancy does not occur, the uterine lining prepares for shedding.

Symptoms usually occur in the following patterns:

PMS:

• Symptoms occur during the last week of the luteal phase (about one to two weeks before your period).
• Symptoms usually start during this phase in the five days before your period.
• Symptoms go away within four days after the bleeding starts.
• Symptoms do not return until at least the 13th day of your menstrual cycle.

PMDD:

• Symptoms occur during the last week of the luteal phase, usually within seven to 10 days before your period.
• Symptoms improve within a few days after the bleeding starts.
• Symptoms go away by the end of the first menstrual week

Frequency

Research indicates that almost 90% of people who menstruate have symptoms of discomfort before their period. About 20% to 40% of people experiencing discomfort have symptoms that meet the criteria for premenstrual syndrome (PMS). While PMDD is considered a more severe form of PMS, PMDD only affects about 2% to 8% of people who menstruate.

Comparing the Average PMS Experience

PMS involves a combination of physical and emotional symptoms that are not well understood due to misinformation. Here is what the average PMS experience involves:

A condition that affects many but not all people who menstruate: While mild to acute premenstrual symptoms affect the majority of people who menstruate, only up to 40% of them have symptoms that qualify as PMS. While PMS is a natural reaction, it is not a necessary part of the menstrual cycle.

A wide range of physical and emotional symptoms: PMS includes over 150 symptoms that affect everyone differently. These symptoms include fatigue, tender breasts, bloating, irritability, and depression that occur in the days leading up to a period. The symptoms vary by person. Despite misconceptions, people who have PMS symptoms are typically not having their period.

Monthly symptoms that can increase stress: PMS can affect your ability to maintain normal sleeping and eating patterns. The effect can cause physical effects that can add to your feelings of stress and how you interact with others.

Relief of symptoms with conservative treatments: The symptoms that occur with PMS can typically be resolved with conservative treatments that involve living a healthy lifestyle. Mild PMS symptoms do not usually interfere with your ability to participate in everyday activities. Prescription medications can relieve severe symptoms that do not respond to lifestyle modifications.

Misdiagnosed Conditions

PMDD and PMS have a range of symptoms that overlap with several other physical and mental health conditions, including:

Lab testing may identify other conditions that share symptoms with PMDD and PMS. Tracking your symptoms can indicate whether they only occur in days before your period or whether they affect you all the time.

While PMS and PMDD align with your menstrual cycle, other conditions are more likely to cause symptoms all the time, regardless of your menstrual cycle. However, some other conditions have symptoms that worsen before the menstrual period, such as depression and irritable bowel syndrome.

Which Provider Has Insights?

You should consult with a healthcare provider if you have symptoms of depression, anxiety, suicidal ideation, mood swings, anger/rage, or irritability that fluctuate across your menstrual cycle or premenstrual symptoms that severely disrupt your life and interfere with your ability to maintain relationships.

Several types of providers can offer insights into your symptoms of PMS and PMDD. Ideally, you will work with a multidisciplinary team of medical providers. If possible, seek out providers who are well-informed and experienced in diagnosing and treating premenstrual disorders.

The type of provider you contact may ultimately depend on which types of symptoms are most severe, your preferences, and the type of providers to which you have access in your health insurance system. The following providers can typically address a wide range of PMS/PMDD symptoms:

• General practitioner/primary care provider: For your initial diagnosis and treatment, your primary care provider can help rule out common physical conditions that may have symptoms easily confused with PMS/PMDD.
• Gynecologist: This type of specialist diagnoses and treats issues related to female reproductive health.
• Psychologist/psychiatrist: These qualified mental health practitioners, especially those interested in reproductive mental health, can provide therapies such as talk therapy (including cognitive behavior therapy) or medications. A practitioner who is aware of PMS/PMDD symptoms can help determine the correct diagnosis for your emotional symptoms.
• Endocrinologist: This type of provider specializes in diagnosing and treating disorders that affect the organs and glands that produce hormones.

The International Association for Premenstrual Disorders advises that you prepare for your appointments by tracking and listing your symptoms for about two months. Presenting this information to your provider can help lead to a quicker diagnosis and treatment.

Consider bringing a partner, trusted family member, or friend to your appointment. They can help you take notes and pose questions that you may not think to ask.

Treatment Differences and Similarities

PMS and PMDD do not have standard treatment regimens. Numerous symptoms can occur with PMDD, and over 150 symptoms have been linked with PMS. No one has all the identified symptoms.

In some cases, one symptom is most prominent. Therefore, treatment must be individualized to each person’s symptoms, preferences, and needs. Since so many symptoms overlap, some treatments may be helpful for both disorders.

For Emotional and Psychological Effects

Conservative Treatments

Conservative treatments are the first tried for PMS. These treatments can improve symptoms without the side effects inherent in drug treatments. These treatments include:

A combination of conservative treatments and prescription drugs is often advised for treating PMDD. The most common prescribed drugs include:

Selective Serotonin Reuptake Inhibitors (SSRIs)

SSRIs are considered the first-line treatment for PMDD and severe PMS mood symptoms. These drugs tend to work effectively at low doses and act quickly. These antidepressants are typically prescribed with either continuous daily dosing all month or intermittently for the 14-day luteal phase before your period begins.

The following SSRIs are Food and Drug Administration (FDA)-approved in the United States for the treatment of PMDD:

Antianxiety Drugs

Antianxiety drugs (anxiolytics) can be effective in treating severe premenstrual anxiety that does not improve with SSRIs or other treatments. These drugs include:

Hormone Therapies: Oral Contraceptives

Oral contraceptives (birth control pills) that contain combinations of estrogen (typically estradiol) and progestin (the synthetic form of progesterone) are used to interrupt the hormonal cycle that triggers PMS symptoms in some people.

In the United States, two combination birth control pills that contain the progestin drospirenone are approved for the treatment of PMDD:

Hormonal Interventions: Leuprolide

For severe premenstrual symptoms that do not respond to any other treatments, therapies that include gonadotropin-releasing hormone (GnRH) agonists, such as Eligard (leuprolide), which suppress ovarian function, can be effective.

Surgical Intervention

When all other options fail to improve severe PMDD symptoms, hysterectomy (removal of the uterus) and bilateral salpingo-oophorectomy (removal of the uterus, fallopian tubes, and ovaries) with hormone add-back therapy can be considered when therapies are ineffective or the side effects and/or costs of treatments are unbearable.

For Physical Symptoms

The same treatments can be used to address physical symptoms such as bloating, breast tenderness, headaches, and muscle aches in PMS and PMDD. These treatments include over-the-counter (OTC) nonsteroidal anti-inflammatory drugs (NSAIDs) such as Advil and Motrin (ibuprofen), Aleve (naproxen), or Bayer (aspirin).

Vitamins, minerals, and herbal remedies have not proven to be effective in treating the symptoms of PMS and PMDD.

Living With PMDD and Bad PMS

Living with PMDD and bad PMS can feel overwhelming. Intense emotional symptoms interfere with your ability to live a normal life. The cyclical nature of symptoms can leave you feeling hopeless and out of control. You can help combat these symptoms with lifestyle strategies that support your mental and physical well-being so you can take charge of your physical and mental health.

When you are dealing with episodes of PMDD or bad PMS:

• Reduce your intake of salt, sugar, alcohol, and caffeine.
• Drink plenty of fluids to reduce bloating and fluid retention.
• Consume a healthy diet containing vegetables, fruit, and whole grains.
• Get regular aerobic exercise by walking, biking, or swimming.
• Manage stress with relaxation and meditation techniques.
• Reassure yourself that symptoms are cyclical and will pass.
• Use prescription medications as directed.
• Attend scheduled counseling sessions even if you don’t feel like going.

Living with PMDD involves maintaining a routine of self-care and healthy lifestyle habits throughout the entire month. Research indicates that you can often reduce premenstrual symptoms with the following lifestyle strategies:

• Follow patterns to support healthy sleep.
• Establish and maintain a lifestyle that embraces a healthy diet and regular exercise.
• Practice relaxation techniques such as meditation, yoga, and mindfulness.
• Avoid stressful and emotional triggers such as arguments.
• Plan relaxing activities throughout the month.
• Track the timing and intensity of your symptoms to predict when symptoms may start and plan accordingly.
• Maintain an ongoing relationship with a mental health provider who can help you manage severe emotions.

When Do PMDD and PMS Go Away?

Symptoms of PMDD and PMS can start anytime between puberty and menopause. For most people who menstruate, these symptoms begin in the mid-20s and remain a problem during the late 20s to early 40s. PMDD and PMS symptoms may get worse with age or during periods of stress.

Research indicates that both PMS and PMDD may begin as early as the teen years, although people may not seek treatment until later. Studies show that 2% to 6% of people who menstruate between the ages of 14 and 16 meet the criteria for PMDD. PMS, PMDD, and other menstrual problems go away at menopause (the end of menstrual periods).

Summary

PMS and PMDD are two ailments that come and go with the hormonal changes that occur during the menstrual cycle. They trigger a combination of physical and emotional effects that occur in the days just before your period and then resolve until the next month.

PMS and PMDD differ in the severity with which the symptoms occur. The symptoms of PMS can cause physical discomfort, mood swings, and depression. These symptoms become much more intense and sometimes dangerous in PMDD.

If you are having symptoms of PMS, try to make lifestyle changes that can help reduce symptoms so you feel normal. If symptoms persist or become severe, contact a healthcare provider for a diagnosis and ways to help you feel better every day of the month.