This handout is designed to help you understand Premenstrual Dysphoric Disorder (PMDD), its symptoms, and how it can be managed, including specific ways we can adjust antidepressant medication to help you feel better.

What is PMDD?

Premenstrual Dysphoric Disorder (PMDD) is a severe form of Premenstrual Syndrome (PMS). While many women experience mild PMS symptoms, PMDD causes much more significant emotional and physical symptoms that can interfere with daily life, work, and relationships. The key feature of PMDD is that symptoms appear in the week or two before your period starts (this is called the luteal phase of your menstrual cycle) and then go away within a few days after your period begins.

What are the Symptoms of PMDD?

PMDD symptoms are more intense than typical PMS and can be very distressing. To be diagnosed with PMDD, you would typically experience five or more of these symptoms in the week or two before your period, with at least one being a significant mood symptom:

Mood Symptoms:

• Marked depressed mood, feelings of hopelessness, or selfdeprecating thoughts
• Marked anxiety, tension, or feelings of being “keyed up” or “on edge”
• Sudden mood swings, feeling suddenly sad or tearful, or increased sensitivity to rejection
• Persistent and marked anger or irritability, or increased interpersonal conflicts

Other Common Symptoms:

• Decreased interest in usual activities (e.g., work, school, friends, hobbies)
• Difficulty concentrating
• Sleeping too much (hypersomnia) or difficulty sleeping (insomnia)
• Feeling overwhelmed or out of control
• Physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of “bloating,” or weight gain

It’s important to track your symptoms daily over a couple of menstrual cycles to see if they fit this pattern. This will also help us in diagnosing and managing your PMDD.

What Causes PMDD?

The exact cause of PMDD isn’t fully understood, but it’s thought to be related to an abnormal brain response to normal hormone changes that happen during your menstrual cycle. Specifically, women with PMDD may be more sensitive to the fluctuations of estrogen and progesterone. These hormonal shifts can affect brain chemicals like serotonin, which plays a crucial role in mood regulation.

How is PMDD Diagnosed?

There isn’t a single blood test for PMDD. Diagnosis usually involves:

• Symptom Tracking: Keeping a detailed daily diary of your symptoms for at least two menstrual cycles. This helps confirm that your symptoms are cyclical and linked to your period.
• Medical History and Physical Exam: Your doctor will ask about your health history and perform a physical exam to rule out other medical conditions that could be causing your symptoms (like thyroid problems or other mood disorders).
• Meeting Specific Criteria: Your doctor will use criteria, like those listed above, from the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) to confirm a PMDD diagnosis.

Managing PMDD with Antidepressants

One of the most effective treatments for PMDD is a type of antidepressant called a Selective Serotonin Reuptake Inhibitor (SSRI). SSRIs work by increasing the levels of serotonin in your brain, which can help improve mood and reduce irritability.
For PMDD, SSRIs can be prescribed in a few different ways:

1. Continuous Dosing: Taking the medication every day throughout your cycle.
2. Luteal Phase Dosing (Intermittent Dosing): Taking the medication only during the luteal phase of your cycle – typically starting about 14 days before your period is expected (around ovulation) and stopping once your period begins or a few days into it.
3. Symptom-Onset Dosing: Starting the medication when your PMDD symptoms first appear and continuing until your period starts.

How We Will Adjust Your Antidepressant Dose for PMDD:

If we decide that an SSRI is a good option for you, we will work together to find the best dosing strategy. Often, for PMDD, we can use luteal phase dosing or symptom-onset dosing. This approach has several potential benefits:

• Targeted Treatment: You’re taking medication specifically when you need it to manage your PMDD symptoms.
• Potentially Fewer Side Effects: Because you’re not taking the medication continuously, you may experience fewer side effects overall compared to daily use.
• Rapid Onset of Action: SSRIs often start working more quickly for PMDD symptoms (within days) than they do for depression (which can take weeks).

Here’s how we might approach adjusting your antidepressant dose:

• Starting the Medication: We will determine the best time in your cycle to start taking the antidepressant each month. This is usually about 1-2 weeks before you expect your period, or as soon as you notice your PMDD symptoms beginning.
• Dosage: We will typically start with a low dose, which is often effective for PMDD. The dose prescribed for PMDD may be lower than what is typically used for depression.
• Stopping the Medication: Once your period begins and your symptoms resolve (usually within the first few days of your period), you will stop taking the medication.
• Tracking and Adjusting: It’s very important to continue tracking your symptoms. This will help us see how well the medication is working and if we need to make any adjustments to the timing or dosage. We may need a few cycles to find the optimal approach for you.
• Communication is Key: Please keep me informed about how you are feeling, any side effects you experience, and how the medication is affecting your symptoms. We will work together as a team.

Important Considerations

• Not a Cure, but Effective Management: While medication doesn’t “cure” PMDD, it can significantly reduce your symptoms and improve your quality of life.
• Side Effects: Like all medications, SSRIs can have side effects (e.g., nausea, headache, sleep changes, decreased libido). With intermittent dosing, these are often minimized or only present while taking the medication. We will discuss potential side effects with you.
• Consistency: It’s important to follow the dosing schedule we agree upon for it to be most effective.
• Other Treatments: Lifestyle changes can also be very helpful for PMDD, including regular exercise, a healthy diet, stress management techniques (like yoga or meditation), and ensuring adequate sleep. Sometimes, birth control pills or other hormonal treatments are considered. We can discuss these options as well.

Please remember, you don’t have to suffer through severe premenstrual symptoms. We are here to help you find relief and improve your well-being. Don’t hesitate to ask any questions you have.