‘My mood plummets’: When PMS symptoms could be something more

PMDD, unlike PMS, is recognized as a disorder because it interferes with normal functioning and its symptoms are much more severe. Illustration: Laura Whelan

In the week before Cara Pomanti’s period starts, her mood starts to sink. She experiences other premenstrual symptoms, like extreme fatigue, but the changes in her emotional well-being are the worst.

“I suffer from depression already, but my mood plummets in this week,” the 22-year-old told Global News. “I usually find it harder to concentrate, am much more emotional — I cry more easily — and have a general sense of hopelessness. This does vary by month, some better than others.”

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Like Pomanti, many women suffer from ongoing period-related symptoms. According to the American College of Obstetricians and Gynecologists, 85 per cent of women experience premenstrual syndrome (PMS), which can cause mild psychological or physical discomfort.

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But there’s a lesser-known condition that affects about one in 20 women called premenstrual dysphoric disorder (PMDD) — and its symptoms can be debilitating.

“We know that women’s mental health, in general, is underfunded and under-researched,” said Dr. Benicio Frey, an associate professor at McMaster University and the medical director of the Women’s Health Concerns Clinic at St. Joseph’s Healthcare Hamilton.

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“And PMDD within women’s mental health is understudied. It’s an area that definitely requires more attention.”

The difference between PMS and PMDD

According to research, PMDD affects three to nine per cent of women, which Frey says is “a lot.” While there are several key reasons why there’s not a lot of public awareness around the disorder, one of the main reasons is because its symptoms overlap with PMS.

Symptoms of PMS include bloating, food cravings, changes in mood, headaches, upset stomach, sleeping too much and joint pain. The Society of Obstetricians and Gynecologists of Canada says common side effects, like tender breasts and menstrual cramps, can often be treated with heat packs and over-the-counter pain medication.

So what’s the difference between PMS and PMDD? While uncomfortable, PMS symptoms often do not result in serious day-to-day impairment, and the syndrome is not medically considered a disorder.

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PMDD, on the other hand, is recognized as a disorder as it interferes with normal functioning and its symptoms are much more severe.

“With PMDD, the symptoms are severe and really, really bothersome,” Frey said. “Women can’t function, they can’t think properly, it’s hard for them to study, it’s hard for them to work, it’s hard for them to carry on their normal lives.

“It’s the same symptoms, but PMDD is the severe form of PMS.”

How to tell if you have PMDD

For 28-year-old Monika, the days leading up to her period make her feel like a different person. While she says she’s not familiar with PMDD and hasn’t been diagnosed with it, her period-related symptoms can make her day-to-day functioning more difficult.

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“About a week before my period, I start feeling bloated, and I start to feel all sorts of emotions from becoming easily irritated to easily upset over things, and being upset can turn into being short-tempered and not being able to understand why — until the period physically comes,” she said.

“As soon as my period comes, I am in extreme pain. From my back to my stomach to feeling fatigued, [and] it takes about two days for me to feel like myself and not in any sort of pain.”

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In order to diagnose PMDD, Frey says patients need to keep a daily symptom diary and track their mental and physical states for at least two menstrual cycles. That way, doctors can look for patterns and determine if a woman meets the criteria for the disorder.

Frey says that the way in which PMDD is identified makes it challenging to diagnose as doctors often rely on self-recorded data. That, paired with the fact that PMDD symptoms typically only last a couple of days a month, makes the disorder harder to spot.

“PMDD is a sort of short condition. It occurs for two, three, four, five days on average,” he says. “Women then end up adapting to it or toughing it out, if you will, and not really seeking treatment.”

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Another reason why PMDD may be hard to diagnose is that many women who think they have PMDD actually have another mental health issue, such as anxiety, depression or bipolar disorder, or have a mental health issue in addition to PMDD.

“If other conditions are also active, it’s a bit more difficult to even see the symptoms occur primarily in the premenstrual period because women may have other symptoms [during other times of the month],” Frey said.
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Recently, Pomanti has been researching PMDD and is going to talk to her doctor about it.

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“For the past two to three months, I’ve been experiencing particularly bad PMS and I was thinking I might have [PMDD],” Pomanti says.

“When my depression worsens due to PMS, I have to really practice compassion for myself and acknowledge these hormonal effects. During this time, I can easily feel like I have lost my grasp on everything and not know what to do. I often tell myself to revisit the thoughts I’m having after this week is over because it’s too difficult and distorted while I’m in it.”

Risk factors of PMDD

According to Frey, PMDD more often affects older women, as pregnancy is a risk factor for the disorder. Doctors suspect this is due to the high levels of hormones women experience from pregnancy, which Frey says can “prime the brain to develop PMDD.”

Women with underlying mental health issues, like anxiety and depression, may also be at risk.

A Canadian study on PMDD found that women with a personal history of major depressive disorder — particularly when related to other reproductive life stages such as depression in pregnancy or postpartum depression — may also have an increased risk of PMDD.

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Frey says that women who have experienced trauma or sexual abuse could be more prone to PMDD, as are women with high levels of life stress.

“There is [also] a link with genetics — but the impact of the genetic risk is relatively low compared to other areas of mental health,” Frey added.

Ways to manage PMDD

Frey says for mild PMDD, exercise and psychotherapy, like cognitive behavioural therapy, can help. Even certain vitamins and minerals like Vitamin B6 and calcium may alleviate some symptoms.

But for more serious cases of PMDD, antidepressants and oral contraceptives are often used to treat the condition.

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“Antidepressants are considered, in the medical books, the first line, because there’s more evidence, and then the hormonal treatments [the pill] are considered second line,” he said.

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“But for many women, either they don’t want to use an antidepressant, or for some reason, they cannot use an antidepressant and prefer hormonal treatment, then [the pill] can be quite helpful.”

Pomanti says that the birth control pill has helped her physical symptoms, but her emotional symptoms continue to be unpredictable.

“I was advised by my doctor to go on birth control when I was sixteen, and this was to address my back pain associated with my period,” said Pomanti.

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“I have tried four to five different brands of the pill because sometimes they weren’t as effective as I needed them to be. The biggest reason I had to change my most recent brand of pill was because my emotional sensitivity and depression was very, very bad leading up to my period and I had to address it.”

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For Monika, she is finding some relief by being aware of her cycle and managing her emotions during heightened times.

“I am pretty on the ball with knowing when to expect my period, so I am able to feel the emotions, and then remind myself, ‘it’s that time of the month …breathe,’” she said.

“Some months, I completely let my emotions get the best of me, which results in negatively affecting my daily routine and mood [but] when I start sensing my mood shift, I am aware, and can steer myself clear from the negative path.”
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