Premenstrual dysphoric disorder (PMDD) is a condition marked by severe depression symptoms, irritability, and tension before menstruation. These symptoms are more severe than those seen with premenstrual syndrome (PMS).

The causes of PMS and PMDD have not been identified.

Hormone changes that occur during a woman's menstrual cycle appear to play a role.

PMDD affects between 3 - 8% of women during the years they are having menstrual periods. The condition is usually worse in younger women.

Seasonal affective disorder (SAD), major depression, anxiety, and similar disorders are seen in many women with this condition.

Other factors that may play a role include:

• Alcohol abuse
• Drinking large amounts of caffeine
• Having a mother with a history of the disorder
• Lack of exercise

The symptoms of PMDD are similar to those of PMS, but they are generally more severe and debilitating. Symptoms occur during the week just before menstrual bleeding and usually improve within a few days after the period starts.

Five or more of the following symptoms must be present:

• Disinterest in daily activities and relationships
• Fatigue or low energy
• Feeling of sadness or hopelessness, possible suicidal thoughts
• Feelings of tension or anxiety
• Feeling out of control
• Food cravings or binge eating
• Mood swings marked by periods of teariness
• Panic attack
• Persistent irritability or anger that affects other peopleTrouble concentrating
• Physical symptoms, such as bloating, breast tenderness, headaches, and joint or muscle pain
• Sleep disturbances

There are no physical examination findings or lab tests specific to the diagnosis of PMDD. A complete history, physical examination (including a pelvic exam), and psychiatric evaluation should be done to rule out other potential conditions.

Keeping a calendar or diary of symptoms can help women identify the most troublesome symptoms and the times they are likely to occur. This information may help the health care provider diagnose PMDD and determine the appropriate treatment.

Women with PMDD may be helped by the following:

• A balanced diet (with increased whole grains, vegetables, fruit, and decreased or no salt, sugar, alcohol, and caffeine)
• Adequate rest
• Regular exercise 3-5 times per week

In addition, it is important to keep a diary or calendar to record the type, severity, and duration of symptoms.

Selective serotonin-reuptake inhibitors (SSRIs) are antidepressant drugs that can treat PMDD. SSRIs include fluoxetine (Prozac, Sarafem), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), citalopram (Celexa), and escitalopram (Lexapro).

Nutritional supplements -- such as vitamin B6, calcium, and magnesium -- may be recommended. Pain relievers such as aspirin or ibuprofen may be prescribed for headache, backache, menstrual cramping and breast tenderness. Diuretics may be useful for women who have significant weight gain due to fluid retention.

After proper diagnosis and treatment, most women with PMDD find that their symptoms go away or drop to tolerable levels.

PMDD symptoms may become severe enough that they interfere with a woman's daily life. Women with depression may have worse symptoms during the second half of their cycle and may require medication adjustments.

As many as 10% of women who report PMS symptoms, particularly those with PMDD, have had suicidal thoughts. The incidence of suicide in women with depression is significantly higher during the latter half of the menstrual cycle.

PMDD may be associated with eating disorders and smoking.

Call 911 or a local crisis line immediately if you are having suicidal thoughts.

Call for an appointment with your health care provider if:

• Symptoms do not improve with self-treatment
• Symptoms interfere with your daily life

Braverman PK. Premenstrual syndrome and premenstrual dysphoric disorder. J Pediatr Adolesc Gynecol. 2007 Feb;20(1):3-12.

Lentz GM. Primary and secondary dysmenorrhea, premenstrual syndrome, and premenstrual dysphoric disorder: etiology, diagnosis, management. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, eds. Comprehensive Gynecology. 5th ed. Philadelphia, Pa: Mosby Elsevier; 2007:chap 36.