PMDD and Perimenopause

About 80% to 90% of women experience premenstrual symptoms (PMS) during their reproductive years, and approximately 2% to 8% face premenstrual dysphoric disorder (PMDD), a more intense form of PMS.⁽¹⁾ Both PMS and PMDD can significantly influence women’s quality of life, especially as they approach perimenopause, the phase when hormonal changes become more noticeable.

Symptoms of PMDD often appear alongside the hormonal changes of perimenopause, making it difficult to distinguish between the two. Many women assume that symptoms of PMDD, such as mood swings, irritability, and anxiety, are a part of the menopausal transition and might not reach out for help.⁽²⁾ Understanding the link between PMDD and perimenopause allows women to identify symptoms early and explore treatments that can improve their well-being and quality of life during the menopausal transition.

Understanding PMDD

PMDD is a severe form of PMS that affects about 2% to 8% of menstruating individuals. While many experience mild discomfort before their period, PMDD causes significant mood, behavioral, and physical disturbances that can interfere with work, relationships, and daily life.⁽¹⁾

Symptoms of PMDD follow a predictable monthly pattern, appearing in the luteal phase (one to two weeks before menstruation) and easing shortly after the period begins.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) classifies PMDD as a depressive disorder due to its profound psychological and functional impact. The diagnosis is based on the following key criteria:⁽³⁾

Criterion A

For a diagnosis of PMDD, at least five symptoms must occur consistently in the luteal phase (the week before menstruation) and subside within a few days after the onset of menstruation. At least one of the five symptoms must be related to mood disturbances, including the following:

• Intense mood swings, such as sudden sadness, tearfulness, or increased sensitivity to rejection

• Persistent irritability, anger, or heightened interpersonal conflicts

• Depressed mood, feelings of hopelessness, or excessive self-criticism

• Pronounced anxiety, tension, or feeling overly stressed or on edge
  

To meet the diagnostic threshold, at least one of the following must also be present:

• Reduced interest in regular activities, such as work, social interactions, or hobbies

• Difficulty focusing or concentrating

• Extreme fatigue, lack of energy, or an overwhelming sense of lethargy

• Significant changes in appetite, including overeating or intense food cravings

• Sleep disturbances, such as difficulty falling or staying asleep or excessive sleepiness

• Feeling overwhelmed or as if losing control

• Physical discomfort, including breast tenderness, bloating, muscle or joint pain, or weight fluctuations

Criterion B

The symptoms must be severe enough to interfere significantly with work, social activities, relationships, or daily responsibilities.

Criterion C

The symptoms must be directly linked to the menstrual cycle, with noticeable improvement in the follicular phase (the week after menstruation). PMDD is distinct from other psychiatric conditions, and symptoms should not be a mere exacerbation of an underlying mood or anxiety disorder.

Criterion D

A definitive diagnosis requires prospective symptom tracking over at least two consecutive menstrual cycles.

PMDD During Perimenopause

Perimenopause is a transitional phase leading to menopause, marked by fluctuating hormone levels that can trigger a range of physical and emotional changes. As menstrual cycles become irregular, estrogen and progesterone levels shift unpredictably, leading to symptoms such as mood swings, anxiety, sleep disturbances, hot flashes, and night sweats.⁽⁴⁾

For women with a history of PMDD, perimenopause can be incredibly challenging. Their heightened sensitivity to hormonal fluctuations may intensify mood disturbances, irritability, and anxiety. 

Research suggests that neuroactive metabolites of progesterone, particularly allopregnanolone, play a key role in PMDD. This metabolite interacts with gamma-aminobutyric acid (GABA) receptors in the brain, which may contribute to emotional symptoms in some women.⁽⁵⁾

During perimenopause, shifting estrogen and progesterone levels further influence neurotransmitter activity, particularly serotonin and GABA, both of which are essential for mood regulation. Additionally, low progesterone and elevated testosterone have been linked to worsening psychological and urogenital symptoms, making symptom management even more important during this stage.⁽⁵⁾

Disruptions in the autonomic nervous system may also contribute to sleep disturbances, fatigue, and cognitive difficulties, further affecting overall well-being. Some women continue to experience premenstrual-like symptoms even after menstruation stops, likely due to persistent neurotransmitter imbalances.

PMDD and Menopause

While menopause marks the end of menstrual cycles, it might not always bring immediate relief from PMDD symptoms. Some women report ongoing mood swings and emotional distress, suggesting that hormonal and neurological factors extend beyond the reproductive years. The impact of these symptoms on sexual health is also notable, with some experiencing a decline in libido or discomfort.

Studies also indicate that individuals who have experienced PMDD are more likely to report increased menopausal complaints, including fatigue, cognitive difficulties, and hot flashes. These changes can significantly impact daily life and emotional well-being.

Common Symptoms of PMDD and Menopause

Many symptoms of PMDD overlap with those of perimenopause:⁽⁶⁾

• Increased emotional sensitivity and mood instability

• Difficulty concentrating, leading to cognitive challenges

• Heightened anxiety and irritability

• Hot flashes and night sweats

• Persistent sleep disturbances

Distinguishing between perimenopausal discomfort and PMDD in later reproductive years is important. Women with PMDD will often experience severe emotional symptoms that significantly disrupt daily life and relationships. These mood disturbances usually follow a predictable monthly pattern. In contrast, perimenopausal mood changes, though similarly troubling, tend to be less cyclic and more irregular due to unpredictable hormone levels.

Managing PMDD and Perimenopause Symptoms

Effective management of PMDD and perimenopausal symptoms typically involves a tailored combination of medical treatments, lifestyle changes, and alternative approaches. 

Hormone Replacement Therapy (HRT)

HRT is an effective option to manage PMMD and menopausal symptoms as it replenishes declining hormones. It’s available in various forms, and the right choice depends on health factors and symptom patterns.⁽⁶⁾ 

• Estrogen-Only Therapy: This is suitable for women who've had a hysterectomy.

• Combined Estrogen and Progesterone Therapy: This is recommended for women who still have a uterus to protect against endometrial hyperplasia.

HRT can also include different forms of hormones, mainly synthetic hormones and bioidentical hormones.

Synthetic hormones, such as ethinyl estradiol and progestin, are chemically altered versions of natural hormones. While they serve the same function, their structure differs from the hormones naturally produced by the body. This difference can affect how they interact with hormone receptors and neurotransmitters, potentially worsening PMDD symptoms in some women.⁽⁶⁾ 

In contrast, bioidentical hormones are structurally identical to the body’s natural hormones and are often better tolerated.

For women who experience worsening symptoms while on synthetic hormones, switching to bioidentical HRT may be a better option. Since every woman’s hormonal sensitivity is different, working with a healthcare provider to find the right balance can make a significant difference in symptom management and overall well-being.

Non-Hormonal Medications

Some common medications used to manage PMDD and perimenopausal symptoms include the following:⁽⁵⁾

• Serotonin Reuptake Inhibitors (SSRIs): They increase serotonin levels and help stabilize mood and reduce irritability, anxiety, and depressive symptoms in PMDD.

• Anxiolytics: These medications can provide short-term relief from acute anxiety and tension, but they’re best reserved for severe cases without underlying psychiatric disorders.

Lifestyle Changes

The following lifestyle modifications are seen to improve PMDD and menopausal symptoms:⁽⁵⁾

• Dietary Changes: Reducing salt, refined carbohydrates, caffeine, and alcohol can ease bloating, anxiety, irritability, and sleep disruptions.

• Exercise: Regular exercise helps lower stress, boosts mood, reduces anxiety, and alleviates physical symptoms like bloating and fatigue.

• Stress Management and Sleep Hygiene: Practicing mindfulness and relaxation exercises and maintaining a consistent sleep schedule help improve mood, reduce irritability, and enhance overall quality of life.

Alternative Approaches

Experts recommend the following approaches to manage symptoms and improve quality of life during perimenopause:⁽⁵⁾

• Vitamin B6: This vitamin enhances neurotransmitter function, reducing mood swings and depressive symptoms.

• Calcium: Supplementation addresses cyclical changes linked to mood fluctuations, anxiety, and physical discomfort.

• Acupuncture and Reflexology: These alternative treatments stimulate relaxation, reduce stress, alleviate physical symptoms like headaches and cramps, and improve emotional well-being.

• Cognitive Behavioral Therapy (CBT): This approach helps women identify, challenge, and change negative thought patterns, which may result in improved mood, reduced anxiety, and better coping strategies for stress.

Getting the Right Support

PMDD and perimenopause together can feel overwhelming, but they can be managed with the right approach. For some women, hormonal fluctuations during perimenopause may intensify PMDD symptoms, while others experience relief as cycles become irregular. If PMS-like symptoms persist after menopause, underlying hormonal shifts or neurotransmitter imbalances may be at play.

Each woman’s experience is unique, but effective solutions are available. With medical guidance, lifestyle adjustments, and personalized treatment options, it’s possible to regain balance and improve well-being.