PMS and PMDD: when mood changes with the menstrual cycle

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For some people, the days before their period pass almost unnoticed. For others, the same days bring irritability, sadness, anxiety or exhaustion that can be strong enough to strain relationships and work, and then fade a few days after bleeding starts.

This article looks at premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD): what they are, what research says about why they happen, why they are so often missed, and what can help. Experiences vary a lot from person to person, and some readers will recognise only parts of what is described here, or none of it.

PMS and PMDD: what the words mean

Many people notice some changes before their period, such as breast tenderness, bloating, tiredness or a shorter fuse. In a UK survey of working women, over 90% reported some premenstrual symptoms and around 40% described them as moderate or severe (Hardy & Hunter, 2021). PMS is the broad term used when these changes are regular and bothersome.

PMDD is a more specific and more severe pattern. It is included as a diagnosis in the DSM-5, and affects roughly 2–5% of people who menstruate before menopause (Epperson et al., 2012). The core of PMDD is emotional: marked mood swings, irritability or anger, low mood, hopelessness, anxiety or tension. Other symptoms can include difficulty concentrating, fatigue, changes in sleep and appetite, and feeling overwhelmed or out of control. What defines PMDD is the timing. The symptoms appear in the week or two before menstruation and improve within a few days after it begins, with a clearly better phase in between.

What seems to be going on in the body

Oestrogen and progesterone levels in people with PMDD usually look similar to those of people without symptoms, so researchers have looked closely at how the brain responds to the normal rise and fall of these hormones.

In a study at the US National Institutes of Health, women with PMDD whose cycles were paused with medication became largely free of symptoms. When hormones were added back, symptoms returned mainly in the first month, while levels were changing, and eased when levels stayed stable (Schmidt et al., 2017). This suggests a sensitivity to hormonal change itself.

One candidate for this sensitivity is allopregnanolone, a substance the body makes from progesterone that usually has a calming effect on the brain through GABA receptors. In PMDD, this calming system appears to respond differently, which may also make the stress response harder to regulate in the second half of the cycle (Hantsoo & Epperson, 2020). Serotonin is involved too, which helps to explain why certain antidepressants can work quickly for PMDD (Hantsoo & Epperson, 2015).

Life history plays a part as well. In a large Icelandic study of almost 12,000 women, those who had experienced more adverse events in childhood were more likely to report premenstrual disorders (Yang et al., 2022). Biology, stress and life experience seem to work together, as they do in many other forms of distress.

How a diagnosis is made

Because memory is unreliable, PMDD is diagnosed by tracking symptoms daily over at least two cycles. A standardised scoring system called C-PASS, built on daily ratings, agreed with expert clinicians in about 98% of cases. The same research found that looking back and estimating one’s symptoms predicted the diagnosis poorly (Eisenlohr-Moul et al., 2017). Recording mood, energy and other symptoms each day, together with the days of bleeding, gives both you and a professional a clearer picture.

Daily tracking also helps to tell PMDD apart from other conditions that get worse before a period, such as depression, anxiety or ADHD. In that case, symptoms are there most of the month and become stronger premenstrually. This is called premenstrual exacerbation, and it is treated differently.

Why it is so often missed

Many people live with severe premenstrual symptoms for years before anyone names them. In interviews with women in the UK who had been diagnosed with PMDD, participants spoke of being misdiagnosed and of “lost decades” before the cyclical pattern was recognised (Osborn et al., 2020). In the United States, people with PMDD described a long path from first symptoms to diagnosis, with barriers on the side of patients, health professionals and society (Chan et al., 2023).

Part of the problem is that menstruation is still surrounded by silence. Researchers who work on menstrual health across very different countries describe menstrual stigma as present everywhere, even if it shows up in different forms (Winkler et al., 2024). When something is hard to talk about, it is also hard to describe to a doctor.

Gender norms play a role too. A review of 77 studies on pain found that women’s symptoms were more often interpreted as emotional or psychological, and taken less seriously, than men’s (Samulowitz et al., 2018). Premenstrual symptoms sit in exactly this space: they are emotional, they come and go, and they are easy to dismiss.

“It’s just your hormones”

There is another side to this. A phrase like “you’re just hormonal” is often used in arguments to set aside what someone feels. Most people who menstruate have heard some version of it, at home, at work or from a doctor.

Two things can be true at the same time. Someone can feel more easily hurt or irritated in a certain phase of their cycle, and what they are upset about can still be real and worth discussing. A cycle can lower the threshold for showing a feeling without inventing the feeling. When “hormones” becomes the explanation for every disagreement, important things in a relationship or a workplace may never be addressed, and the person can start to doubt their own perceptions.

It can help to separate the two questions. One is “is this a phase in which I react more strongly?” The other is “what is this conversation actually about?” Some couples find it useful to name the phase together and agree to return to a difficult topic a few days later, without dropping it. Others prefer not to connect conflicts to the cycle at all. Both are valid choices.

When it becomes serious

PMDD can be very painful. A meta-analysis found that women with PMDD were almost seven times more likely to have attempted suicide than women without premenstrual disorders, and that PMS was also linked to higher rates of suicidal thoughts (Prasad et al., 2021). If your thoughts become very dark in certain weeks, this is a reason to look for help, and it is worth telling a professional about the timing.

What can help

Treatment for PMDD is well studied. Options include certain antidepressants (SSRIs), which can be taken every day or only in the second half of the cycle, some hormonal treatments that reduce cycle fluctuations, and psychological approaches such as cognitive behavioural therapy (Hantsoo & Epperson, 2015). Which option fits depends on the person, their health and their wishes, and is best discussed with a doctor, ideally with daily tracking notes in hand.

People who live with premenstrual changes also develop their own ways of coping. In an Australian study, women described strategies such as planning around their cycle, reducing demands in difficult days, taking time for themselves, paying attention to their body and telling others what was going on (Read et al., 2014). In the UK work study, women with more severe symptoms used fewer such coping approaches, and many suggested that workplaces could help with more flexibility and more openness about the topic (Hardy & Hunter, 2021).

Some ideas that people find useful:

• tracking your cycle and symptoms, so that difficult days are less of a surprise
• planning lighter days and fewer big decisions in the phase that is usually harder
• regular sleep, movement and meals, which support mood across the whole month
• explaining the pattern to the people close to you in a calm phase, if you want to
• treating yourself with the same understanding you would give a friend in the same situation

When to look for support

It may be time to talk to a doctor or therapist if premenstrual changes affect your relationships, your work or how you see yourself, or if you notice that you live in fear of certain weeks. Some people also find support in peer communities of people with PMDD.

You may also find Depression: what it is, how it feels and what helps useful.

More about therapy with me.

References

• Chan, K., Rubtsova, A. A., & Clark, C. J. (2023). Exploring diagnosis and treatment of premenstrual dysphoric disorder in the U.S. healthcare system: a qualitative investigation. BMC Women’s Health, 23(1), 272. https://doi.org/10.1186/s12905-023-02334-y
• Eisenlohr-Moul, T. A., Girdler, S. S., Schmalenberger, K. M., Dawson, D. N., Surana, P., Johnson, J. L., & Rubinow, D. R. (2017). Toward the reliable diagnosis of DSM-5 premenstrual dysphoric disorder: The carolina premenstrual assessment scoring system (C-PASS). The American Journal of Psychiatry, 174(1), 51–59. https://doi.org/10.1176/appi.ajp.2016.15121510
• Epperson, C. N., Steiner, M., Hartlage, S. A., Eriksson, E., Schmidt, P. J., Jones, I., & Yonkers, K. A. (2012). Premenstrual dysphoric disorder: evidence for a new category for DSM-5. The American Journal of Psychiatry, 169(5), 465–475. https://doi.org/10.1176/appi.ajp.2012.11081302
• Hantsoo, L., & Epperson, C. N. (2015). Premenstrual dysphoric disorder: Epidemiology and treatment. Current Psychiatry Reports, 17(11), 87. https://doi.org/10.1007/s11920-015-0628-3
• Hantsoo, L., & Epperson, C. N. (2020). Allopregnanolone in premenstrual dysphoric disorder (PMDD): Evidence for dysregulated sensitivity to GABA-A receptor modulating neuroactive steroids across the menstrual cycle. Neurobiology of Stress, 12, 100213. https://doi.org/10.1016/j.ynstr.2020.100213
• Hardy, C., & Hunter, M. S. (2021). Premenstrual symptoms and work: Exploring female staff experiences and recommendations for workplaces. International Journal of Environmental Research and Public Health, 18(7), 3647. https://doi.org/10.3390/ijerph18073647
• Osborn, E., Wittkowski, A., Brooks, J., Briggs, P. E., & O’Brien, P. M. S. (2020). Women’s experiences of receiving a diagnosis of premenstrual dysphoric disorder: a qualitative investigation. BMC Women’s Health, 20(1), 242. https://doi.org/10.1186/s12905-020-01100-8
• Prasad, D., Wollenhaupt-Aguiar, B., Kidd, K. N., de Azevedo Cardoso, T., & Frey, B. N. (2021). Suicidal risk in women with premenstrual syndrome and premenstrual dysphoric disorder: A systematic review and meta-analysis. Journal of Women’s Health, 30(12), 1693–1707. https://doi.org/10.1089/jwh.2021.0185
• Read, J. R., Perz, J., & Ussher, J. M. (2014). Ways of coping with premenstrual change: development and validation of a premenstrual coping measure. BMC Women’s Health, 14, 1. https://doi.org/10.1186/1472-6874-14-1
• Samulowitz, A., Gremyr, I., Eriksson, E., & Hensing, G. (2018). “Brave men” and “Emotional women”: A theory-guided literature review on gender bias in health care and gendered norms towards patients with chronic pain. Pain Research & Management, 2018, 6358624. https://doi.org/10.1155/2018/6358624
• Schmidt, P. J., Martinez, P. E., Nieman, L. K., Koziol, D. E., Thompson, K. D., Schenkel, L., Wakim, P. G., & Rubinow, D. R. (2017). Premenstrual dysphoric disorder symptoms following ovarian suppression: Triggered by change in ovarian steroid levels but not continuous stable levels. The American Journal of Psychiatry, 174(10), 980–989. https://doi.org/10.1176/appi.ajp.2017.16101113
• Winkler, I. T., Lhaki, P., & Baumann, S. E. (2024). Its manifestations may vary, but menstrual stigma is universal. Women’s Health, 20, 17455057241262007. https://doi.org/10.1177/17455057241262007
• Yang, Q., Þórðardóttir, E. B., Hauksdóttir, A., Aspelund, T., Jakobsdóttir, J., Halldorsdottir, T., Tomasson, G., Rúnarsdóttir, H., Danielsdottir, H. B., Bertone-Johnson, E. R., Sjölander, A., Fang, F., Lu, D., & Valdimarsdóttir, U. A. (2022). Association between adverse childhood experiences and premenstrual disorders: a cross-sectional analysis of 11,973 women. BMC Medicine, 20(1), 60. https://doi.org/10.1186/s12916-022-02275-7

This article is exploratory and meant for information and reflection. It cannot capture the full complexity of any individual situation, and your own experience may be different. It does not replace a diagnosis or treatment.

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