Pain, discomfort, mood swings including tearfulness and anger are symptoms that most women would consider as a “normal” part of their monthly cycle. Often women simply accept that for 30-35 years of their life this phenomenon will occur every month and there is not much we can do about it. This experience also impacts partners and other family members, who are simply bystanders in this. They figured out that their best strategic approach is to stay low to avoid exacerbating the emotional turbulence their loved one is experiencing. So, when do these “typical” premenstrual symptoms become not “normal”? Or is it possible that pain, tearfulness and lashing out were never meant to be part of women’s monthly cycle?
What is severe?
Those who have moderate-to-severe premenstrual symptom are estimated to be between 20-50% of all women. About 5% of women report the most severe symptoms and impairment in day-to-day functioning with premenstrual symptoms (Pearlstein & Steiner, 2008). On the severe end of this premenstrual symptom continuum sits premenstrual dysphoric disorder (PMDD). PMDD can be defined as psychological, physical and behavioural symptoms occurring about a week before the woman’s menstrual cycle. According to the Diagnostic and Statistical Manual 5th text-revised edition (DSM-5-TR), an individual would have to meet the following criteria to have the diagnosis of PMDD:
- Symptoms would occur on the week leading up to the onset of menses, and becomes minimal or absent the week after menses
- May experience some of the following symptoms:
- Mood swings, sad, tearful, sensitivity to rejection
- Increased irritability or anger, conflict with others
- Low mood, hopelessness, belittling oneself or excessive modesty
- Increased anxiety, tension, being on edge
- Additionally, may experience
- Less interest in usual activities
- Difficulties with concentration
- Lack of energy
- Significant changes in appetite (increase or decrease and/or food cravings)
- Sleeping too much or too little
- Sense of being out of control or overwhelmed
- Muscle or joint pain, swelling, breast tenderness, bloating, weight gain
- Five of the above 11 symptoms need to be present in most of the menstrual cycles (DSM-5-TR).
PMDD vs PMS
It is important to reiterate that about 5 percent of women would meet criteria for PMDD. When someone doesn’t quiet have the extreme severity of symptoms and may not have five of the above symptoms, they may meet the diagnostic criteria for premenstrual syndrome (PMS), which is simply a less severe version of PMDD (Pearlstein & Steiner, 2008).
Anger, moodiness – why?
One of the symptoms of PMS and PMDD is a noticeable increase of anger, irritability or interpersonal conflict (DSM-5-TR). These affective changes are the most common symptoms associated with PMS and PMDD (Akyol et al. 2013). Interestingly, research evidence supports that women with PMDD have significantly more anger and less control of it, often leading to an increase in communication problems compared to the average healthy woman (Akyol et al. 2013, Dogu et al. 2021).
Cognitive Failures
Beyond the psychological issues, women with PMS/PMDD have been found to have marked cognitive difficulties and overall poorer cognitive performance during the menstrual period, however, after menstruation these difficulties disappear (Dogu et al. 2021). Such cognitive difficulties can manifest as forgetting people’s names, forgetting to take medication or attend appointments, forgetting important events or shopping lists, losing things, failure to notice street signs or remember addresses, and poor concentration, distractibility and attention (Dogu et al. 2021).
Monthly cycle and hormones
It is part of the diagnostic criteria that the symptoms discussed at the beginning would occur during the last 5-7 days prior to menstruation. Thus, indicating that the hormonal changes that take place in the body are potentially responsible for these undesirable symptoms. Medical science now understands that in the last week of the monthly menstrual cycle (Luteal phase) both oestrogen (growth hormone) and progesterone (happy hormone) drop significantly to give way to the blood nest to detach and start menstruating. Therefore, it has been suggested that problems in this stage of a woman’s menstrual cycle resulting in an imbalance of oestrogen and progesterone could be the cause of PMDD/PMS (Yen et al. 2019). Investigating the levels of oestrogen and progesterone, it has been identified that women with PMDD had lower levels of oestrogen, which had a knock-on effect on progesterone levels, which in turn impacted the severity of PMDD.
Treatment: physical and psychological
Pharmacological treatments are available, which include antidepressants, diuretics, hormonal therapy such as oestrogen, progesterone supplementation or contraceptives.
There is supporting evidence to indicate for the benefit of alternative medical interventions, such as herbal medicine in controlling PMS/PMDD (Jang et al. 2014). Herbal medicine intervention showed 50% or better improvements of symptoms, without any reported adverse reactions.
In addition to addressing the symptoms from a biological standpoint, cognitive behavioural therapy (CBT) is also recommended to address the psychological symptoms. Psychological therapy would aim at reducing the distress, improve recognition and insight of emotional and mental challenges experienced when symptomatic, and teach the person with practical skills such as self-care and conflict management that will provide practical assistance in times of need.
Co-Author: Sharyn Jones, B Psych (Hons).
Sharyn Jones is a Brisbane psychologist with 10 years of experience working with adults, adolescents, children and their parents.
To make an appointment with Sharyn try Online Booking. Alternatively, you can call Vision Psychology Wishart on (07) 3088 5422 or M1 Psychology Loganholme on (07) 3067 9129.
Co-Author: Katalin Mezei, BA (Hons) Psych & Crim, G. Dip Psych, MSc Health Psych
Katalin Mezei is a Provisional Psychologist now based in Brisbane, having completed my undergraduate and Master’s training in the United Kingdom. My aim is to help people identify my clients’ core values and help them live according to them.
To make an appointment with Katalin, you can Book Online, or call Vision Psychology Wishart on (07) 3088 5422 or M1 Psychology Loganholme on (07) 3067 9129.
References:
Akyol, E.S., Arisoy, E.O.K., Caykoylu, A. (2013). Anger in women with premenstrual dysphoric disorder: Its relations with premenstrual dysphoric disorder and sociodemographic and clinical variables. Comprehensive Psychiatry. 24(2013): 850-855.
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed. Text revision). Washington, DC: American Psychiatric Association.
Dogu, S.E., Ekici, G., Ekici, B. (2021). Comparison of Mood, Physical Symptoms, Cognitive Failure and Life Satisfaction in Women with Premenstrual Dysphoric Disorder, Premenstrual Syndrome and No/Mild Premenstrual Syndrome: A Controlled Study. Bezmialem Science. 2022, 10(5):551-9.
Jang, S.H., Kim, D., Choi, M. (2014). Effects and treatment methods of acupuncture and herbal medicine for premenstrual dysphoric disorder: systematic review. BMC and Alternative Medicine. 2014, 14:11.
Pearlstein, T., Steiner, M. (2008). Premenstrual dysphoric disorder: burden of illness and treatment update. Journal of Psychiatry Neuroscience. 33(4):291-301.
Yen, J., Lin, H., Lin, P., Long, C., Ho, C. (2019). Early- and Late-Luteal-Phase Estrogen and Progesterone Levels of Women with Premenstrual Dysphoric Disorder. International Journal of Environmental Research and Public Health. 2019, 16, 4352. doi:10.3390/ijerph16224352