Q. During the two weeks before my period every month, I get premenstrual symptoms so severe that they are seriously affecting my work, social life and romantic life. I’ve heard that S.S.R.I. antidepressants can help, but should I really go on meds for something so cyclical?
Premenstrual dysphoric disorder, or PMDD, is a much more severe but less common form of premenstrual syndrome (or PMS) that can be tricky to diagnose. It’s characterized by a slew of psychological and physical symptoms — irritability, despair, anxiety, appetite changes, lethargy, trouble sleeping, bloating, headache — many of which can be mistaken for other health problems, like regular PMS, thyroid issues, depression or bipolar disorder.
What differentiates PMDD symptoms from those other ailments, though, is their timing and severity, said Crystal Edler Schiller, an assistant professor of psychiatry at the University of North Carolina School of Medicine and associate director of behavior therapy and reproductive science at the university’s Center for Women’s Mood Disorders.
PMDD symptoms only occur during the two weeks before menstruation begins, and resolve within a few days after it starts, Dr. Schiller said. And unlike PMS, PMDD’s symptoms are typically so severe that they interfere with daily life. “You may go from feeling like your usual self and then feeling like you’re coming out of your skin, uncomfortable, irritable, not able to function normally in social situations, at work and at home,” she said. “When it’s at its most severe, it can be really debilitating.”
Despite its severity, PMDD is “still seen as a fringe diagnosis,” Dr. Schiller added, since it was only recognized as a distinct disorder in 2013, and not all health care providers have experience with it or know how to spot it. “So many of our patients say, ‘I feel alone in this’ or ‘I feel crazy and no one recognizes it,’” she said.
To get an accurate diagnosis, a health care provider — typically a psychiatrist or an obstetrician-gynecologist — will ask you to track and rate your symptoms every day for two to three months. In Dr. Schiller’s clinic, “about a third of people who think they have PMDD don’t actually have it once we do the prospective ratings,” she explained. So it’s critical to work with a knowledgeable doctor before jumping to conclusions or treatment plans.
If you’ve established that you have PMDD, there are effective treatment options. Selective serotonin reuptake inhibitors — or S.S.R.I. antidepressants, which are thought to treat depression and anxiety by increasing the availability of the chemical messenger serotonin in the brain — are some of the first options health care providers suggest.
What causes PMDD and how might antidepressants help?
Scientists haven’t yet figured out why some people develop PMDD and others don’t. They do know that the disorder, which can emerge at any point during childbearing years, is caused by the fluctuation of hormones during the last 14 days of the menstrual cycle, called the luteal phase, said Dr. Kristina Deligiannidis, the director of women’s behavioral health at Northwell Health’s Zucker Hillside Hospital in New York. “We don’t know if it’s the drop in estrogen during the luteal phase or the dramatic rise in progesterone,” she added. “But it could be some combination of the two things.”
Large, randomized, placebo-controlled clinical trials — the most rigorous types of studies — have found that low doses of S.S.R.I.s, taken during just the last two weeks of the menstrual cycle, can greatly alleviate PMDD symptoms. In one study published in 2005, for instance, researchers asked 373 women with PMDD to take a pill for each of the 14 days before menstruation for three months: One group took 12.5 milligrams of the antidepressant paroxetine CR (Paxil-CR), a second group took 25 milligrams of the same medication, and the third group took a placebo. Of the 292 women who completed the trial, those in the antidepressant groups tolerated the drugs and reported significantly reduced symptoms of PMDD, with no major differences between the two doses.
“As long as you keep track of where you are in your cycle, that works really well,” Dr. Deligiannidis said. Sertraline (Zoloft), fluoxetine (Prozac) and paroxetine (Paxil) have been approved by the Food and Drug Administration to treat PMDD, but numerous trials of other S.S.R.I.s — like citalopram (Celexa), escitalopram (Lexapro) and fluvoxamine (Luvox) — have shown benefits, too.
Why these antidepressants are effective is still a bit of a mystery, Dr. Deligiannidis said. “We know that S.S.R.I.s must be working a little bit differently than how they work for depression or anxiety disorders,” she said, since their benefits for those conditions can take weeks to kick in while for PMDD, symptoms can be relieved within days.
If you have PMDD and are already taking S.S.R.I.s, your doctor may recommend that you increase the dosage during just the lead-up to menstruation.
What else works for PMDD?
Not every treatment works for everyone, but fortunately, there are other options to try.
Birth control. For those who don’t respond well to S.S.R.I.s or who don’t want to take them, oral contraceptives containing estrogen and synthetic progesterone have been shown to alleviate symptoms. “The goal of using an oral contraceptive is to keep the hormone levels stable day to day,” Dr. Schiller said. But women must take the pill continuously throughout the month (which means skipping the placebo pills at the end of the menstrual cycle) so that they don’t experience a period or the change in hormones that triggers their symptoms.
Yaz is the only contraceptive that is F.D.A.-approved for treating PMDD, but Dr. Schiller said that other oral contraceptives can be effective, too. It just may take some trial and error to figure out the right one for you.
Cognitive behavioral therapy. For those who want to avoid medication altogether, some research suggests that cognitive behavioral therapy, a form of talk therapy that focuses on reframing negative thoughts and behaviors, can lessen PMDD and PMS symptoms. “The research on C.B.T. therapy is promising,” said Dr. Teresa Lanza di Scalea, a psychiatrist specializing in women’s reproductive mental health and an affiliate faculty member at Dell Medical School at the University of Texas at Austin.
Though keep in mind that C.B.T. alone is typically not enough to ease severe PMDD symptoms. In such cases, doctors might recommend it in combination with medication.
Lifestyle changes. Prioritizing exercise, sticking with a consistent sleep schedule and reducing stress as much as possible during the weeks before your period can also help, Dr. Lanza di Scalea said. “I’ve found these lifestyle changes, which do take effort, can feel very empowering for women.”
As with C.B.T., lifestyle changes can only go so far in alleviating severe cases of PMDD on their own, but they can supplement other treatments.
Calcium. There is also some limited evidence that taking certain supplements, particularly calcium, may lessen PMDD symptoms. Though the supplements may not work in severe cases, they may be worth trying. “If women are not taking a multivitamin with calcium, I usually have them start that,” Dr. Schiller said about her patients with PMDD.
Injectable medications. If none of these options quell your symptoms, your doctor may suggest that you consider an injectable medication called leuprolide acetate (Lupron Depot), which can be used off-label to treat PMDD. This medication, which can be given once a month or every three months, stops the ovaries from producing estrogen and progesterone, which can eliminate monthly symptoms.
For some women, it can make a “huge difference in terms of mood and ability to function,” Dr. Schiller said. The downside: It may not be sustainable in the long term because it’s expensive — around $2,000 (or more) per injection, she said — and insurance often doesn’t cover it. It can also cause side effects like headache, fever and muscle aches.
Surgery. If you have exhausted all other treatments for PMDD, the last option is to remove the ovaries. While extreme, Dr. Schiller said, many patients have success with this surgery.
“It’s a matter of finding a provider who will work with you to find a treatment that works,” she added.
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