Premenstrual syndrome

Also called PMS, PMDD, Premenstrual dysphoric disorder, PMT

Symptoms in the two weeks before a period. PMDD is the severe form, it is a recognised diagnosis, and it carries a real suicide risk.

What it is

Physical and emotional symptoms in the luteal phase, the roughly two weeks before a period, which resolve once bleeding starts.

Most women have some. It becomes a diagnosis when it interferes with life.

**Premenstrual dysphoric disorder** is the severe form, affecting perhaps 3 to 8 per cent of women. It is a recognised psychiatric diagnosis, and it is not an exaggerated version of ordinary irritability: it involves severe depression, hopelessness, rage and anxiety, sufficient to damage relationships and work, and it carries a substantially increased risk of suicidal thoughts and attempts. That is the reason this entry does not treat the subject lightly.

The cause is not abnormal hormone levels, which are usually normal. It is an abnormal sensitivity to normal hormonal fluctuation.

**Diagnosis requires prospective symptom tracking over at least two cycles.** Recalling symptoms afterwards is unreliable, and a daily record is what distinguishes PMDD from a mood disorder that happens to worsen premenstrually. This matters because the treatments differ.

Effective treatments exist and are under-offered: SSRIs, which can be taken only in the luteal phase and work within days rather than weeks, combined hormonal contraception taken continuously, and, in severe cases, GnRH analogues with add-back HRT.

Being dismissed is the norm. Many women are told it is just hormones for years.

Signs you might notice

Emotional: irritability, anger, low mood, tearfulness, anxiety, feeling overwhelmed or out of control, and in PMDD, hopelessness and despair.

Physical: bloating, breast tenderness, headaches, joint and muscle aches, fatigue, disturbed sleep, food cravings.

Cognitive: poor concentration, forgetfulness.

The defining feature is timing. Symptoms appear in the luteal phase and resolve within a few days of bleeding starting, with a symptom-free week or so afterwards.

Urgent: thoughts of suicide or self-harm, which are a recognised feature of PMDD and must be treated as serious rather than as hormonal.

Not PMS: symptoms present throughout the cycle, which suggests a mood disorder that worsens premenstrually and needs treating in its own right.

How it can affect day-to-day life

The cyclical nature is what makes it so destabilising. People describe becoming a different person for two weeks and then having to repair the damage in the other two, over and over.

Relationships and work suffer, and the shame afterwards is a substantial part of the burden.

Tracking is genuinely useful beyond diagnosis: knowing which days are coming allows planning of demanding tasks, difficult conversations and support.

It often worsens in the years approaching the menopause, when cycles become erratic and symptoms less predictable.

It commonly coexists with ADHD, autism, depression and anxiety disorders, and symptoms of all of those worsen premenstrually, which is worth recognising rather than treating as a separate problem each month.

Hysterectomy with removal of the ovaries cures PMDD and is a last resort with major consequences, and it should follow a trial of medical ovarian suppression first.

Supporting someone well

Track symptoms daily for at least two cycles, using a chart or app. This is required for diagnosis and it is what gets taken seriously.

Ask about SSRIs, including luteal-phase-only dosing, which many clinicians do not know about.

Ask about continuous combined hormonal contraception, without a break.

Take suicidal thoughts seriously at any point in the cycle.

Plan around the predictable days where possible.

Exercise, sleep and reducing alcohol all help modestly and are worth doing alongside rather than instead of treatment.

Ask for referral to a gynaecologist or a specialist premenstrual disorders service if first-line treatment fails.

Ask for medical ovarian suppression to be trialled before any consideration of surgery.

Do not accept it is just hormones as a management plan.

Where to get help

A GP practice, with two cycles of tracking in hand.

Gynaecology or a specialist premenstrual disorders clinic for severe or resistant symptoms.

Mind for information on PMDD and mental health support.

Samaritans on 116 123, any time.