- PMDD versus PMS, what's the difference between the two,
and how do we treat it?
That's what this video is about.
I'm Dr. Tracey Marks, a psychiatrist
and I do videos on mental health
education and self improvement.
This video is based on a viewer question from Mel.
"Can you please do a vid on PMDD?
"I'm having trouble knowing if it's that or bipolar II."
Thank you Mel.
PMDD stands for premenstrual dysphoric disorder,
and this is not to be confused
with premenstrual syndrome, or PMS.
PMS is changes in mood during certain parts
of your menstrual cycle and it affects about 80% of women.
The mood changes can be mild to moderate.
In fact, some women will just see it
as feeling a little moody
the week before their menstrual cycle.
PMDD is a severe form of PMS.
It's almost like turning into
a werewolf when the full moon rises.
(woman screaming)
(monstrous sound)
- [Girl] Mommy?
- And for some people, it's just that drastic.
It affects three to 8% of women,
so it's not as common as PMS.
PMDD became an official diagnosis
in 2013 with the fifth edition of the Diagnostic
and Statistical Manual of Mental Disorders.
Prior to that, it was in the appendix
of the DSM under Other Conditions.
Here's the criteria and it's a little complicated.
There is a total of 11 symptoms,
and you have to have five
of them the week before your period starts.
Then the symptoms start to improve just within days
of starting your period.
Then they become minimal or absent
the week after your period.
It's almost like if you become normal again.
And this doesn't have to happen for every single period,
but it happens for most of the time.
And here are the symptoms.
They are divided into two categories,
an emotional category and a physical category.
Marked emotional lability,
such as mood swings or feeling suddenly sad or tearful,
or increased sensitivity to rejection.
Irritability or anger, or increased interpersonal conflicts.
You are having trouble getting along with people.
Depressed mood, feelings of hopelessness
or being consumed with putting yourself down.
Anxiety, tension or feeling keyed up or on edge.
You must have one or more of these in this category.
Here's the second category.
Decreased interest in your usual activities,
such as work, school, friends.
Trouble concentrating.
Low-energy.
Appetite changes that can be undereating
or overeating or even having food cravings.
Hypersomnia, which is sleeping too long
or insomnia which is hardly sleeping.
A sense of being overwhelmed or out of control.
Physical symptoms like breast tenderness or swelling,
joint or muscle pain, or feeling bloated.
You must have one of these in this category
and then between the two groups, you need to have five.
That's a lot of criteria,
but here's how I've seen this look.
I see the woman who may
have been diagnosed with bipolar disorder
because of the wide mood swings,
and this is like what Mel asked in her question.
But she's not sure she fits the diagnosis,
because there's a lot of times when she feels good.
She doesn't even see why she needs medication
and the medication still doesn't seem
to always help in the first place.
She doesn't always put it together with the timing
of her cycle, she just knows
that there are times when her anger is just out of control,
like she's a completely different person.
This is one way PMDD can look.
What makes this happen?
It boils down to a drop in progesterone.
Let me show you.
Let's assume your menstrual cycle is 28 days.
In the first two weeks,
a follicle in your ovary grows into an egg.
The egg is released and leaves behind an empty follicle.
This empty follicle is called the corpus luteum,
which is Latin for yellow body.
This yellow body secretes progesterone,
which builds up your uterus to carry a baby.
If you don't get a fertilized egg,
the yellow body stops secreting
progesterone and withers away.
With that, you get a quick drop in progesterone.
This happens one to two weeks before your period starts.
With no more progesterone,
that nice cushiony uterine lining sheds,
which is your menstrual cycle.
Some women are more sensitive to the drop in progesterone,
and here's how it affects you mentally.
Progesterone is converted
to another hormone called allopregnanolone.
allopregnanolone binds to GABAA receptors.
This is the same receptor that alcohol
and benzodiazepines xanax bind to.
So allopregnanolone has the effect
of decreasing anxiety and depression.
So for women who are sensitive to this drop,
what you can experience can be similar
to withdrawing from xanax or alcohol,
which is a terrible feeling.
How can you make this connection?
Keep a daily diary of your symptoms for two months.
Researchers use the Daily Record
of Severity of Problems to screen for PMDD.
That's the official tool.
I have a diary you can use
that's based on the screening tool.
The link is in the description and at the end of the video.
If you're already a part of my email community though,
it's already in your email inbox.
So after you complete this information for two months,
if it looks like you fit this pattern,
take this diary to your doctor for treatment.
You could start with your gynecologist.
If your gynecologist is not comfortable treating the problem
with an antidepressant, you could
see your primary care doctor
and see if he or she will do it,
or you can see a psychologist.
Here's how we treat this problem.
The main medication treatment is SSRIs,
or selective serotonin reuptake inhibitors.
When you take an SSRI for depression,
it takes about four to six weeks
to see the effect of the medication.
However, SSRIs also accelerate the conversion
of progesterone to allopregnanolone,
and this effect works faster than the effect the SSRIs
have when they increase serotonin to treat your depression.
You would start taking the medication seven
to 10 days before your
menstrual period is supposed to start.
You can stop taking it after your period starts,
which is called intermittent dosing.
Or you can stay on it, which is called continuous dosing.
And you may wanna stay on it if you continue
to have some depression in between your periods,
but if this is the case,
then it's not really PMDD
but depression with premenstrual exacerbation.
Paroxetine, sertraline,
and fluoxetine are all FDA-approved for PMDD
to take intermittently or daily.
A bit about intermittent dosing.
For medications with a short half-life like paroxetine,
you can experience withdrawal symptoms
if you suddenly stop the medication.
I did a video on this called Brain Zaps and Antidepressants.
I'll put a link in the description
and in the top corner of this video.
We do tend to use, though,
lower doses of these medications for this purpose,
so taking a small dose may not result
in the withdrawal symptoms.
Also, fluoxetine has a very long half-life
and it takes a month a completely get out of your system,
so I'm actually not sure how useful it
is to even stop fluoxetine
for 10 days when by the time you get ready to take it again,
you've still got a lot of it in your system.
Another medication option is hormone treatment,
and you'll definitely need your gynecologist
for this kind of treatment.
The combination pill drospirenone and ethinyl estradiol,
also called Yaz, is FDA-approved for PMDD.
A more drastic approach though
is to use a medication called Leuprolide.
This medication shuts down your estrogen and progesterone.
And this effectively is a medical menopause.
About 60 to 70% of women respond to this medication,
but it does come with the side effects of hot flashes,
night sweats and all the issues
that would normally come along with menopause.
What if you don't want to take medication?
You can try diet modifications such as eliminating caffeine,
sugar, nicotine, and alcohol, and minimizing sodium.
You think you can do all that?
You would combine this with lifestyle changes
like sleeping seven to nine hours a night
and getting regular exercise,
like three to five times a week.
Some nutritional supplements have been shown to be helpful
and these would be things like calcium,
1200 milligrams a day, vitamin B6, 50
to 100 milligrams a day.
You don't want take more than 100 milligrams though,
because higher doses can cause peripheral neuropathy,
and this can feel like burning,
pain, or even weakness in your hands and feet.
Other supplements would be magnesium and vitamin E.
There are some herbal remedies
that have been shown in studies to be helpful,
and this would be agnus-castus fruit extract,
also known as chasteberry, and ginkgo biloba.
Light therapy may be helpful
but more studies are needed
to establish just how long
you should use the light and how often.
Check out the other videos in my playlist on women's health.
See you next time.