What Is Premenstrual Dysphoric Disorder (PMDD)?

“I always know when it’s starting,” says Lily, 17, sighing. “I feel tired and sad and fat. I get angry and upset at the smallest, dumbest stuff. I know it’s not real, but it still feels so bad.”

For most women and teenage girls, periods are just a part of life. At worst, a monthly inconvenience, at best a reminder our bodies are on track, working like they’re supposed to be. But for girls like Lily who have premenstrual dysphoric disorder (PMDD), the onset of menstruation can feel like a week of total hell.

Like its better known but less extreme cousin, premenstrual syndrome (PMS), PMDD is a constellation of physical and emotional symptoms. They occur during what’s called the luteal phase of the menstrual cycle, right before your period, when the uterus preps for the possibility of pregnancy with a surge of hormones.

Symptoms of PMDD and PMS often appear similar and include:

• Moodiness: feelings of depression, anxiety, irritability or even rage that seem to come out of nowhere
• Excessive crying or crying for no reason
• Feeling overwhelmed or like you’re barely getting by
• Intense sensitivity to rejection: worrying that everyone is mad at or unhappy with you
• Trouble concentrating or struggling to stay on on task
• Increased or decreased appetite
• Physical discomfort: exhaustion, bloating, cramps, headaches, tender breasts and body aches

Symptoms typically start 5-8 days before your period but can begin earlier, and go away once the period begins. Onset of PMDD can be any time after puberty.

An estimated 75 percent of women and girls experience some emotional and physical discomfort around their periods, but the impact of PMS on their lives is usually relatively mild. The symptoms of PMDD are far more severe and often cause problems that persist even after the tampon box is back in the cabinet.

“We all can have mood swings before the start of our periods, but in the case of PMDD we’re talking about feeling like a different person,” says Stephanie Samar, PsyD, a clinical psychologist who works with young women at the Child Mind Institute. It’s only PMDD if it is seriously impairing.

For example:

• A girl with PMS might feel tired or a little out of it. A girl with PMDD might be almost unable to get out of bed, or struggle to concentrate on even simple tasks.
• A girl with PMS might feel grumpy or frustrated. A girl with PMDD might feel moments of irrational rage, find herself fighting with loved ones out of nowhere, or end up damanging friendships or romantic relationships.
• A girl with PMS might be more emotional and find herself crying at things like sad commercials. A girl with PMDD is likely to experience feelings more akin to a major depressive episode, including feelings of hopelessness, worthlessness, misery and even suicidal thoughts.

PMDD is caused by a heightened sensitivity to the hormones estrogen and progesterone, both of which spike during the week before menstruation. In 2017, researchers at the National Institutes of Health found evidence that PMDD is likely genetic. Girls whose mothers have a history of severe premenstrual symptoms are more likely to have PMDD.

When PMDD is in full swing, girls are extra sensitive and respond more rashly and more intensely to anything that reads as rejection. Something like an offhand comment from her boyfriend or a sibling’s unwillingness to turn off the TV can trigger a major meltdown.

One of the most difficult aspects of PMDD is that though the symptoms that cause these blowups disappear once girls get their periods, the resulting conflicts, academic difficulties and interpersonal problems don’t. “I’d get my period and feel okay again,” Lily says, “but by then I’d done so much damage it almost didn’t matter. I felt better, but the problems were still there.”

After a particularly awful premenstrual week during which she’d missed an important homework assignment, blown off swim practice, and “fought with basically everyone,” Lily’s mother suggested they talk to her gynecologist. The doctor told Lily to start recording her symptoms.

Tracking is the first step to determining whether someone has PMDD. To make a diagnosis, experts require tracking for a minimum of two cycles showing consistent patterns in behavior and mood. If you think your daughter might have PMDD, work with her to mark down symptoms: what they are, how bad they get, and how long they last. Paper calendars work well, and many period tracking apps have a function that allows users to record symptoms. Teens can track by themselves, or parents can do it with them.

 Once two or more cycles have been tracked, make an appointment to speak to a gynecologist. Let the doctor know that you think your daughter may have PMDD, and share the tracking information you’ve gathered. Since PMDD is still a relatively new diagnosis, some doctors may need time to research the best treatment options for your child.

It is important to find someone who’ll be thoughtful and thorough, Dr. Samar notes. “If you believe this diagnosis fits but your doctor isn’t listening or is minimizing your worries, consider asking for a second opinion,” she adds. “You need to find someone who understands your concerns and takes them seriously.”

 In some cases, doctors may recommend medication as a treatment for PMDD. Birth control pills are often the first choice because they can help regulate and balance premenstrual hormonal shifts. In some cases, doctors may prescribe antidepressants. If your child already takes antidepressants, her doctor may recommend increasing the dosage during the week when her symptoms are most intense.

 The same information you collected in tracking can also make it easy to do some preemptive scaffolding at home. “Knowing how your PMDD affects you is powerful information,” says Dr. Samar. “Planning ahead can help minimize the impact.”

Planning how she’ll manage stress, interpersonal interactions and physical symptoms while she’s feeling good can help her navigate difficult situations when she’s feeling bad.

• If she often gets into fights, she might avoid making big social plans, like parties or dates. If problems do come up, she might make an agreement to revisit upsets or conflicts when she’s feeling like herself again.
• Stock the house with healthy food and plan to drink plenty of water.
• Alcohol can often make symptoms worse. If she’s of age, she could pledge not to drink until after she gets her period.
• Encourage exercise. “We know exercise is a big help when it comes to PMDD,” says Dr. Samar. Help her get moving. Signing up for a yoga class or planning to go for run can help relieve symptoms and help her feel more relaxed.
• Girls can also use cognitive behavioral techniques to help manage some of the more unruly emotions, says Dr. Samar. “Try to challenge thoughts and emotions you know might be out of proportion where you can,” she suggests. “Slow down and give yourself a second to say, Am I responding this way because I’m really this upset? Or am I responding this way because I’m more sensitive right now?”

The more girls build and practice coping skills, the better they’ll become at mitigating the impact of PMDD, something that will become even more important as they grow up, says Dr. Samar. “PMDD doesn’t go away. So these are skills that they’ll need all their lives.”

 “This is a serious disorder, but historically we haven’t treated it as such,” says Dr. Samar. “A lot of women and girls who experience PMDD aren’t even aware that it’s out of the realm of normal functioning.” Lily counts herself among them. Since hitting puberty at 13 she’d assumed her symptoms were a normal, if horrible, part of having her period. “I thought this was what everyone went through,” she says, “and this was just how it had to be.”

One of the first things girls with PMDD — and their families and doctors — need to understand is that they can’t just “get over it,” Dr. Samar explains. “This is organic. It’s not something you can choose not to feel.”

Parents should take care to validate their daughters’ experience, even while trying to help them learn to manage their emotions in a healthier way. “Don’t say, ‘Oh you’re just saying that because you’re on your period, you’ll be over it soon,’ ” she explains. Instead, she suggests parents instead try something more along the lines of, “I can see how upset you’re feeling. Let’s take a break now and talk this over when you’re feeling a little calmer.”

For Lily, finding out that she had PMDD was a lifesaver. “Before I understood what was going on it was like I’d spend three weeks feeling more and more panicky, like oh, it’s coming, and the fourth just losing my mind.” But after being diagnosed, she says, things have become brighter and easier. Lily’s gynecologist put her on birth control and she’s learned some techniques to help her manage her emotions. “Before it was like a tsunami,” she says, “uncontrollable and just totally devastating. Now it’s more like little waves. It’s not perfect, but it is a lot easier and I can deal with that.”