PMDD: The intersection of Mental Health & Menstrual Health

It’s just past 10 pm, and I get a frantic message. “HELP. ” I open up my email to find a note from a client who has a history of gynecological issues and  PMDD. Over our time working together, those few days before starting her menstrual cycle are fraught with extremely challenging emotions ranging from paranoia to anxiety, depression and mental confusion.

PMDD is a condition that affects 3-8% and likely as high as 18-30% of Menstruators (1). This debilitating disorder is experienced in the Luteal phase ( 5-10 days before starting a new cycle). It is marked by significant mood changes and sensitivity to the fluctuation of hormones during that time. It is distinguished from Pre Menstrual Syndrome based on the severity of mood changes.

Symptoms include:

• Severe Irritability/Aggression
• Severe Anxiety/Depression
• Poor concentration 
• Poor working memory and confusion
• Paranoia
• Feeling Overwhelmed and Exhausted
• Hypersomnia

For some, a PMDD diagnosis comes after many years of concerns being dismissed by health care providers. Some menstruators have indicated a lack of understanding, mainly because the PMDD experience is subjective. Another challenge is that PMDD is often Misdiagnosed as Bipolar Disorder which has overlapping symptoms. Between 15-27% of menstruators with Bipolar Disorder meet the criteria for PMDD (2).

Social and Relational Impact

What do you do when you come face to face with thoughts that a person you perceived as a close friend, family member or ally is now an enemy with malicious intentions? What do you do when faced with a profound lack of self-worth or thoughts that you are truly alone in the world. You don’t just notice these thoughts, they feel like the truth. It feels impossible to bring awareness to any other version of reality. This is a window into the PMDD experience. Family and social relationships are significantly impacted by the intrusive thoughts experienced. Angry outbursts, meltdowns and thoughts of self-harm are increased considerably and are cyclical in nature. These behaviours can be even more isolating, especially when there is a lack of awareness, understanding or social support from loved ones or the wider community.

Workplace Impact

PMDD significantly affects a person’s ability to collaborate with others and is often marked by the desire to withdraw socially. Those with PMDD experience reduced ability to problem solve, inability to focus, reduced productivity and absenteeism (3). Organizations can support employees by increased awareness through educational resources on menstrual health, robust and inclusive wellness programmes that provide practical strategies. These strategies range from work reassignment, a focus on solo projects during this time and building supportive teams to increase flexibility. 

Topics related to menstrual health have often been stigmatized, especially in the workplace, with many menstruators fearful of being perceived as inconsistent or less productive than their counterparts.  This plays into the centuries-old narrative of Pathologizing Menstruators’ lived experience and judgements as being difficult or having an unnatural desire for privacy and independence(4).

PTSD complicates PMDD

Is there a link to the severity and experience of PMDD and PTSD? In my work with clients, I’ve noted that many have unprocessed childhood trauma and that issues related to feeling powerless, unloved or unprotected are amplified in the premenstrual phase of the cycle.  In one study, most of the participants reported that they experienced childhood abuse before the onset of PMDD (5).

Conventional Treatment

PMDD is typically treated using SSRIs and Cognitive Behavioural Therapy (6). While this may be helpful in some cases, if there is a Misdiagnosis of Bipolar Disorder, those with PMDD typically do not respond to the Antidepressants and mood-stabilizing drugs used for BD (7).

A Holistic Approach to PMDD

Somatic Therapy and Improving Vagal Tone

The vagus nerve is a bundle of nerves connected to all the internal organs. It is linked to the parasympathetic nervous system or the rest and digest system. Studies show that Vagus nerve dysfunction is common in those who have suffered with PTSD, Anxiety and Depression. Similarly, Vagus nerve stimulation has been shown to reduce the severity of these conditions (8). 

Those with PMDD can improve Vagal tone with breathwork, massage, gargling and laughter. Somatic therapy builds body awareness, grounding into the sensations that are connected to intrusive thoughts. When a person experiences Trauma, the associated emotions become trapped in the body. Somatic therapy helps identify where this energy is stored and employs the use of  movement to clear this energy out of the body.

Therapeutic Nutrition

 Over 70% of the body’s serotonin is produced in the gut. Serotonin helps regulate mood, and studies show that alterations in the serotonergic system may cause PMDD. Supporting Digestive health includes reducing the intake of inflammatory foods like sugar and alcohol, including probiotic-rich foods and supplements, as well as increasing enzyme-rich foods to help the breakdown and absorption of nutrients. Similarly, Increased intake of Essential Fatty Acid has been shown to improve mood and inflammation associated with PMDD (9).

Lifestyle Changes

Menstrual Cycle awareness and an appreciation for the ebbs and flows of energy are of critical importance for all menstruators, especially those who suffer from menstrual health disorders.  This encourages people to become more strategic about using their energy and organizing life in a more cyclic, spiralic and expansive way. While PMDD can be highly debilitating, there is an opportunity to heal long-held unprocessed emotions that perhaps went unaddressed. PMDD’s feelings often point to a wounded inner child that deserves support, empathy, compassion, and understanding. Communal healing spaces, in addition to traditional Behavioral Therapy, can prove to provide context for the complex emotions experienced during the Luteal phase. 

References

1. Halbreich, Uriel, et al. “The prevalence, impairment, impact, and burden of premenstrual dysphoric disorder (PMS/PMDD).” Psychoneuroendocrinology 28 (2003): 1-23
2.  Teatero, Missy L., Dwight Mazmanian, and Verinder Sharma. “Effects of the menstrual cycle on bipolar disorder.” Bipolar disorders 16.1 (2014): 22-36.
3.  Saunders, Kate EA, and Keith Hawton. “Suicidal behaviour and the menstrual cycle.” Psychological medicine 36.7 (2006).
4. Jurvanen, Sanna. “The Subjective Experience of Pre Menstrual Dysphoric Disorder PMDD)-A qualitatative study exploring consequences of PMDD symptoms in relation to occupational and private life.” (2017)
5. Ussher, Jane M. “Diagnosing difficult women and pathologising femininity: Gender bias in psychiatric nosology.” Feminism & Psychology 23.1 (2013): 63-69.
6.   Wittchen, H-U., Axel Perkonigg, and Hildegard Pfister. “Trauma and PTSD–An overlooked pathogenic pathway for Premenstrual Dysphoric Disorder?.” Archives of Women’s Mental Health 6.4 (2003): 293-297.
7. Steiner, Meir, et al. “Expert guidelines for the treatment of severe PMS, PMDD, and comorbidities: the role of SSRIs.” Journal of women’s health 15.1 (2006): 57-69.
8. Studd, John. “Severe premenstrual syndrome and bipolar disorder: a tragic confusion.” Menopause international 18.2 (2012): 82-86
9. Souza, Rimenez R., et al. “Vagus nerve stimulation reverses the extinction impairments in a model of PTSD with prolonged and repeated trauma.” Stress 22.4 (2019): 509-520.