When Hormones and Mental Health Collide

PMDD or PME? Why This Diagnostic Debate Is Hurting Patients

I. Introduction

A while ago, the subreddit for PMDD started drawing hard lines over whether someone has PMDD or PME. They forbade discussions of using antihistamines to treat PMDD, saying that if someone’s symptoms improve after taking antihistamines, it’s a sign that they had PME (worsening of an existing condition) rather than PMDD.

Additionally, some women who posted that they have multiple conditions, such as PTSD, major depressive disorder, and anxiety disorders, received comments that if they have these disorders, their premenstrual symptoms are PME rather than PMDD.

As a result, several new subreddits cropped up as alternatives for women who felt unwelcome or were outright muted or banned from posting on r/pmdd. The sad consequence is further isolation and reduced access to various voices, sharing, and resources.

To understand why this controversy matters, we need to first understand what these disorders actually are.

II. Understanding PMDD and PME

Premenstrual disorders (PMDs) represent a spectrum of menstrual-related conditions that significantly impact the lives of millions of menstruating females worldwide¹.  These disorders refer to a collection of physical and emotional symptoms that typically occur during the luteal period of the menstrual cycle and subside with the beginning of menses.²

The International Society for Premenstrual Disorders (ISPMD) has defined two main categories of PMDs: core PMDs and variant PMDs.

• Core PMDs:

  • Premenstrual Syndrome (PMS)

  • Premenstrual Dysphoric Disorder (PMDD), which can be further categorized into predominantly physical, predominantly emotional, and mixed types.

• Variant PMDs encompass premenstrual exacerbations (PME) of underlying medical or psychiatric conditions, non-ovulatory PMDs, progesterone-induced PMDs, and PMDs without menstruation.³

A diagnosis of PMDD, the most severe form of PMD, requires emotional symptoms plus significant distress or disruption to one's life. Despite their prevalence, PMDs often go undiagnosed and undertreated, leading to significant impacts on individuals' mental and physical well-being.⁴

PMDD vs. PME: The Controversy

Of course, differentiating between PMDD and PME (premenstrual worsening of existing conditions) is not easy - in fact, it’s “the most significant difficulty” in PMDD diagnosis.⁵ The DSM diagnostic criteria states,

E) Consider Other Psychiatric Disorders The disturbance is not merely an exacerbation of the symptoms of another disorder, such as major depressive disorder, panic disorder, persistent depressive disorder (dysthymia) or a personality disorder (although it may co-occur with any of these disorders).

First, no one should diagnose another person online based on a few sentences, particularly when not trained. But also, PMDD is highly co-morbid with mental health disorders⁶ (and only 26.5% of women who fit the diagnostic criteria for PMDD had no other mental health disorder)⁷.

And if we think about it for a moment, it makes total sense.

Comorbidity with Other Mental Health Conditions

Premenstrual exacerbation of symptoms was found for several mental health disorders, including generalized anxiety disorder, depressive disorders, schizophrenia, and panic disorder.⁸ Women with generalized anxiety disorder were found to be more likely to have PMDD⁹, and PTSD (post-traumatic stress disorder) and BPD (borderline personality disorder) symptoms have been found to fluctuate with the menstrual cycle. However, the effect of the menstrual cycle phase appears inconsistent.¹⁰

As mentioned in my article about the relationship between ADHD and PMDD (not published yet but almost complete), women with ADHD report both a premenstrual worsening of ADHD symptoms¹¹ (i.e., PME) and are more likely to qualify for a PMDD diagnosis¹².

III. The interplay of PMDD and other conditions

Trauma and PTSD

Trauma and PTSD are both independently associated with PMDD (Piontek et al., 2021). Additionally, there is a potential bidirectional relationship.

Depression and bipolar

Around 60% of women with mood disorders report PME, with some women with bipolar show symptoms of exacerbation around ovulation. PME of mood disorders predicts a more severe illness course.¹³

Different types of PMDD

To get a PMDD diagnosis, what you need is to experience emotional systems premenstrually, consistently, in a way that causes significant distress or disturbance to your life. And that’s basically it. Everything else is irrelevant or in a giant cloud of mystery: did you struggle with these types of symptoms since you first started menstruating, or did they start after a trigger event, like giving birth or experiencing significant stress? Do you experience severe symptoms for the entire luteal period, or do you experience a dip right after ovulation, feel OK for a while, and then really struggle in the last few days until you start menstruating? Do you have mainly physical symptoms, emotional symptoms, or both? Do you have the same symptoms every month, or are they constantly changing? All these questions and many others may be highly relevant to the best course of treatment.

It makes sense that there would be different types of PMDD and PMD patterns and various reasons for the broad range of symptoms. Maybe for some women, the trigger is hormonal, while for others, it’s a nutritional deficiency or emotional reasons. Perhaps for some, there’s a combination of reasons.

In this video examining the research into different patterns of PMDD, when asked, “Is the distinction between PME and PMDD real?” the answer is “probably not” - although understanding more about different types of premenstrual disorders or hormonal sensitivities may of course help adjust treatment.

There are different causes for PMS symptoms according to Chinese medicine, too: they may be caused by liver qi stagnation, blood deficiency, or spleen qi deficiency. I don’t know much about TCM to speak about it beyond anecdotal experiences from women who say that acupuncture helped their symptoms.

PMDD/severe PMS may lead to other diagnosis

When your life is constantly feeling unmanageable due to PMDD symptoms, it makes sense that one would develop symptoms of depression or anxiety even when they’re “supposed to” feel “good” and “symptom-free.”

PMDD symptoms can include severe mood swings, suicidal ideation, and irritability. Symptoms can lead to interpersonal conflict, missed work days, medical bills, weight gain, and more. All these things can cause further stress and the development of additional disorders - which may or may not be resolved if and when the PMDD is treated. Because who wouldn’t get anxious or depressed when your life spirals every two weeks?

Issues with mental health diagnosis in general

Mental health diagnosis is not an exact science. There’s an issue with inter-rater reliability, meaning that the same person can see several different psychologists or psychiatrists and come out with various diagnoses.

How we define diagnoses changes; PMDD was added to the DSM in 2013. Before that, it was called Late Luteal Phase Dysphoric Disorder. Maybe in the future, PMDD will be called something else. Perhaps the way we approach the diagnosis of mental and emotional disorders will change completely.

Conclusion

PMDD may occur with PME or other psychiatric disorders, or PME may occur without PMDD. "To distinguish between PME and PMDD, clinicians should use daily tracking tools, clinical evaluation during luteal and follicular phases, and collateral informants to assess if the symptoms in the premenstrual period differ in quality (in the case of PMDD) or merely in quantity/intensity (in the case of PME)."¹⁴ However, even that is not so simple when you take into account that symptoms may change over time without affecting the overall burden of the disease (i.e., an individual may experience a few months of irritability and rage and then a few months of primarily anxiety).

Furthermore, how important is it to distinguish between PME and PMDD? Well, if you’re a psychiatrist, it may be necessary. If you need a diagnosis for your insurance or you need to find the proper medication, it may make a big difference. But if you’re a woman who struggles with premenstrual symptoms, how important is it for you personally to define whether what you’re struggling with is called PME or PMDD? Finding effective strategies for managing symptoms and improving quality of life may be a better focus.

Ultimately, the goal should be to empower individuals with the knowledge and resources they need to navigate their symptoms effectively while continuing to advocate for increased awareness, research, and improved diagnostic and treatment options for all premenstrual disorders.

1. Reilly, T. J., Patel, S., Unachukwu, I. C., Knox, C.-L., Wilson, C. A., Craig, M. C., Schmalenberger, K. M., Eisenlohr-Moul, T. A., & Cullen, A. E. (2024). The prevalence of premenstrual dysphoric disorder: Systematic review and meta-analysis. Journal of Affective Disorders, 349, 534–540. https://doi.org/10.1016/j.jad.2024.01.066

2. Yonkers, K. A., Pearlstein, T., & Rosenheck, R. A. (2003). Premenstrual disorders: bridging research and clinical reality. Archives of Women’s Mental Health, 6(4), 287–292. https://doi.org/10.1007/s00737-003-0026-4

3. Kadian, S., & O’Brien, S. (2012). Classification of premenstrual disorders as proposed by the International Society for Premenstrual Disorders. Menopause International, 18(2), 43–47. https://doi.org/10.1258/mi.2012.012017

4. Halbreich, U., Borenstein, J., Pearlstein, T., & Kahn, L. S. (2003). The prevalence, impairment, impact, and burden of premenstrual dysphoric disorder (PMS/PMDD). Psychoneuroendocrinology, 28(3), 1–23. https://doi.org/10.1016/s0306-4530(03)00098-2

5. Cary, E., & Simpson, P. (2024). Premenstrual disorders and PMDD- a review. Best Practice & Research Clinical Endocrinology & Metabolism, 38(1). https://doi.org/10.1016/j.beem.2023.101858

6. Hartlage, S. A., & Gehlert, S. (2001). Differentiating premenstrual dysphoric disorder from premenstrual exacerbations of other disorders: A methods dilemma. Clinical Psychology: Science and Practice, 8(2), 242–253. https://doi.org/10.1093/clipsy.8.2.242

7. Wittchen, H.-U. ., Becker, E., Lieb, R., & Krause, P. (2002). Prevalence, incidence and stability of premenstrual dysphoric disorder in the community. Psychological Medicine, 32(1), 119–132. https://doi.org/10.1017/s0033291701004925

8. HSIAO, M.-C., HSIAO, C.-C., & LIU, C.-Y. (2004). Premenstrual symptoms and premenstrual exacerbation in patients with psychiatric disorders. Psychiatry and Clinical Neurosciences, 58(2), 186–190. https://doi.org/10.1111/j.1440-1819.2003.01215.x

9. Yen, J.-Y., Lin, P.-C., Huang, M.-F., Chou, W.-P., Long, C.-Y., & Ko, C.-H. (2020). Association between Generalized Anxiety Disorder and Premenstrual Dysphoric Disorder in a Diagnostic Interviewing Study. International Journal of Environmental Research and Public Health, 17(3), 988. https://doi.org/10.3390/ijerph17030988

10. Mu, E., Thomas, E. H. X., & Kulkarni, J. (2022). Menstrual Cycle in Trauma-Related Disorders: A Mini-Review. Frontiers in Global Women’s Health, 3. https://doi.org/10.3389/fgwh.2022.910220

11. Jong, Wynchank, D., Esther van Andel, Beekman, A., & Kooij, S. (2023). Female-specific pharmacotherapy in ADHD: premenstrual adjustment of psychostimulant dosage. Frontiers in Psychiatry, 14. https://doi.org/10.3389/fpsyt.2023.1306194

12. Dorani, F., Bijlenga, D., Beekman, A. T. F., van Someren, E. J. W., & Kooij, K. (2021). Prevalence of hormone-related mood disorder symptoms in women with ADHD. Journal of Psychiatric Research, 133, 10–15. https://doi.org/10.1016/j.jpsychires.2020.12.005

13. Kuehner, C., & Nayman, S. (2021). Premenstrual Exacerbations of Mood Disorders: Findings and Knowledge Gaps. Current Psychiatry Reports, 23(11). https://doi.org/10.1007/s11920-021-01286-0

14. Hantsoo, L., & Riddle, J. (2021). Treatment of Premenstrual Dysphoric Disorder (PMDD). Advances in Psychiatry and Behavioral Health, 1(1), 91–106. https://doi.org/10.1016/j.ypsc.2021.05.009