Severe PMS and PMDD: symptoms, diagnosis and treatment

The NHS describes premenstrual syndrome (PMS) as the symptoms women can experience in the weeks before a period, saying that most women have PMS at some point and that symptoms differ between women and from month to month. The most common symptoms include mood swings, feeling depressed or irritable, anxiety, tiredness or poor sleep, bloating or cramping, breast tenderness, headaches, spots, greasy hair and changes in appetite or food cravings.

Severe PMS is not a separate NHS category, but the NHS recognises that a small number of women have a more severe form called premenstrual dysphoric disorder (PMDD). Its symptoms are similar to those of PMS but much more intense, and can have a much greater negative effect on everyday life. If your symptoms regularly stop you working, socialising or looking after yourself, they deserve a proper assessment rather than being dismissed as just hormones.

According to the NHS, PMDD symptoms usually start around 1 or 2 weeks before each period and improve a few days after the period starts. Emotional symptoms can include feeling depressed, hopeless, anxious or worried, feeling angry or irritable, having less interest in things you normally enjoy, feeling overwhelmed or out of control, and having suicidal thoughts.

Physical symptoms include breast tenderness, joint and muscle pain, being more tired than usual, sleep problems or sleeping too much, and bloating. The NHS says these can make it difficult to work, socialise and maintain relationships. The cyclical pattern is the key to recognising PMDD: relief after the period begins distinguishes it from depression or anxiety that continues all month, although PMDD can also worsen an existing mood condition.

The NHS says it is not fully understood why women get PMS, but it may be because of changes in hormone levels during the menstrual cycle, with some women more affected by those changes than others. For PMDD it is not known exactly what causes it; it may be increased sensitivity to the natural changes in oestrogen and progesterone during the cycle, and the NHS says it has been linked to being very sensitive to hormone changes or to certain differences in inherited genes.

This is useful because it explains why hormone levels themselves are usually normal in people with PMDD, and why blood tests of hormones are not the usual route to diagnosis. The condition reflects how the brain responds to normal cyclical change.

The NHS advises keeping a diary of symptoms for at least 2 menstrual cycles to share with your GP. A GP who thinks you might have PMDD will ask about symptoms and how they affect your life, and may diagnose PMDD if symptoms happen every month, around 1 or 2 weeks before your period, and have been present for at least 2 months.

Record the date each period starts and rate each symptom daily, including mood, sleep, appetite, pain, bloating and how well you functioned at work and home. Note any time of the cycle when you feel entirely well. Bring the diary to the appointment; it often makes the pattern obvious and helps your clinician rule out other causes such as thyroid problems, anaemia or an underlying mood disorder.

For PMS, the NHS suggests regular exercise, a healthy balanced diet (some people find smaller meals every 2 to 3 hours better), plenty of sleep, stress reduction such as yoga or meditation, painkillers such as ibuprofen or paracetamol for pain, avoiding smoking and not drinking too much alcohol. If these do not help or symptoms affect daily life, a GP may recommend hormonal medicine such as the combined contraceptive pill, cognitive behavioural therapy or antidepressants.

For PMDD, the NHS says the main treatments a GP may offer are: medicines for anxiety or depression, usually an antidepressant called an SSRI; painkillers or anti-inflammatory medicines such as ibuprofen or naproxen for joint or muscle aches; hormonal treatments such as the combined pill; and talking therapies such as CBT. If these have not helped, surgery may be considered with the aim of stopping periods, by removing the ovaries, fallopian tubes or the womb. The NHS says this is not suitable if you want to get pregnant.

On complementary options, the NHS says therapies and supplements such as acupuncture, reflexology, vitamin B6, calcium, vitamin D and magnesium may help but there is not much evidence that they work, and you should check with a GP or pharmacist before starting regular supplements if you take other medicines. If symptoms continue after treatment, the NHS says you may be referred to a gynaecologist, psychiatrist or counsellor.

The NHS is clear that anyone with PMDD symptoms who feels suicidal should call 999 or go to A&E, not drive themselves, and bring any medicines. If you are not in immediate danger but are struggling, Samaritans can be called free on 116 123, and the NHS signposts urgent mental health help through NHS 111.

Make a GP appointment sooner if mood symptoms are severe each month, if self-care measures have not helped, or if you notice symptoms continuing through the whole cycle, which may suggest depression, anxiety or another condition needing separate treatment.

Start with your GP, who can review a symptom diary, exclude other conditions, offer an SSRI or the combined pill and refer to talking therapy. Persistent severe symptoms can lead to referral to gynaecology or psychiatry. Support groups, including those listed by the NHS such as The PMDD Project and Mind, can provide peer support alongside medical care.

Private gynaecologists and psychiatrists can assess PMDD in more depth and offer quicker appointments. Because treatment may involve long-term medicine or, rarely, surgery, ask any provider about the evidence behind each option, how long you would need treatment and how your GP will be kept informed.