The debilitating impact of Premenstrual Dysphoric Disorder (PMDD)

How is PMDD diagnosed?

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Associate Professor Chen says that women who have PMDD would have at least one of the following key symptoms:

Feelings of low mood, hopelessness or self-deprecating thoughts
Marked anxiety, tension or feeling on edge
Unstable mood and frequent crying (medically known as affective lability)
Persistent irritability causing conflict in relationships

Additional symptoms to fulfil a total of five symptoms including the key symptoms above:

Loss of interest
Lack of concentration
Lethargy, marked lack of energy
Food cravings or binge eating
Sleeping too much or too little
Feeling out of control
Physical symptoms like breast pain, headache, joint/muscle aches, bloating and weight gain.

“These symptoms should be present over two cycles or longer, and there should be no symptoms at all during the follicular phase (after menstrual period, before ovulation),” she adds.

While the exact cause of PMDD is unknown, she reveals studies have shown that hormones affecting the functioning of neurotransmitter systems that influence mood and thinking may trigger PMDD. Some women are also more sensitive to hormonal changes during the menstrual cycle. A disturbance in the brain's pathways that affect serotonin production could possibly be the cause of this medical condition.

“There is also likely an interplay between the mood pathway and the female hormonal pathway. PMDD is also likely to be genetic and there are other risk factors that might cause you to develop it, such as high levels of stress, obesity and a history of traumatic incidents,” Associate Professor Chen explains.

If a woman experiences at least five types of severe PMS symptoms that affect her ability to function, for two to three months, she would benefit from seeking a medical assessment, says Associate Professor Chen. This involves taking of medical history and evaluation of symptoms.

“It is recommended that women track their symptoms for at least a couple of months. Other conditions that may influence PMDD symptoms would have to be ruled out as well. Most commonly, some women with depression may experience a premenstrual worsening of their symptoms,” she adds.

Changing life plans

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Courtney's diagnosis didn't come easy, though. It took seeing three medical professionals to figure out what was going on.

“I was in dance school in New Zealand and trained for hours,” she shares. “Before my period and during my cycle, I would get really bad pain and it affected my ability to perform at a high intensity. It affected my mood as it was hard to understand why this was happening and it caused me to want to isolate and not go to school so much so I ended up missing classes."

“The school spoke to me about my attendance so I went to see a school nurse in October 2019. She gave me contraceptive pills, saying it will help with my pain,” she adds.

Things actually got worse for Courtney as she had really bad mood-related reactions to the pills. While she usually kept her composure, she was suddenly crying a lot. She'd call her parents in tears and they were horrified. She felt like she wanted to give up and realised she needed help.

“I thought the symptoms were just me getting used to the pills so I kept taking them,” recalls the 22-year-old. “I came back to Singapore after two or three months of taking the pills and saw a gynaecologist, who told me to stop taking them. He thought I had endometriosis or polycystic ovary syndrome (PCOS) but I did some scans and it wasn't the case.”

When Courtney saw the second gynaecologist, he asked her about her moods and put her on another type of hormone pills. However, the same thing happened and he told her to stop taking them as soon as he noticed the change. It was this doctor who diagnosed her with PMDD. She was also diagnosed with depression and anxiety.

Courtney admits she struggled once she was diagnosed in January 2020: “I had a lot of mixed feelings, it was hard to accept that this was real. I didn't really understand it but there was some sense of relief because I had an answer; it was not just me making a fuss of things with all those symptoms. It's been a journey and mood and mentality play a big part.”

Another reason why it was tough for her to accept the diagnosis was that she realised she had to change her life plans. She was in dance school training to be a full-time performer and she realised she might not be able to show up for the intense training and rehearsals that are needed in the professional dance scene.

It just so happened that the covid pandemic hit at that time and her school, being very small, stated that they could not properly care for its international students during the rapidly-approaching and indefinite lockdown period when schools would close. So they made an announcement just 48 hours before New Zealand commenced its lockdown and most international students left.

Once back in their home countries, international students joined virtual classes but when restrictions eased and in-person classes took over, the remote-learning medium was terminated and they were forced to withdraw from the course altogether. They could only re-enroll if borders were to open to international travelers, which only happened more than two years later, in July 2022. As far as Courtney knows, none of them had plans to return by then.

Don't just deal with it

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Courtney finds it hard to talk about PMDD as it's usually perceived as 'normal' PMS. She also shared her experience on Instagram.

“When I tell other women that I have PMDD, the reaction is either 'Oh, what's that?' or they'll say, 'Oh I have the same issues here and there, my cramps are really bad, sometimes I faint'. I feel like it's not often a conversation about understanding each other's symptoms seriously,” she says.

Those close to her were more understanding of her diagnosis. Her best friend in New Zealand saw her every day and said what she was going through was “not normal”. Her sister in Singapore has quite bad periods too but Courtney's is “on a different level”. And her mother was relieved with the diagnosis as ever since Courtney was young and brought up her symptoms, “She would say I don't know why it's so bad for you”. She has encouraged her parents to read up about PMDD.

Courtney is currently on antidepressants for really bad mood swings and prescription painkillers for cramps. She did see a TCM specialist for a while and felt it helped her menstrual flow get thinner, with fewer clots. She plans to get TCM help again soon.

She avoids foods that trigger her sensitive stomach, such as dairy and oily and spicy foods. And, during her period, she eats bland food like soup and steamed foods. She also takes a lot of vegetables to help with bowel movements and drinks lots of water.

Associate Professor Chen recommends women with PMDD adopt strategies that include medication and cognitive-behavioural therapy, which helps to reduce negative thoughts and develop effective coping strategies. They should also adopt healthy lifestyle behaviours.

“Regular aerobic exercise has benefits on PMS symptoms,” she advises. “Taking 100mg of vitamin B6 daily may benefit some women. Avoid intake of alcohol, caffeine, smoking and refined sugars. Eat small meals throughout the day and these meals should be high in complex carbohydrates and low in fat and protein. Stress-reduction techniques such as yoga may help reduce these symptoms.”

Courtney now works freelance in the arts and disabilities sector. She plans to continue with her studies overseas and get on the journey to becoming more independent. For now, she would like to meet more women who have PMDD and share their lived experiences.

“I would like women to learn about their symptoms and go and get diagnosed so that they can start living their life with an understanding of what's going on,” says Courtney. “Women can learn more about it and even maybe help a friend get diagnosed.

“Many women are not aware of women's conditions and that they are legit medical conditions to get treatment for. Pay attention to your body and don't second guess or doubt when you're struggling. Women should support each other in women's health issues and be encouraging, instead of just having to deal with it,” she adds.