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Premenstrual Dysphoric Disorder and ADHD: Managing the Overlap and Enhancing Treatment

Writer's picture: PetraPetra
4 days ago5 min read

I have written about Premenstrual Dysphoric Disorder (PMDD) previously in my blog post on feminising hormones and ADHD, and for a while, I have been wanting to expand on that with a PMDD post on its own. PMDD or PMS is present in a significant number of my ADHD assessment and therapy clients. Often, it has not been extensively discussed before, and generally not with a person's GP.


PMDD is a severe form of premenstrual syndrome (PMS). While PMS is common and involves symptoms like bloating, mood swings, and mild discomfort, PMDD is much more intense and disruptive, with a range of physical and emotional symptoms, and there is evidence that the prevalence is significantly higher in people with ADHD.


History of PMDD as a Diagnosis

PMDD was first included in the DSM-III-R in 1987 as “Late Luteal Phase Dysphoric Disorder,” a provisional diagnosis. It wasn't until the DSM-5, published in 2013 that PMDD moved from the back of the DSM to the ranks of officially recognised diagnosable disorders. This recognition was crucial for validating those affected's experiences and guiding appropriate treatment.


DSM-5 Criteria for PMDD

According to the DSM-5, PMDD is characterised by mood disturbances that occur in the luteal phase of the menstrual cycle (post-ovulation) and significantly interfere with daily life. To be diagnosed with PMDD, an individual must experience at least five of the following symptoms, with one of the first four and one of the last seven symptoms being present:


  1. Marked affective lability (e.g., mood swings, feeling suddenly sad or tearful, or increased sensitivity to rejection)

  2. Marked irritability or anger or increased interpersonal conflicts

  3. Markedly depressed mood, feelings of hopelessness, or self-deprecating thoughts

  4. Marked anxiety, tension, and/or feelings of being keyed up or on edge

  5. Decreased interest in usual activities (e.g., work, school, friends, hobbies)

  6. Subjective difficulty in concentration

  7. Lethargy, easy fatigability, or marked lack of energy

  8. Marked change in appetite, overeating, or specific food cravings

  9. Hypersomnia or insomnia

  10. A sense of being overwhelmed or out of control

  11. Physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of “bloating,” or weight gain


In many ways, PMDD can look like acute depression symptoms. A person may also experience suicidal thinking during the luteal phase. Ideally, these symptoms should be tracked prospectively for at least two menstrual cycles to confirm the diagnosis. So, collecting data about these symptoms may be necessary for receiving treatment.


What Causes PMDD?

The exact cause of PMDD isn't fully understood, but research suggests that it is primarily related to the body's response to hormonal changes during the menstrual cycle.


The menstrual cycle is a complex process involving the coordinated fluctuation of several hormones, primarily estrogen and progesterone. In the first half of the cycle, known as the follicular phase, estrogen levels gradually rise, peaking just before ovulation. This surge in estrogen helps to mature the ovarian follicle and prepare the endometrium for potential implantation.


Following ovulation, the luteal phase begins, during which progesterone levels increase significantly, supporting the thickening of the endometrial lining. Meanwhile, estrogen levels also remain relatively high but start to fluctuate. If fertilisation does not occur, both estrogen and progesterone levels sharply decline towards the end of the luteal phase, leading to the shedding of the endometrial lining and the onset of menstruation.


These hormonal fluctuations are essential for the menstrual cycle but can cause significant physical and emotional changes, especially in individuals with heightened sensitivity to these hormonal shifts.


Sensitivity to Hormonal Fluctuations

One of the key factors in PMDD is not just the hormonal changes themselves but the individual's sensitivity to these changes, as there are plenty of people experiencing these same hormonal changes without experiencing significant dysphoric symptoms. Increased sensitivity to these regular changes can be due to genetic, environmental, and neurochemical factors.


  1. Neurotransmitter Involvement Hormonal fluctuations, particularly the drop in estrogen and rise in progesterone, can affect the balance of neurotransmitters in the brain. Estrogen, for instance, enhances the production and activity of serotonin and dopamine, both of which are crucial for mood regulation and cognitive function. When estrogen levels fall, serotonin and dopamine levels can also decrease, leading to mood swings, irritability, and cognitive difficulties. In individuals with PMDD, this neurochemical imbalance may be more pronounced, contributing to severe symptoms.

  2. Genetic and Environmental Factors Research suggests that genetics may play a role in PMDD. Individuals with a family history of mood disorders or PMDD are more likely to experience the condition themselves. Additionally, environmental factors such as stress, diet, and lifestyle can influence hormone sensitivity and exacerbate PMDD symptoms.


PMDD and ADHD: A Complex Relationship

Research indicates a higher prevalence of PMDD among individuals with ADHD. The hormonal fluctuations in the menstrual cycle, particularly the drop in estrogen levels, can exacerbate ADHD symptoms. Estrogen is known to influence dopamine levels in the brain, a neurotransmitter crucial for attention and executive function. Lower estrogen can lead to lower dopamine, worsening ADHD symptoms.


Furthermore, stimulant medications commonly used to treat ADHD may become less effective during the luteal phase of the menstrual cycle. This can be particularly challenging for individuals with both ADHD and PMDD, as they may experience a significant decline in their ability to manage ADHD symptoms when they need it the most.


Evidence-Based Treatments for PMDD

Several treatments are effective in managing PMDD symptoms:


  1. Lifestyle Modifications: Regular exercise, a balanced diet, and stress management techniques can help alleviate some symptoms of PMDD.

  2. Cognitive-Behavioural Therapy (CBT): CBT can be effective in addressing the mood-related symptoms of PMDD by helping individuals develop coping strategies and challenge negative thought patterns.

  3. Medications:

    1. Selective Serotonin Reuptake Inhibitors (SSRIs): SSRIs are often the first line of treatment for PMDD and can be taken continuously or only during the luteal phase. For people already on an SSRI, a higher dose may be taken during the luteal phase.

    2. Hormonal Therapies: Birth control pills, especially those that combine estrogen and progesterone, can help stabilise hormonal fluctuations. However, there is a recent study suggesting that women with ADHD are six times more likely to experience depression while using oral contraceptives compared to women without ADHD.

    3. Gonadotropin-Releasing Hormone (GnRH) Agonists: These medications can suppress ovarian hormone production in severe cases, producing a temporary menopause-like state.

  4. There are some supplements with evidence that can be learned best through this PMDD and ADHD webinar.


Conclusion

PMDD is a serious and often debilitating condition that requires careful management, especially for those also dealing with ADHD. Understanding the interplay between hormonal changes and neurotransmitter levels can help in developing effective treatment plans. With the right combination of lifestyle changes, therapy, and medication, individuals with PMDD can achieve significant relief and improve their quality of life.




There are many more resources to be found at the bottom of my Women and ADHD: Hormones blog post.



 
 
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