Why are some people more susceptible to severe PMS? Psychologists seek answers

Many people who menstruate experience mild physical or psychological symptoms of premenstrual syndrome (PMS), such as bloating, tender breasts, sadness, and irritability, according to the International Association for Premenstrual Disordersopens in new window (IAPMD). For most of these people, such symptoms aren’t a big deal. But for a small percentage of those who menstruate—about 6%—premenstrual symptoms are so severe and extensive that they interfere with daily life.

For these individuals, premenstrual dysphoric disorder (PMDD) can cause intense symptoms like anger, mood swings, depression, anxiety, and conflict in the weeks before bleeding begins. In some patients, the symptoms that occur during what some with PMDD call “werewolf week” become so severe that they have resorted to hysterectomies or even suicide.

[Related: PMS vs. PMDD: What’s the difference?]

Now psychologists and others are getting closer to figuring out why some people are more susceptible. Researchers like Tory Eisenlohr-Moul, PhD, who chairs IAPMD’s clinical advisory board, are finding that an abnormal sensitivity to the normal rise and fall of hormones during the menstrual cycle is to blame. That hormonal sensitivity doesn’t just cause PMDD, said Eisenlohr-Moul, an associate professor of psychiatry and psychology at the University of Illinois at Chicago. It can also exacerbate other mental and behavioral health conditions, including borderline personality disorder, posttraumatic stress disorder (PTSD), and attention-deficit/hyperactivity disorder (ADHD).

For Hudson, New York, writer Chloe Caldwell, PMDD meant developing overwhelming feelings of rage and paranoia in the week before her period. For 3 weeks of every month, she felt like her normal self. “And then I would completely transform into the Hulk,” said Caldwell, who described mental and emotional symptoms that threatened a new romantic relationship and other aspects of her life. Then her therapist asked if she had heard of PMDD. “It was a relief to have a label,” said Caldwell, who went on to write a memoir called The Red Zone: A Love Storyopens in new window (Soft Skull Press, 2022) about how she struggled with but eventually overcame the disorder.

By asking about PMDD, Caldwell’s therapist proved herself unusual, according to Eisenlohr-Moul. “Most psychologists don’t know much about it yet, but they really should,” she said, especially since most patients who seek care from psychologists are females of reproductive age.

[Related: Four questions to ask patients about their menstrual cycles]

To help the often misunderstood, underserved population of patients experiencing severe menstrual-related symptoms, practitioners should familiarize themselves with the emerging science on the mechanisms underlying PMDD and related problems, Eisenlohr-Moul and other psychologists said. They should understand the issue’s seriousness without contributing to the stigma that is sometimes associated with premenstrual problems. And they should learn how to diagnose and treat those with what is now known as “hormonal sensitivity.”

In the late 1990s and early 2000s, researchers began to focus on people who experience the most severe premenstrual symptoms. That first generation of researchers established that PMDD exists in a small subset of people who menstruate and began laying the groundwork for further research into the mechanisms at play.

The researchers found that PMDD is not a hormonal imbalance, a common misconception. Instead, it is an abnormal sensitivity in the brain to the normal rise and fall of hormones during the menstrual cycle, said Eisenlohr-Moul. Hormonal sensitivity might not happen only in those who menstruate, she added. Although hormonal sensitivity in men is even more understudied than in people who menstruate, one early study by pioneering PMDD researcher Peter J. Schmidt, MD, and colleagues found that a small minority of male participants were unusually sensitive to fluctuations in testosterone and experienced disturbances in mood along with the rise and fall of that hormone (Archives of General Psychiatry, Vol. 61, No. 10, 2004opens in new window).

Since those early days, PMDD has become an official diagnosis. The Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) added PMDD in 2013; the International Statistical Classification of Diseases and Related Health Problems (ICD-11) followed suit in 2019. Those additions sparked controversy, said anthropologist Kathryn Clancy, PhD, author of Period: The Real Story of Menstruationopens in new window (Princeton University Press, 2023). Some argued that hormones make all women a little unhinged; others claimed that PMDD was a made-up diagnosis that stigmatizes those who menstruate.

What’s needed is more nuance, said Clancy, a professor of anthropology at the University of Illinois at Urbana-Champaign. “It’s not mutually exclusive to say that women are not hysterical and to say that there are a significant number of people with menstrual cycles who are suffering greatly and deserve far more attention than they have received,” she said. “It’s possible for something like PMDD to exist and to severely affect up to 6% of cycling people and to say the existence of this condition doesn’t mean by extension that all cycling people have some sort of mental health condition.”

PMDD researchers are also motivated to take a more nuanced approach. The field is currently exploring how hormonal sensitivity manifests itself during other phases of life, including peripubertal, peripartum, and perimenopausal changes. Researchers are also discovering that some people who menstruate experience symptoms at other points in their cycles, not just in the two weeks before their periods. “We know that the pattern that people have isn’t always consistent with what we think of as premenstrual,” said Eisenlohr-Moul.

Researchers are also delving into the complexities of how hormonal sensitivity presents in clinical practice.

Take suicidality in adolescent girls. Data from the U.S. Centers for Disease Control and Prevention (CDC) Youth Risk Behavior Survey in 2021 found that almost a third of high school girls had seriously thought about attempting suicide. Of course, girls have plenty of external reasons to feel sad. That same CDC survey found that nearly 20% of girls had experienced sexual violence in the past year, for instance. But hormonal sensitivity probably plays a role, too, said Eisenlohr-Moul. The introduction of hormonal fluctuations around puberty has something to do with the huge increase in depression and suicidality in girls that isn’t seen in boys, she speculated.

Hormonal sensitivity seems to drive self-injurious thoughts and behaviors in adults, too, Eisenlohr-Moul has found. In a study of almost 600 individuals ages 13 to 62 with a PMDD diagnosis, 72% reported lifetime active suicidal ideation, 49% reported planning suicide, and 34% had made an attempt (BMC Psychiatry, Vol. 22, 2022opens in new window). More than half reported nonsuicidal self-injury. In another study, Eisenlohr-Moul and her fellow researchers identified a potential mechanism behind hormonal sensitivity’s link to suicide: acute premenstrual withdrawal from sex hormones (Translational Psychiatry, Vol. 12, 2022opens in new window). People with premenstrual disorders, including PMS and PMDD, are also at higher risk of falls, car accidents, and other forms of injury in addition to suicidal behavior, a Swedish study has found (Yang, Q., et al., BMC Medicine, Vol. 19, 2021opens in new window).

While early researchers focused on menstruators with clear on/off patterns of premenstrual distress, Eisenlohr-Moul and others are now exploring the more complex cases they commonly see in clinical practice—patients who have hormonal sensitivity along with other psychiatric disorders.

That overlap is common, said Laura Payne, PhD, an assistant professor of psychology in the psychiatry department at Harvard Medical School. In a synthesis of the literature on the menstrual cycle’s effect on women’s mental health, Payne and colleagues found that psychiatric symptoms were often exacerbated during the premenstrual and menstrual phases (Harvard Review of Psychiatry, Vol. 30, No. 2, 2022opens in new window). Although more high-quality studies are needed, said Payne, there was clear evidence that depression, suicide attempts and suicide, psychosis, mania, and alcohol use increase during these phases, while stress, anxiety, and binge eating are elevated throughout the nearly 2-week-long luteal phase. (The luteal phase begins halfway through a 28-day menstrual cycle, after ovulation, and prepares the uterus for a potential pregnancy.) “Overall, the premenstrual and menstrual phases seem to be the most vulnerable times for women, meaning they could experience a worsening of psychiatric symptoms,” said Payne, explaining that the review included studies looking at all women, not just those with PMDD.

The exacerbation of symptoms doesn’t necessarily occur only in the premenstrual phase, Payne and other researchers are finding. In a small study of patients with borderline personality disorder, for example, reactive aggression—things like yelling at someone in response to frustration or other strong emotions—increased during the midluteal phase, while proactive aggression—being aggressive as a way of getting needs met—increased during the follicular phase (Aggressive Behavior, Vol. 46, No. 2, 2020opens in new window). (The follicular phase starts when menstrual bleeding begins and ends when ovulation occurs.). “Borderline personality disorder is characterized by high levels of fluctuating symptoms,” said lead author Jessica R. Peters, PhD, a member of the IAPMD’s clinical advisory board and associate professor of psychiatry and human behavior at the Alpert Medical School of Brown University. “Being able to predict even a piece of that would be invaluable.”

To account for hormonal sensitivity’s potential impact on clients, practitioners might think of the menstrual cycle as a fifth vital sign, said Payne.

Asking about the date of the last menstrual period can draw the clinician’s attention to especially vulnerable times and allow for advanced planning around stress reduction, coping skills, and self-care. Researchers should also pay attention to the menstrual cycle’s effect, Payne said. “I question how our existing research findings would apply differently if the menstrual cycle were included as a variable in so many different psychiatric research studies,” she said. “Not accounting for that variability introduces a question of just how generalizable the results are.”

Consider ADHD. Practitioners have long thought of ADHD as stable, and a diagnosis can only happen if it was present during a patient’s childhood, before puberty or menstruation begins, said Michelle M. Martel, PhD, a University of Kentucky psychology professor. But findings from a small pilot study suggest that may not be the best way to think about ADHD, said Martel. In that study, Martel and other researchers found that ADHD symptoms increased during both the early follicular and early luteal, or post-ovulatory, phases (Psychoneuroendocrinology, Vol. 88, 2018opens in new window). “If you’re doing an assessment of a naturally cycling woman and she’s at the beginning of her cycle, you might see fewer ADHD symptoms and she may not meet the diagnostic criteria,” said Martel. “At the end of her cycle, symptoms might increase.”

Failing to take the menstrual cycle’s impact into account can have dire practical consequences for patients, said Jenna Rieder, PhD, an assistant professor of psychology at Thomas Jefferson University in Philadelphia. In a study of women with a history of trauma, Rieder and colleagues found that trauma-related symptoms rose and fell along with the hormone estradiol, with increased symptoms during their cycle’s first few days when estradiol is low and reduced symptoms when estradiol levels are higher close to ovulation (Psychological Trauma: Theory, Research, Practice, and Policy, Vol. 14, No. 5, 2022opens in new window).

“Our data suggest that the day of the month when you ask someone to self-report symptoms could mean the difference between meeting the clinical criteria for PTSD or not,” said Rieder. If you ask about symptoms when estradiol is high, she pointed out, the patient could miss out on benefits like veterans’ compensation or insurance coverage.

In addition to considering the menstrual cycle’s effect on existing disorders, clinicians should also assess whether menstruating patients with troublesome symptoms have PMDD. An official diagnosis requires patients to rate symptoms daily over two cycles using a tool like the Daily Record of Severity of Problemsopens in new window in order to determine whether symptoms are related to the menstrual cycle. Often clinicians diagnose PMDD based on brief interviews in which they ask patients to recall symptoms over the past year, but that approach results in “a huge false positive rate,” said IAPMD clinical advisory board member Jaclyn Ross, PhD, a clinical research scientist at the University of Illinois at Chicago and founder of a specialty clinic for premenstrual disorders in private practice.

When it comes to treating PMDD, many psychologists don’t get a lot of training, said Liisa Hantsoo, PhD, an assistant professor of psychiatry and behavioral sciences at the Johns Hopkins School of Medicine and an IAPMD clinical advisory board member. For one thing, she said, this relatively new diagnosis is an understudied area and often underrecognized even by health care providers. And it’s extra tricky because it falls at the crossroads between mental health and physical health. “Sometimes people with PMDD can get shuttled back and forth,” said Hantsoo, explaining that a patient might visit a gynecologist first only to be advised to seek treatment from a mental health professional. “It’s often frustrating for people with PMDD, because it’s hard to even know which provider to go to.”

In a survey of more than 2,500 patients with PMDD, Hantsoo and colleagues found that patients rated gynecologists highest when it came to awareness of and knowledge about PMDD, followed by psychiatrists and then general practitioners. Psychologists and other therapists trailed all three types of physicians on the knowledge and awareness front, but patients rated them highest for compassion (Journal of Women’s Health, Vol. 31, No. 1, 2022opens in new window). “Therapists were the most likely to listen, validate concerns, and take patients seriously,” said Hantsoo.

That said, the frontline treatments for PMDD are medical. Oral contraceptives can stabilize hormonal fluctuations, for example, while selective serotonin reuptake inhibitors (SSRIs) can alleviate symptoms of anxiety and depression. In extreme cases, patients may seek relief via chemically or surgically induced menopause. Psychologists have a key role to play in helping patients navigate the often challenging medical environment, said Ross. “We need to be equipping patients to be effective advocates for themselves,” she said.

Still, Ross said, “there’s also a lot of desire and need right now for more behavioral interventions.”

Although more research is needed, there’s some evidence that cognitive behavioral therapy (CBT) can help. In one literature review, researchers found that CBT significantly reduced or even eliminated PMS (Landolt, N. K., & Ivanov, K., Psychology, Health & Medicine, Vol. 26, No. 10, 2021opens in new window). Anecdotal accounts suggest that some of the techniques used in dialectical behavioral therapy—such as diary cards used to track emotions and coping skills—can also be helpful.

Mindfulness may be another useful tool, said Ross. “Mindfulness of thoughts, emotions, and urges across the menstrual cycle can be helpful because it can give PMDD patients more agency in managing their symptoms,” she said. “PMDD patients’ cognitions, emotional experiences, and overall distress can look quite different in the follicular phase versus the luteal phase, and the patient’s mindful awareness of those differences can be a powerful intervention.” By being mindful of where they are in their cycle, patients can make choices and engage in behaviors that are most effective, Ross explained. If a patient notices that they feel intense anger and the urge to scream at their partner during the luteal phase, for example, they might find it useful to practice mindfulness of their negative emotions, consider whether high-conflict conversations with their partner are effective during high-distress phases, and instead choose self-soothing strategies and remember that these emotions are temporary. During the follicular phase, on the other hand, patients may be able to communicate their concerns to a partner in a more productive manner. “If we can help patients learn how to mindfully identify their different experiences and capacities across the cycle, we can equip them to choose and enact skills that will be most helpful to them in a given moment,” said Ross.

In addition to helping patients to be mindful of their cycles, psychologists can take advantage of the cyclical nature of menstrual symptoms to teach patients helpful skills, said Hantsoo. “It’s like doing a fire drill,” she said. “During the follicular phase—the 2 weeks when they’re not having symptoms—we can practice CBT or mindfulness skills … Then when the fire comes in the luteal phase, they can access those skills more readily.”

Clinicians also need to keep in mind the special needs of transgender men and nonbinary individuals, who may menstruate in the absence of gender-affirming hormone therapy that stops periods, said Peters, coauthor of an IAPMD tip sheetopens in new window on PMDD in transgender individuals. Peters encourages psychologists to be good allies through such actions as using gender-inclusive language, leaving space on intake forms for patients to explain their gender, and asking permission to ask potentially sensitive questions, such as whether the patient is on hormone replacement therapy. “Trans and nonbinary people face so much burden in this world and often need psychological care so badly, so we need to be especially sure our spaces are safe and welcoming,” said Peters.

For Caldwell, treatment worked. After a lot of trial and error, she said, she has been able to minimize her symptoms via therapy, an antidepressant in the week before her period, and good self-care habits. “What’s sad about this is that it’s so understudied,” she said. “We’re all trying to figure things out on online forums.”

Eisenlohr-Moul and other researchers believe that patients deserve better. In addition to finding answers to questions about how hormonal sensitivity works, who’s most at risk, and how to treat it, the emphasis must be on translating what’s already known into practice, said Eisenlohr-Moul. “It’s still a struggle to get patients with PMDD recognized, much less those people with messier, more complicated forms of hormonal sensitivity,” she said. “We’re still trying to get the earlier phase of the literature translated, so that we don’t get physicians Googling PMDD in front of their patients—so that they understand this is real and treatable.”