PMDD, PMS and Menopause | Menopause Care

Up to 75% of women (1) experience predictable symptoms month in, and month out in the run-up to their period. Known as premenstrual syndrome (PMS), this can cause a variety of temporary emotional and physical changes that can disrupt your day-to-day life.

Premenstrual Dysphoric Disorder (PMDD) is a severe form of PMS that affects around 5% of menstruating individuals (2) and it can cause significant distress and routinely debilitate sufferers.

So, what happens when someone with PMS or PMDD enters perimenopause and is faced with additional symptoms brought on by fluctuating levels of oestrogen or progesterone? In this guide, we discuss PMS, PMDD and menopause, explaining how they interact with one another and how their symptoms can be effectively managed.

What is premenstrual syndrome?

Premenstrual syndrome (PMS) is a chronic condition characterised by cyclical and repetitive psychological, physical, and behavioural symptoms occurring in the luteal phase of the normal menstrual cycle (that is, the time between ovulation and onset of menstruation) and diminish by the end of menstruation There are over 150 different psychological, physical, and behavioural symptoms that may be associated with PMS (3).

Psychological symptoms include depression, anxiety, irritability, loss of confidence, and mood swings.
Physical symptoms include bloating and breast pain.
Behavioural symptoms include reduced cognitive ability, irritability and aggression.

What is premenstrual dysphoric disorder (PMDD)?

Premenstrual Dysphoric Disorder (PMDD) is a severe form of PMS that affects around 5% of menstruating individuals (2) . PMDD is characterised by debilitating symptoms that can impair someone’s ability to function normally, impact work and affects relationships (2). The diagnostic criteria for PMDD continues to be debated and a number of different classifications are used. The current classification of PMDD in DSM-5 advises that for a diagnosis of PMDD a woman must have (4):

At least one of the following symptoms must be present:

Marked mood lability/mood swings
Marked depressed mood, feelings of hopelessness or self-deprecating thoughts
Marked irritability or anger or increased interpersonal conflicts.
Marked anxiety or tension

Additionally there must be further symptoms, reaching a total of five between the two lists:

Reduced interest in usual activities
Difficulty concentrating
Lethargy, easily tired, or lack of energy
Marked changes in appetite
Sleep changes (hypersomnia or insomnia)
A sense of feeling overwhelmed or out of control
Physical symptoms, such as breast tenderness or swelling, joint or muscle pain, bloating, or weight gain

These symptoms must cause significant distress or impaired functioning.

The difference between PMS and PMDD

PMS is relatively common, but PMDD is a more severe form that can significantly disrupt daily life and have an adverse impact on your emotional well-being. The key difference between PMS and PMDD lies in the severity of their symptoms and impact.

In PMDD, there is an increased risk of experiencing suicidal thoughts and behaviour, which is why it is very important that this condition is recognised and treated appropriately.

If you need further help or know of someone who does, the following resources may be beneficial:

NHS mental health support
Urgent help from Mind
Samaritans or call 116 123

What causes PMS and PMDD?

PMS and PMDD is driven by cyclical ovarian activity and women who have PMS and PMDD are more sensitive to the reduction of oestrogen and the increase in progesterone post ovulation.

Who gets PMS?

PMS can occur in any woman during child bearing years. It is estimated that as many as 30% of women can experience moderate to severe PMS, with 5-8% suffering severe PMS/PMDD, this being around 800,000 in the UK.

Women who have PMS and PMDD are sensitive to changes in oestrogen and progesterone levels and PMS appears to begin and increase in severity at times of marked hormonal changes such as puberty, post pregnancy and perimenopause. Therefore women with a background of PMS/PMDD often have a history of postnatal depression and are at an increased risk of mood changes during perimenopause (5).

How is PMS and PMDD diagnosed?

There isn’t a specific diagnostic test for PMS or PMDD. Instead, a diagnosis is derived from review of your medical history and symptoms.

Your doctor should ask you about physical symptoms, psychological symptoms and behavioural symptoms and how these symptoms impact on daily activity.

A diagnosis of PMS/PMDD is based on prominence of symptoms during the luteal phase of the menstrual cycle, which resolve with the onset of menstruation or soon after, followed by a symptoms free week. Your doctor may ask you to keep a diary of your symptoms for 2-3 menstrual cycles in order to confirm whether symptoms follow this cyclical pattern. Here is example of a treatment diary from the National Association of Premenstrual Syndromes (NAPS).

If symptoms are present at other times during the menstrual cycle, then this would be more suggestive of premenstrual exacerbation (PME). Premenstrual exacerbation of underlying disorders (e.g. migraine, OCD, ADHD) can lead to worsening of symptoms of these conditions during the premenstrual phase (6).

If you are experiencing PME, then the focus of treatment should initially be on optimising treatment of the affected underlying condition. That said, hormonal approaches can often be very helpful and may be needed in addition.

PMDD, PMS and perimenopause

So, what happens when someone with PMS/PMDD enters perimenopause and is faced with additional symptoms brought on by fluctuating levels of oestrogen or progesterone?

Women may notice that they are experiencing PMS/PMDD for the first time during perimenopause and emergence of PMS symptoms is often an early sign of perimenopause (the transition before menopause)

This change is sometimes misdiagnosed as depression or anxiety because the symptoms can be similar. In more severe cases, where mood swings are extreme, these symptoms could be mistaken for more serious mental health conditions like bipolar disorder or psychosis.

How to tell if symptoms are PMS/PMDD or perimenopause

It can be challenging to distinguish between PMS/ PMDD symptoms, and perimenopause / menopause symptoms because they can overlap. However, there are some key differences:

Timing

PMS and PMDD symptoms occur in the luteal phase and typically subside with the start of the period.

Perimenopause symptoms can occur at any time during the cycle and are not restricted to the luteal phase. Irregular periods may also make tracking symptoms harder.

Cycle changes

PMS and PMDD occur in the context of regular menstrual cycles however perimenopause is often marked by changes in menstrual patterns, such as shorter or longer cycles, skipped periods, heavier/lighter bleeding or bleeding between periods.

Symptoms

While PMS and PMDD primarily affect mood and physical symptoms around menstruation, perimenopause may introduce additional symptoms like hot flashes, night sweats, vaginal dryness, and sleep disturbances that aren’t typically associated with PMS or PMDD.

Age

PMS and PMDD can occur at any reproductive age, but the onset of worsening symptoms after the age of 40 may indicate the beginning of perimenopause (7).

PMS symptoms during menopause

For many individuals, PMS and PMDD symptoms can worsen during perimenopause (7). The hormonal fluctuations during this time can lead to more pronounced mood swings, irritability, and physical discomfort and their unpredictability can make managing them more challenging.

As menopause approaches and periods become irregular or stop altogether, PMS symptoms may change. Some individuals may notice their symptoms become less frequent or stop entirely once menopause is reached. Common PMS symptoms during perimenopause may include:

Mood swings and irritability
Depression and anxiety
Feeling upset or emotional
Fatigue and low energy
Breast tenderness
Bloating and water retention
Food cravings or changes in appetite
Difficulty concentrating
Sleep disturbances
Headaches
Spotty skin
Greasy hair (8)

Can you get PMS and PMDD after menopause?

After menopause, PMS and PMDD end because they are directly linked to the menstrual cycle and ovulation (8). However, some individuals may experience similar symptoms such as mood swings and irritability which may feel similar to PMS. These symptoms are usually linked to a significant decline in oestrogen rather than cyclical hormonal changes (9).

Managing PMS and PMDD in perimenopause

The good news is that there are effective treatments available to help manage the symptoms faced during perimenopause and menopause. Many of these treatments involve balancing your hormones but there are also non-hormonal options.

Hormone replacement therapy (HRT)

HRT helps to stabilise the hormones that are fluctuating during your menstrual cycle or perimenopause. As PMS/PMDD are related to hormone sensitivity, levelling these out with HRT can help reduce PMS/PMDD symptoms.

This treatment also helps alleviate symptoms of menopause such as hot flushes, night sweats, vaginal dryness and mood changes.

One option for managing PMS during perimenopause is using an intra-uterine system (IUS), such as the Mirena coil, alongside transdermal oestrogen. The Mirena coil provides a steady, localised release of progesterone within the womb, reducing the risk of systemic side effects often associated with oral progesterone. At the same time, a transdermal oestrogen patch delivers a consistent dose of oestrogen, helping to maintain hormonal balance. This combination can be an effective and well-tolerated approach for managing PMS symptoms during perimenopause.

The combined oral contraceptive pill (COCP)

A combined oral contraceptive pill (COCP) can help manage PMS symptoms by regulating hormones and preventing ovulation. Research suggests that newer COCPs, particularly those containing ethinylestradiol and drospirenone, may be more effective for PMS relief.

In the UK, the COCP most similar to those studied is Eloine, which contains 20 micrograms of ethinylestradiol and 3mg of drospirenone. It is taken in a 28-day cycle, with 24 active pills and 4 placebo pills. Other options, such as Drovelis and Yasmin, also contain drospirenone and may be beneficial. Another newer option is Zoely, which contains estradiol, a type of oestrogen naturally found in the body.

Current evidence suggests that taking the COCP continuously, without a break or placebo pills, is more effective for managing PMS than following the traditional cycle with a pill-free week (3).

The Progesterone only pill

A newer progesterone-only pill, Slynd (containing 4mg drospirenone), can be a great option for managing PMS symptoms during perimenopause. It works by preventing ovulation, helping to regulate hormones, and can also improve symptoms like irregular or heavy bleeding.

Slynd is especially useful for women who need contraception, have problematic bleeding, or cannot take a combined pill (COCP) due to medical reasons. Additionally, it can be used as the progesterone part of HRT, alongside oestrogen in the form of a patch, gel, or spray.

Slynd is taken in a 28-day cycle, with 24 active pills and 4 placebo pills. However, to better control symptoms and prevent hormone fluctuations, it is recommended to skip the placebo pills and start the next pack immediately without a break. This continuous use can be particularly beneficial for managing PMS or PMDD more effectively.

Find out more about how contraception can help during menopause.

Gonadotropin-releasing hormone (GnRH) analogues

These medications temporarily stop the ovaries from working, bringing on a temporary menopause. They are often combined with a small amount of HRT to prevent side effects from low oestrogen levels and maintain bone density. This tends to be prescribed in specialist Gynaecology clinics.

Selective serotonin reuptake inhibitors (SSRIs)

SSRIs are a type of antidepressant and can be used specifically during the second phase of the menstrual cycle when your symptoms are at their worst, or they can be taken continuously.

These medications can be effective in easing the emotional and psychological symptoms of PMS and PMDD and work differently (and more quickly) than when used to treat clinical depression.

Painkillers or anti-inflammatories

Over-the-counter painkillers, such as paracetamol, or anti-inflammatory medication, such as ibuprofen, can be used to help curb the physical symptoms of PMS/PMDD like headaches and muscle pain (10).

Surgery

In very severe cases where no other treatment has worked, your doctor may put forward a hysterectomy to remove your womb, ovaries and fallopian tubes. This eliminates PMDD symptoms by stopping your body’s ability to menstruate (3).

However, this treatment will induce surgical menopause which results in immediate menopause symptoms. This can be managed with HRT.

Supplements

There is some evidence that certain supplements may help with PMS and PMDD symptoms, though they are not typically recommended as a standalone treatment. Supplements are often understudied, and their actual ingredient levels may not always match the label. They can also interact with medications, particularly cancer treatments, so it’s important to consult a doctor before taking them.

Magnesium: Small studies have suggested that magnesium may be helpful in PMS when taken regularly but more data is needed (5).
Agnus Castus: Some small studies suggest it may help with PMS symptoms. However, due to a lack of standardised quality control, there is a risk of contamination, especially with supplements bought online.5.
Calcium and Vitamin D supplements: There are some small studies which have suggested that a high intake of calcium and vitamin D may reduce the risk of PMS along with being beneficial for bone density but further research with larger studies are needed.

Psychological therapies

Psychological therapies, including cognitive behavioural therapy (CBT) and dialectical behavioural therapy (DBT), can also be very helpful. Studies have found that CBT is highly effective in helping women adopt coping strategies and with stress management which can make the symptoms of PMDD less debilitating (11).

Lifestyle changes

In addition, dietary, lifestyle and supplementary approaches play an important role in management and, in milder forms of PMS, may be all that is required. They may include:

Regular exercise
Dietary changes - cutting down on excess sugar and white refined carbohydrates such as pizza and white bread is helpful as these carbohydrates cause a rapid release of blood glucose which can affect mood swings and cravings.
Oily fish and the essential fats in fish have been shown to improve PMS symptoms and pain.
Green vegetables which have high magnesium and folate can help PMS symptoms and there is a focus on a high fibre diet also being helpful
Optimising your sleep routine and getting enough sleep
Reducing alcohol intake
Stopping smoking
Limiting caffeine
Minimising stress (10)

Implementing lifestyle changes in order to manage PMS, PMDD and PME effectively can greatly improve your quality of life, helping you feel more in control of your emotions and ensuring you are better able to enjoy your personal life and relationships.

If you think you might be experiencing PMS, PMDD or PME, or if your symptoms are getting worse, it’s important to talk to your GP or one of our Menopause Care specialists who can guide you toward the right treatment options. Our clinicians can help you understand the relationship between perimenopause and PMS/PMDD, and give you evidence-based, tailored advice for symptom management. To get started, book a consultation with a menopause doctor.

DisclaimerAt Menopause Care, we ensure that everything you read in our blog is medically reviewed and approved. However, the information provided is not meant to replace professional medical advice, diagnosis, or treatment. It should not be relied upon for specific medical advice.

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