Jake Goodman
I want to start today with a confession.
I have been meaning to write this newsletter for months. And honestly, I kept putting it off.
Not because the topic is not important. It is one of the most important things I could write about.
But because I am a male psychiatrist writing about a condition I will never personally experience.
I have written about depression from a place of personal experience. I have written about anxiety, burnout, and the kind of exhaustion that follows you into your days off. I know those things not just as a clinician but as a human being who has lived them.
PMDD is different. I will never know what it feels like from the inside.
But that is actually why I decided I needed to write this today. Because the women who have it deserve more voices talking about it. And staying quiet because I felt vulnerable about my perspective was the wrong call.
So here we go. Let’s talk about PMDD.
A quick life update before we dive in
I just got back from San Francisco where I spoke at the American Psychiatric Association Annual Meeting. It was so much fun.
My talk was about how to build an integrative private practice in psychiatry today — how to think outside the box, how to treat the whole person rather than just reaching for the prescription pad, and how to build something that actually reflects your values as a clinician.
But the moment that meant the most to me had nothing to do with the talk itself.
People came up to me throughout the conference — psychiatrists, medical students, mental health professionals from all over the world — and introduced themselves as readers of this newsletter!
Two years ago, I was writing this newsletter to about 6 subscribers – my wife, my parents, my sister, and a few friends.
The fact that it has reached people across the world who are interested in brain health — that is everything. My goal has always been to get mental health education to the masses. Moments like that remind me why.
Okay. Back to PMDD.
The Patient I Will Never Forget
During my residency, a woman came to see me.
She was not sure if she had depression or anxiety. Maybe both. She just knew something was wrong. She felt irritable, emotionally raw, sometimes hopeless. She was struggling in her relationships. She felt like a different person at times.
But as I listened more carefully, something stood out.
Her symptoms were not constant. They followed a pattern. Every month, in the one to two weeks leading up to her period, everything got worse. Then her period would come, and within a day or two — sometimes hours — she felt like herself again.
I had learned about a condition called Premenstrual Dysphoric Disorder — PMDD — in medical school and early residency. Sitting across from her, I realized she met the criteria.
I remember feeling nervous making that diagnosis for the first time. I walked through the criteria with her carefully. We talked it through together. She agreed that the pattern matched her experience.
Then we built a treatment plan. And within a few months, the cyclical mood disturbances and anxiety that had been disrupting her life essentially went away.
She told me she finally felt like she could live the life she had always wanted.
I have never forgotten that interaction. And now, every single time I sit across from a woman who is struggling, PMDD is on my radar.
What PMDD Actually Is
Premenstrual Dysphoric Disorder is a cyclical mood disorder tied to the hormonal changes of the menstrual cycle — specifically the luteal phase, which is the second half of a menstrual cycle, occurring after ovulation and ending when your period begins
It is not Premenstrual syndrome (PMS)
PMS is common. Bloating, mild irritability, some physical discomfort. Many women experience some version of it.
But PMDD is different. It is a cyclical mood disorder that causes mood disturbance, anxiety, irritability, brain fog, and sometimes depression — severe enough to meaningfully disrupt work, relationships, and daily functioning.
And then, typically within a day or two of menstruation beginning, the symptoms lift. Sometimes dramatically and quickly.
That cyclical pattern — the predictable onset and offset tied to the menstrual cycle — is the defining feature of PMDD. It is what separates it from depression or anxiety.
What The Criteria Actually Look Like
To meet the clinical criteria for PMDD, a person must experience at least five of the following symptoms during the luteal phase, with at least one being from the first group:
Core mood symptoms (at least ONE required):
- Mood swings or increased sensitivity to rejection
- Irritability or anger
- Depressed mood, hopelessness, or self-deprecating thoughts
- Anxiety or tension
Additional symptoms (at least FOUR required):
- Decreased interest in usual activities
- Difficulty concentrating
- Fatigue or low energy
- Changes in appetite, overeating, or food cravings
- Hypersomnia (sleeping too much) or insomnia
- Feeling overwhelmed or out of control
- Physical symptoms such as breast tenderness, bloating, joint pain, or weight gain
These symptoms must be present during at least 2 symptomatic cycles, must improve after menstruation begins, and must be absent in the week after the period ends.
Crucially — they must cause significant distress or impairment.
What PMDD Gets Mistaken For
This is where so many women fall through the cracks.
Because PMDD can look like major depressive disorder (MDD). It can look like generalized anxiety disorder (GAD). It can be mistaken for bipolar disorder. It can even be mistaken for borderline personality disorder.
The key that unlocks the diagnosis is TRACKING.
When you map the symptoms of PMDD against the menstrual cycle, the pattern becomes undeniable. The symptoms cluster in the luteal phase and lift after menstruation. That timing is everything.
This is why I ask about the menstrual cycle when I am evaluating mood and anxiety in women. And it is why I encourage symptom tracking — even just a simple daily note about mood rated on a scale of one to ten — over at least two cycles before drawing conclusions.
Why This Diagnosis Matters So Much
Because women with PMDD have often been suffering for years.
They have been told they are too emotional. Too sensitive. That they need to manage their stress better. That this is ‘just how periods are’.
Some have been put on the wrong medication for years, trying to treat an anxiety disorder or bipolar disorder.
Getting an accurate PMDD diagnosis is not just clinically important. It is validating in a way that can be healing. The relief of understanding that there is a name for what you have been experiencing — that it is real, that it is not your fault, and that there are effective treatments — is something I have watched transform people.
A Note From Me
PMDD is underdiagnosed, undertreated, and under-discussed. Women who have it are often told their suffering is normal or, worse, that it is a personality problem rather than a medical one…
If anything here resonated with you, please do not dismiss it. Talk to a clinician who takes it seriously.
Treatment Options
This is where PMDD gets interesting. Because the treatment approach is unlike almost anything else in psychiatry.
SSRIs — but not necessarily every day
SSRIs (selective serotonin reuptake inhibitors) are the first line pharmacological treatment for PMDD. But here is what makes this unique.
Unlike depression, where SSRIs need to be taken every day, and typically take four weeks to build therapeutic effect, PMDD can respond to SSRIs taken ONLY during the luteal phase — the one to two weeks before menstruation begins. PMDD dosing also tends to be lower than typical dosing for depression.
This is called intermittent or luteal phase dosing. And it works. Research supports it consistently.
For many women, this is life changing. They are not taking medication every day. They take it only during the specific window when their symptoms occur. And it works within days rather than weeks.
For women with more severe or continuous symptoms, daily dosing may be more appropriate. This is an individualized decision made with a clinician.
Hormonal contraception
Certain forms of hormonal birth control — particularly those that suppress ovulation — can significantly reduce or eliminate PMDD symptoms by stabilizing the hormonal fluctuations that trigger them.
This is typically managed in partnership with a primary care physician or OBGYN. As a psychiatrist, I always make sure my patients with PMDD have that conversation with their PCP or OBGYN if they have not already.
Lifestyle — and this one is critical.
Exercise is one of the most consistently supported non-pharmacological interventions for PMDD. Regular aerobic exercise throughout the cycle — not just when symptoms are present — appears to reduce symptom severity meaningfully.
Reducing caffeine and sugar, particularly in the luteal phase, appears to help reduce anxiety and improve mood stability.
Stress management — breathwork, mindfulness, therapy, sleep — all matter here in ways that are real and evidence supported.
Emerging research — interesting but not yet ready
There is some early research exploring the use of certain antihistamine medications (i.e. diphenhydramine) during specific phases of the cycle for PMDD. This is off label treatment not approved by the FDA. The theory is that rising estrogen levels during the luteal phase increase histamine levels which can worsen mood and anxiety, and that taking an antihistamine reduces these symptoms. But if you follow my newsletter, you know I’m not a fan of long term use of diphenhydramine (Benadryl) for many reasons – including increasing risk of dementia.So this is an interesting area and I am watching it closely. But the evidence is not yet strong enough for me to recommend it to my patients. I will write more about this as the research matures.
*Jake Goodman is a board-certified psychiatrist sharing science-backed tools to protect your memory and improve your mental health
Source: https://jakegoodmanmd.substack.com/p/pmdd-the-diagnosis-most-women-never
Reference: Carlini SV, Deligiannidis KM. Evidence-Based Treatment of Premenstrual Dysphoric Disorder: A Concise Review. J Clin Psychiatry. 2020 Feb 4;81(2):19ac13071. doi: 10.4088/JCP.19ac13071. PMID: 32023366; PMCID: PMC7716347.
