Once a month, most women experience the hormonal shifts, physical symptoms, and emotional fluctuations that characterize their periods. However, for 5-8% of menstruating women, “that time of the month” isn’t just the combination of bleeding, cramps, and mild mood swings experienced by most [1]. These women suffer from premenstrual dysphoric disorder, or PMDD, a disorder linked with the menstrual cycle that has debilitating impacts on both mental and physical health. PMDD is thought to arise from an abnormal response to hormonal changes during a woman’s menstrual cycle. There is a set stretch of time during the month (typically the luteal phase directly before bleeding actually begins) when a woman experiences the symptoms, followed by relief with the hormonal shift that comes during actual menstruation. Mood-related symptoms include depression, anxiety, heightened irritability, and anger, along with painful physical symptoms like sore breasts, bloating, body aches, and weight gain [1]. While these symptoms can also occur in women without the disorder, PMDD sufferers experience them with such severity that it impairs their ability to function normally one to two weeks out of each month. Often, the disorder makes them feel tired and low in energy, overwhelmed and out of control, avoidant of their usual activity, and can even inhibit their ability to concentrate on their day to day activities.

A Reddit support group for PMDD sufferers with over 32,000 members provides a space for women to share their experiences, frustrations, and tips about living with the condition [2]. Members post about medications and birth control methods that have been helpful, as well as coping mechanisms and other advice. In one such post, commenters gave advice for different things that help them through the most difficult experiences with the disorder, such as paced breathing or mindfulness based stress reduction [3]. However, despite the supportive nature of the community, the overall message that arises from scrolling through these posts is the sheer difficulty of coping with this disorder every month. Post titles like “I’m spiraling and I feel so lost” and “I hate living this way” demonstrate just how hopeless the disorder can render life for so many women [4-5]. This hopelessness isn’t simply anecdotal either; PMDD can lead to suicidal ideation for many, and 30% of women who suffer from PMDD attempt suicide [6]. In fact, a study showed that women with PMDD are 70% more likely to experience suicidal ideation than non-sufferers [3].

Why, then, does such a severe and even life-threatening condition remain so pitifully under-researched? The lack of research on PMDD has very real and fatal effects. One of the most upsetting aspects is that such lack of research has translated to supporting beliefs that PMDD is not a real disorder and that it does not exist at all. A study conducted to confirm the PMDD asked 31 women who met the criteria for PMDD diagnosis, 34 women who did not have symptoms, and 23 men to track their daily symptoms for two full cycles (with two 28 day artificial cycles used for the male patients) [7]. The subjects rated the severity of 16 symptoms linked with PMDD diagnosis. While the study concluded that “results indicated no differences between the groups in the frequency of stressful events” (including work related or interpersonal issues), it also found that the PMDD group “rated their problems as more disturbing and evidenced a cyclical pattern...suggestive of some impaired functioning.” Despite its small sample size and clear evidence of the cyclical nature of PMDD, this study is still used to undermine the existence of PMDD.

Furthermore, experts in the medical field continue to question the existence of PMDD and perpetuate the belief that it is not real. Psychology professor Joan Chrisler and president of the Society for Menstrual Cycle Research stated that women claiming to suffer from PMDD do not need medical treatment, and instead should seek out “a nap or a divorce” [8]. This type of rhetoric, particularly coming from significant authority figures within the sphere of menstrual cycle research, is incredibly damaging to PMDD sufferers. It is hugely worrisome that women are experiencing mental health crises to the point of attempting suicide, but even female researchers in the field of psychology continue to brush off PMDD as a “cultural syndrome” rather than devote time and resources to investigating how to address this problem.

Another troublingly common problem for women who have PMDD is misdiagnosis. In a study done on women who were screened for PMDD symptoms, thier respective interviews demonstrated the harmful effects of the long term psychological symptoms, with quotes like “I just got to a point where I couldn’t–I didn’t want to live. I just wanted to be dead” [9]. For these women, the repetition of debilitating symptoms each month led to extreme distress that was not addressed by medical professionals. One woman described being diagnosed with bipolar, chronic fatigue, and depression at different points, and was medicated for all with little benefit. The study also discusses the downplaying of women’s symptoms, stating that “women described how over the years that followed, their pleas for recognition went both unacknowledged and unheard.” Without the proper diagnosis, they continued to suffer both from PMDD’s lack of credibility and the symptoms not adequately addressed by medical professionals.

More research conducted on PMDD would certainly benefit those who suffer from it. However, beyond those directly affected by it, the condition also has wider implications on the study of other affective mood disorders like depression and bipolar disorder. One crucial characteristic of PMDD is its predictability; the distinct time before a period will encompass the negative symptoms, with relief upon the arrival of a period. This repetitive, established cycle is hugely significant in the study of affective disorders. It is easier to study the difference between an affective state and a stable state in a patient with PMDD because the transition between the two states is predictable and regular, unlike other cyclical mood disorders like bipolar disorder. By gaining a better understanding of PMDD, scientists could have applicable models and precedent for research on other cyclical mood disorders. And yet, the research on PMDD is staggeringly scarce. The first large-scale bibliometric analysis of PMDD research data was not conducted until 2021; only 2,833 studies were identified with pertinent data from the time span of 1945 to 2018. In comparison, a 2019 bibliometric analysis of erectile dysfunction studies from 2008 to 2018 comprised 8,880 published papers [10-11]. With numbers like these, it is unsurprising that the actual biological causes of PMDD have yet to be understood. In fact, progesterone, one of the hormones thought to be a cause of PMDD, is one of the least studied hormones by psychiatrists and neuroscientists [12].

Being a PMDD sufferer myself, my life is split into two parts: the time before my period and the time after. The symptoms I experience have painful consequences for me and those who surround me; I become tearful, anxious, angry, and so irritable that it’s often impossible to conduct a conversation with me. I’ve ignited fights with close friends, lashed out at my parents, cried myself to sleep, and confined myself to my bed amidst panic attacks for days at a time during the week prior to my period, only to have to pick up the broken pieces of my life when the symptoms recede. It is exhausting. Thousands of women like me are leading miserable lives for half of each month, with many committing suicide because they are not being properly treated or acknowledged. It is time for science to give us the attention we desperately need. Only by recognizing PMDD as a valid disorder and devoting significant resources to research on it can we begin to offer a glimmer of hope to those who are suffering.

References:
1. Premenstrual dysphoria disorder: It's biology, not a behavior choice. Harvard Health. (2017, May 30). Retrieved May 3, 2022, from https://www.health.harvard.edu/blog/premenstrual-dysphoria-disorder-its-biology-not-a-behavior- choice-2017053011768
2. R/PMDD. reddit. (n.d.). Retrieved May 3, 2022, from https://www.reddit.com/r/PMDD/
3. Pilver, C. E., Libby, D. J., & Hoff, R. A. (2013). Premenstrual dysphoric disorder as a correlate of suicidal ideation, plans, and attempts among a nationally representative sample. Social psychiatry and psychiatric epidemiology, 48(3), 437–446. https://doi.org/10.1007/s00127-012-0548-z
4. R/PMDD - [deleted by user]. reddit. (n.d.). Retrieved May 3, 2022, from https://www.reddit.com/r/PMDD/comments/rh65gq/deleted_by_user/
5. R/PMDD - I hate living this way. reddit. (n.d.). Retrieved May 3, 2022, from https://www.reddit.com/r/PMDD/comments/reu6yq/i_hate_living_this_way/
6. The Recovery Village Drug and Alcohol Rehab. (2021, April 19). PMDD Facts & Statistics: The recovery village. The Recovery Village Drug and Alcohol Rehab. Retrieved May 3, 2022, from https://www.therecoveryvillage.com/mental-health/pmdd/pmdd-statistics/
7. Gallant, S & Popiel, D & Hoffman, D & Chakraborty, P & Hamilton, J. (1992). Using daily ratings to confirm premenstrual syndrome/late luteal phase dysphoric disorder. Part II. What makes a “real” difference?. Psychosomatic medicine. 54. 167-81. 10.1097/00006842-199203000-00004.
8. Daw, J. (2002, October). Is PMDD real? Monitor on Psychology, 33(9). https://www.apa.org/monitor/oct02/pmdd
9. Osborn, E., Wittkowski, A., Brooks, J. et al. Women’s experiences of receiving a diagnosis of premenstrual dysphoric disorder: a qualitative investigation. BMC Women's Health 20, 242 (2020). https://doi.org/10.1186/s12905-020-01100-8
10. Gao, M., Gao, D., Sun, H., Cheng, X., An, L., & Qiao, M. (2021). Trends in research related to premenstrual syndrome and premenstrual dysphoric disorder from 1945 to 2018: A Bibliometric analysis. Frontiers in Public Health, 9. https://doi.org/10.3389/fpubh.2021.596128
11. Hui, J., He, S., Liu, R. et al. Trends in erectile dysfunction research from 2008 to 2018: a bibliometric analysis. Int J Impot Res 32, 409–419 (2020). https://doi.org/10.1038/s41443-019-0161-8
12. Rubinow, David R. (2021). One Small Step for PMDD, One Large Step for Affective Disorders. American Journal of Psychiatry, vol. 178, no. 3, 2021, pp. 215–217., https://doi.org/10.1176/appi.ajp.2020.20121793