Premenstrual dysphoric disorder (PMDD) is a mood disorder characterized by emotional, cognitive, and physical symptoms. PMDD can cause significant distress and impairment during the luteal phase of the menstrual cycle (between ovulation and menstruation). Symptoms typically improve within a few days after the onset of menses, and are minimal or absent in the week after menses. Code: 625.4 (N94.3) PMDD has a profound impact on an individual's quality of life and dramatically increases the risk of suicidal ideation and even suicide attempts. Many women experience discomfort or mild mood changes before menstruation, but 5–8% experience severe premenstrual syndrome (PMS), causing significant distress or functional impairment. Within this group, some will meet the criteria for PMDD.

PMDD's exact cause is unknown. Ovarian hormone levels during the menstrual cycle do not differ between those with PMDD and the general population. But because symptoms are present only during ovulatory cycles and resolve after menstruation, it is believed to be caused by fluctuations in gonadal sex hormones or variations in sensitivity to sex hormones.

In 2017, National Institutes of Health researchers discovered that women with PMDD have genetic changes that make their emotional regulatory pathways more sensitive to estrogen and progesterone, as well as their chemical derivatives. The researchers believe this increased sensitivity may cause PMDD symptoms.

PMDD was added to the list of depressive disorders in the Diagnostic and Statistical Manual of Mental Disorders in 2013. It has 11 main symptoms, of which five must be present for a PMDD diagnosis. Roughly 20% of females have some PMDD symptoms, but either have fewer than five or do not have functional impairment.

The first-line treatment for PMDD is with selective serotonin reuptake inhibitors (SSRIs), which can be administered continuously throughout the menstrual cycle or intermittently, with treatment only during the symptomatic phase (approximately 14 days per cycle). Hormonal therapy with oral contraceptives that contain drospirenone have also demonstrated efficiency in reducing PMDD symptoms. Cognitive behavioral therapy, whether in combination with SSRIs or alone, has shown to be effective in reducing impairment. Dietary modifications and exercise may also be helpful, but studies investigating these treatments have not demonstrated efficacy in reducing PMDD symptoms.

Signs and symptoms Clinicians consider mood symptoms, physical symptoms, and impact on the patient's life in making the diagnosis of PMDD. Mood symptoms include dysphoria, emotional lability (rapidly changing emotions), irritability and anger that may lead to conflict, anxiety, feeling on edge, hopelessness, difficulty concentrating, appetite changes, sleeping more or less than usual, or feeling out of control. The physical symptoms are similar to the symptoms of premenstrual syndrome, such as breast tenderness or swelling, joint pain, muscle pain, weight gain, and bloating.

Because of the broad variety in clinical presentation, the onset of symptoms only during or around the luteal phase is key for diagnosing someone with PMDD rather than any other mood disorders. PMDD follows a predictable, cyclic pattern. Symptoms begin in the late luteal phase of the menstrual cycle (after ovulation) and end or are markedly reduced shortly after menstruation begins. On average, the symptoms last six days but can start up to two weeks before menses, meaning symptoms can be felt for up to three weeks out of a cycle. Severe symptoms can begin and worsen until the onset of menstruation, with many not feeling relief until a few days after menstruation ends. The most intense symptoms occur in the week and days leading up to the first day of menstrual blood flow. The symptoms usually cease shortly after the start of the menstrual period or a few days after it ends. Various symptom and severity tracking questionnaires exist to document presence and severity of symptoms throughout consecutive menstrual cycles.

The International Society for the Study of Premenstrual Disorders (ISPMD) defines two categories of premenstrual disorders: core PMD and variant PMD.

Core PMD has six characteristics, mainly focusing on the cyclical nature of PMDD and its typical onset pre-menses tracked for more than two menstrual cycles. The four classified variant PMDs involve more unexpected variables that cause the onset of premenstrual distress, such as PMD with absent menstruation or premenstrual exacerbation, wherein the symptoms of another preexisting psychological disorder may be heightened as a result of PMDD onset.

Epidemiology About 5–8% of women who are of reproductive age experience severe premenstrual syndrome; most of them also meet the criteria for PMDD.

Pathophysiology PMDD mood symptoms are only present in menstruating women. Thus, symptoms do not occur during pregnancy, after menopause, or in women who have anovulatory cycles. Other mood disorders typically persist across all reproductive life events and are independent of a woman's menstrual cycle.

The current consensus on the cause of PMDD is a combination of heightened sensitivity to fluctuating levels of certain hormones (i.e., the reproductive hormones), environmental stress, and genetic predisposition. The sex steroids—estrogen and progesterone—are neuroactive; they have been noted in rat models to be involved in serotonin pathways. Serotonin is involved in mood regulation alongside estrogen, whose receptors are found in the prefrontal cortex and hippocampus—the regions most known for their involvement in regulating one's mood and cognition overall.

While the timing of symptoms suggests hormonal fluctuations as the cause of PMDD, a demonstrable hormonal imbalance in women with PMDD has not been identified. Levels of reproductive hormones and their metabolites in women with and without PMDD are indistinguishable. It is instead hypothesized that women with PMDD are more sensitive to normal levels of hormone fluctuations, predominantly estrogen and progesterone, which produces biochemical events in the nervous system that cause the premenstrual symptoms. These symptoms are more predominant in women with a predisposition to the disorder.

It is apparent that premenstrual disorders are biologically driven and are not simply psychological or cultural phenomena. PMDD has been reported by menstruating women worldwide, indicating a biological basis that is not geographically selective. Most psychologists infer that this disorder is caused by both a reaction to hormone flux and also genetic components. There is evidence of heritability of (retrospectively reported) premenstrual symptoms from several twin and family studies done in the 1990s, with the heritability of PMDD proving to be about 56%.

Genetic factors Whether or not this disorder has a specific genetic basis is still being discussed in the academic community. The possible genetic factors contributing to PMDD also have yet to be thoroughly researched. However, multiple genetic factors that contribute to the moodiness, depression, irritability, increased appetite, trouble sleeping, acne, fluid retention, headaches, nausea, and other symptoms associated with this disorder have recently been identified.

Many studies have noted that a polymorphism of the brain-derived neurotrophic factor gene (BDNF), a gene that helps support neurons in their function and survival in the brain by creating a protein that helps in the growth, maturation, and maintenance of these cells, may play a role in causing PMDD symptoms. This is because the result of this polymorphism mimics the hallmarks of PMDD: volatile moods, depression, and irritability centered around the menstrual cycle. This gene has been studied extensively in its association with depression and, promisingly for PMDD research, mice homozygous for the BDNF polymorphism exhibited anxiety-like traits that fluctuated and changed around the mice's estrus, analogous to the human's menstruation, therefore mimicking some of the symptoms of PMDD.

Risk factors Environmental stressors have also been found to increase the risk for PMDD symptoms prospectively. Environmental components such as stress, hormonal fluctuation, and epigenetics play a key role in the pathology and onset of the disorder. Some studies have noted evidence of interpersonal trauma (domestic violence, physical or emotional trauma, or substance use) or seasonal changes (making PMDD potentially comorbid with seasonal affective disorder) having an impact on PMDD risk. But the most common pre-existing disorder found in those diagnosed with PMDD is major depression, wherein they either had it or were misdiagnosed when they should have only been diagnosed with PMDD. Finally, an easily modifiable risk factor for PMDD is cigarette smoking. One meta-analysis found dramatically increased risk of developing PMDD in menstruating women who smoke.

Relationship to pregnancy and menopause Women with PMDD usually see their symptoms disappear while they are pregnant. Premenstrual dysphoric disorder is primarily a mood disorder that is associated with onset of menstruation; pregnancy, menopause, and hysterectomies all cause menstruation to cease, thereby stopping the proposed sex steroid-/serotonin-caused symptoms from occurring. PMDD symptoms can get worse following pregnancy or other associated events such as birth and miscarriage.

Studies on the association between PMDD and postpartum depression (PPD) have provided conflicting results. While one large study of women with prospectively confirmed PMDD did not find a higher prevalence of postpartum depression in that population than in controls, others have found a positive association, and one study found a bidirectional relationship between PMDD and PPD (meaning that previous history of PMDD raises the risk of future PPD, and vice versa).

Mental health comorbidities The lifetime incidence of other psychiatric disorders is high among women with PMDD. An older review article (2002) utilizing the previous edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) which used studies from 1966 to 2002 on PMS and mental health disorders and selected for patients who retrospectively met the diagnostic criteria for PMDD found that major depressive disorder, seasonal affective disorder, and generalized anxiety disorder often co-occur in PMDD. Another systematic review study suggests that patients with bipolar disorder, type I or II, have a higher incidence of PMDD. While the diagnosis of PMDD requires a mental health provider to determine that the symptoms a woman is facing are not due to an underlying mental or physical health condition, other conditions often co-occur and impact the quality of life and treatment plan for people with PMDD. A 2025 study of the Reddit peer support community r/PMDD found that users showed a decrease in associations with depression and anxiety after engaging in the forum, possibly reflecting a reconfiguration of symptom interpretation.

Suicidality Previous links to suicidality and PMS have been made, but women with PMDD are more likely still to consider and attempt suicide even when controlling for mental health comorbidities. Despite the increase in suicidal ideation and attempts in this population, the data currently suggests that suicidal ideation or action is not more likely to occur during the late luteal phase when PMDD symptoms would occur. It is difficult to study whether treatment reduces suicidality because of the multifaceted reasons provided for suicidal ideation. However, treatment has been well documented to reduce physical and emotional symptoms of PMDD.

Diagnosis