When extreme PMS makes Life unbearable

Suffering without a diagnosis and the constant question "What is wrong with me?". This is the reality for PMDD sufferers when they experience unexplained symptoms in the second half of their menstrual cycle. In the first few days after the end of the period, everything is still fine. Only in the second half (the luteal phase) does the horror begin again.

• Note: This article deals with the topics of mental illness and suicide.

Suddenly the world around you turns "grey", your partner is incapable of doing anything and is annoying, every cry of the children becomes torture and the stress level at work hits the ceiling within seconds.

You just drag yourself through everyday life in the hope that the condition will soon be over. However, it is not "over" until menstruation starts.
For PMDD sufferers, four days after the start of the period, the sun shines more beautifully again and the romping children are adorable ... And the cycle starts all over again.

This is the definition of PMDD, which has only recently received media attention, although (statistically) one in ten women of childbearing age suffers from it.

The PMDD symptoms

Premenstrual dysphoric disorder (PMDD) is a complex disorder that combines physical and emotional symptoms. Depressive and manic moods are typical. The feeling of losing control, anxiety to panic attacks and "brain fog" can occur as well as physical symptoms. These include water retention, chest pain, fatigue, stomach problems, back pain or migraines.

PMDD is complex because although the disease is triggered by a physical process in the body, it can have severe psychological effects and even lead to suicide. That is why PMDD has been listed by the WHO since 2019 with the code GA34.41, which places it under behavioural and neurodevelopmental disorders.

With PMS, women tend to experience physical symptoms, whereas with PMDD, the focus is more on psychological complaints," says Dr Matthai, a Viennese gynaecologist.

As US TV star Gia Allemand demonstrates, medical advice should be sought, especially in severe cases. Allemand took her own life in 2013 as a result of her PMDD condition. In her name, "The Gia Allemand Foundation" was founded, which today operates as the "International Association for Premenstrual Disorders" and is dedicated to public relations and education for PMDD.

Things to know about PMDD

• The causes have not been definitively researched, as they can vary. However, hormonal factors are thought to be the main cause. One possibility is an abnormal reaction of the brain to the progesterone that increases during the luteal phase and the neuroactive steroid allopregnanolone.
• A specific drug is currently still in the development stage. It is still uncertain whether and when it will come onto the market.
• For the diagnosis of PMDD, it is important to recognise the temporal relationship between menstruation and symptoms: Only when the symptoms are noted in a calendar (for at least two cycles) can it be recognised whether it is PMDD, says US doctor Diana Dell in her guidebook "The PMDD Phenomenon".

Viennese gynaecologist Dr Christian Matthai writes about PMDD in his current book "Meine Sprechstunde". L'Officiel Austria interviewed him.

Dr Matthai, PMDD is a complex disease. What are its symptoms?

Dr Christian Matthai: "Premenstrual Dysphoric Disorder (PMDD) is a complex of symptoms in which depressive disorders, anxiety and panic attacks are present."

What is the significant difference between PMS and PMDD?

Dr Christian Matthai: "In terms of symptoms, we can distinguish between the more common and somewhat milder form, classic PMS, and the extremely stressful Premenstrual Dysphoric Disorder (PMDD). This most serious form of PMS is present when at least 5 symptoms are present. With PMS, women tend to experience physical symptoms, whereas with PMDD, the focus is more on psychological complaints. The classic physical symptoms include breast tenderness and breast pain (mastodynia), bloated abdomen and flatulence in general, water retention (oedema), fatigue, ravenous appetite, headaches and abdominal pain, as well as sleep disturbances. Classic psychological symptoms include irritability, lability and tearfulness, depressed mood, tension, anger, aggression, forgetfulness and concentration problems."

What role do hormone fluctuations play in the female cycle? Is a deficiency of a certain hormone to blame?

Dr Christian Matthai: "The exact cause of PMS is not yet completely clear. A hormonal background is obvious, as the complaints always have a connection to the female cycle. The following factors are in the focus of science as possible causes: permanent negative stress, chronic inflammation, progesterone and/or oestrogen deficiency, a deficiency of the amino acid L-tryptophan and/or the neurotransmitter serotonin. The GABA-A receptor, which is very important for the psyche, the sleep hormone melatonin, the stress messengers dopamine, noradrenalin and cortisol are also under discussion."

Does PMDD persist until menopause or can other hormonal changes, such as childbirth, change or even suspend the symptoms?

Dr Christian Matthai: "One of the advantages of getting older is the fact that PMS no longer affects women in the post-menopause, who no longer have a menstrual cycle and therefore no menstruation. Even after childbirth, a woman's hormonal situation can change."

What life circumstances can exacerbate PMDD?

Dr Christian Matthai: "Science focuses on the following triggers: permanent negative stress, chronic inflammation or exposure to hormonally active, harmful substances that we consume through food. These include, for example, plasticisers such as bisphenol A."

The WHO has categorised PMDD in ICD-10 with the code F32.81 under behavioural and neurodevelopmental disorders. Should one consult a gynaecologist or a psychiatrist?

Dr Christian Matthai: "Basically, both specialists can help. I see gynaecologists as the primary contact persons. In severe cases, where psychotropic drugs are used, the patients are then referred to psychiatrists. In some women, the symptoms can be so severe that suicidal thoughts arise. Then a classical therapy with antidepressants becomes unavoidable."

Is there another way to use hormones?

Dr Christian Matthai: "For women who do not need or do not want to use hormonal contraception, a bioidentical hormone therapy with progesterone can be used. Progesterone therapy is started in the middle of the cycle and is usually applied cyclically over 10 to 14 days. Doses between 100 and 400 mg are usually effective. As progesterone can make you tired, it is recommended to use it in the evening before going to bed."

Which foods should one avoid with PMDD and which ones should one prefer?

Dr Christian Matthai: "In the second half of the cycle, sufferers should avoid sugar and simple carbohydrates. Whole grain products are the best substitute. Coffee and alcohol should also be avoided, as their consumption can worsen symptoms. Furthermore, the consumption of animal fats and salt should be reduced. Saturated fats, especially in meat, sausages and fatty dairy products, promote inflammation, and salt promotes water retention. Omega-3 fatty acids belong to the healthy polyunsaturated fatty acids and act as natural anti-inflammatories. They are available in capsule form or as an oil. Dosages between 1 and 2g per day have an anti-inflammatory effect. And weight can also play a role: Women who are overweight usually benefit from weight loss for PMS as well."

Which vitamins are particularly helpful for PMDD?

Dr Christian Matthai: "The B vitamins are involved in numerous metabolic processes. Since they are of great importance for the psyche as well as for hormone balance, the use of a vitamin B complex is profitable for many PMS patients. An analysis of the B vitamins before starting a therapy [via blood testing, note] is useful. Magnesium, like the B vitamins, is also involved in numerous metabolic processes. In addition, magnesium and vitamin B6 are essential cofactors of the body's own serotonin production. In addition, magnesium has an antispasmodic effect and can thus also bring relief from lower abdominal discomfort. Daily doses between 300 and 450 mg are effective. The daily amount should always be divided into 2 to 3 individual portions. A magnesium analysis before starting to take magnesium is not absolutely necessary, since magnesium can hardly be overdosed."

Why is there still so little awareness of PMDD among doctors in Europe, in contrast to i.e. the USA? If you Google "PMDD" among Viennese gynaecologists, there are only a handful who mention it on their website ...

Dr. Christian Matthai: "Just because you rarely read about it online doesn't mean that we doctors don't address this issue or take it seriously. Nevertheless, the number of women who feel left alone with their complaints is still too large. I agree with you on this point."

What can women do who now recognise the symptoms in themselves and think they might be suffering from PMDD?

Dr Christian Matthai: "In any case, those affected should talk about it and get help from doctors or pharmacists if necessary. It can also be helpful to talk to friends and other sufferers - there are self-help groups for this. Even the knowledge that you are not alone helps many people. But I know from experience that there is a solution for all PMS or PMDD symptoms. At this point, I would like to take away the fear and give confidence to all women.