Treating PMDD — The Criminally Underestimated Vibe Killer
Disclaimer: This article is not intended to promote self-diagnosis or self-medication. This is merely a deep-dive literature review into PMDD backed by sources, that includes a study on the observed relationship between anti-histamines and PMDD symptoms. Act at your own discretion and always consult with a medical professional.
At the conclusion of this article, I delve into a medication that is low-risk and low-cost that I will be experimenting with starting from my next luteal phase. I wish to try it before seeking out more serious medication. It is not an encouragement, nor a recommendation to do the same. For educational purposes, I will be recording my results in a later article.
I will propose a dark analogy, but one I feel to be the most fitting in its depiction.
From the moment you get out of bed to the moment you lay back on it to sleep, you get most if not everything you wanted to get done, done. These things make you adequately happy each day, and you’re overall content with your level of productivity. You take a few moments to relax in between work, and suddenly you remember. You remember that it is coming for you, but you let the thought pass. It’s only the first week, you’ve still got so much time!
The second week rolls in and your energy levels are at an all-time high! You’re smashing your short-term goals out of the water with the motivation and discipline rivaled only by an anime protagonist and David Goggins, bless his heart. You’re in dynamic overdrive and nothing can stop you. Nothing, except it. It’s closer than it was the week before, but you’ve got so much wind under your wings, that you can’t even remember how it felt like. You’re finally in love with yourself and all the effort you put in. You’ll be fine.
You’re now halfway through the third week, but something doesn’t feel right. The energy of the past two weeks has dwindled to whispers of themselves at this point, but the show must go on. You’re feeling yourself slipping up more than usual, and the hateful voice in your head is back again. You can’t always be at 100% a 100% of the time after all, and you’re grateful for the second wind of the week before. While you count on it to come back next month, you’re also filled with intense fear and anxiety because you can finally hear it catching up to you, and now it’s faster.
You’re now on the last 10 days of the cycle, and it is lying right beside you in bed. a feeling so familiar. Was it always here? You can’t get out of bed, “Why not? You’re so lazy it’s disgusting,” it pillow talks to you. You agree, and thus you give it permission to enter you. Enter your mind, body, and soul and you never had a choice. You haven’t achieved anything to be proud of in life, your friends know it, and your parents know it. You’re a mess and you always have been. Forget meeting up with friends, what a horrible thing to be perceived by people you love.
What was last week like? You can’t remember, all that remains is a fog of dust and clouds where your thoughts used to be. The next days are a blur and you can’t tell when one ends and the other begins. Your skin is sallow and your brain hurts. You’re filled with such intense anxiety and depression that it feels impossible to ever get back to the version of you that existed a few weeks ago. It feels so much worse than last month, and the blood on your arm tells you it’s only going to get worse. What a horrible life.
Until you get your period. Rinse, wash repeat. The first week begins again, and the whiplash from the week before feels like memories of a past life. Is this how life is supposed to be? Is half of the month supposed to feel as if you were a ghost driving a meat suit? Never mind, the show must go on.
This is what PMDD feels like for menstruating individuals. Sufferers report feelings of utter hopelessness, despair, uselessness, lack of self-worth and confidence, increased substance abuse, and suicidal ideation within what feels like a completely different body 1–2 weeks out of the month. In the analogy, around week 2 of their cycle — on average — is where they report feeling “overly happy” and “high”. Research has shown that this is merely how they’d feel throughout the month without PMDD.
What causes PMDD?
Premenstrual Dysphoric Disorder — named after the effect of creating an almost out-of-body unease — is a severe form of premenstrual syndrome (PMS). PMDD has quite a mysterious backstory, as there is very little known about what turns the milder, more common PMS into PMDD. Hlay et al. propose that some individuals may have a predisposition to higher sensitivity to the levels of hormone increase during this time. Both syndromes manifest as physical and psychological patterns that repeat cyclically throughout a menstruating individual’s cycle, but where mild PMS affects 70–75%, PMDD only affects around 5–8% of these individuals. In a review by Robert F Casper, MD (2022), it is outlined that while hormones are most likely to blame, specifically spikes of estrogen and progesterone and fall of serotonin, it isn’t clear why some individuals experience PMDD, and others only mild PMS or none at all.
What PMDD is not caused by, as Dr. Payne of patient.info states, is a hormonal imbalance, a theory that was once proposed, but rather an individual’s own sensitivity to the hormones.
The Hormones
For PMDD sufferers, I've found it very helpful to learn and remember just how much of a hold the cycle has on our mood, energy levels, and mental and physical performance.
Let’s look at a standard menstrual cycle. Ranging from 22–38 days, overseeing and regulating this cycle are our luteinizing and follicle-stimulating hormones, produced by the brain’s pituitary gland, which stimulate the ovaries to then produce the estrogen and progesterone hormones. As such, the cycle can then be split up into three phases:
- The follicular phase — before the release of the egg
- The ovulatory phase — the egg is released
- The luteal phase — after the egg is released
These phases will be explained in two parts. One part scientifically, with the purpose of educating and reinforcing medical terms that all menstruating individuals should be familiar with. And then one part practical, explaining what you tend to feel during each phase of the cycle.
Jessica E. McLaughlin M.D. states that the first day of the follicular phase starts from the first day of menstruation, and this is where estrogen and progesterone are at their lowest levels in the cycle. As a result of this, the thickened lining of the uterus begins to break down and shed, and this is why bleeding occurs. Follicle-stimulating hormone levels take a slight increase as they begin to attach several follicles to the ovaries — each containing one egg. Later on in this phase, follicle-stimulating hormone levels begin to steadily decrease until only one follicle makes the cut and starts to develop. This follicle produces estrogen, slowly raising estrogen hormone levels. This phase lasts about 10–14 days.
In the follicular phase, it’s not uncommon for individuals to have higher energy levels as well as better skin, mental clarity, and overall confidence. This is usually where you would make most of your social plans, overload more at the gym, work with more focus, and sleep better. The increase in estrogen gives the mood a boost and may even help you feel more in tune with others around you. In an interesting paper by Derntl et al. associating the follicular phase with empathy, they found some correlation between this phase and increased interest in social interaction and performance.
The second phase is the ovulatory phase — lasting only a short 16–32 hours, begins when the luteinizing hormone takes a dramatic surge, rupturing the dominant follicle and releasing our first egg drop of the cycle. Around this time, one may feel a dull pain in their lower abdomen dubbed the “mittelschmerz”, or “middle pain”. This pain lasts a few hours to a day and is usually felt on the side the ovary released its egg, mostly thought to be caused by the rupturing of the follicle. The ovary egg-drop event doesn’t alternate between the ovaries and is random every month, it’s a surprise.
During the ovulatory phase, individuals don’t tend to feel too dissimilar from the previous phase, they’re still getting things done at an adequate energy level. Though it’s not uncommon to experience a little bit of lethargy and anxiety due to estrogen being at the cycle’s all-time high.
We then find ourselves in the godforsaken luteal phase. Godforsaken for some, just another Tuesday for the lucky majority. Lasting around 14 days, the ruptured follicle that dropped the egg slowly starts closing and forms into something called a corpus luteum, which then proceeds to produce exponential amounts of progesterone. Estrogen levels also shoot up during this phase. The corpus luteum then starts to break down after around 14 days, in which the levels of estrogen and progesterone decrease and a new menstrual cycle begins.
The Luteal Phase and PMDD
The symptoms of PMDD are significantly more likely to rear their heads during this phase of the menstrual cycle. Though no single test is available at the moment to test for PMDD, it is recommended that an individual test their physical and behavioral changes during this phase for at least three cycles. Many studies, such as this, mandate that symptoms must not be present during other phases of the cycle, however, I personally believe that the physical and emotional fallout caused by this phase amongst PMDD sufferers can leave them feeling overwhelmed even during other phases.
For example, during the luteal phase, the individual might experience deep feelings of anxiety and agitation due to high levels of progesterone and estrogen, causing them to lash out or conversely, isolate from family and loved ones. Once the follicular phase comes back around and they find themselves “coming to” as their hormones start to decrease back to baseline, the effort they must put into fixing the mess they caused can leave them feeling emotional fatigue, distress, and shame.
For this reason, I urge medical professionals not to write off PMDD when patients also complain about emotional distress during other times of the month, as long as they report feeling especially overwhelmed during those dreaded 14-or-so days. Casper further recommends a blood test either way, though not necessary for PMS diagnosis, it‘s worth it in case other underlying health issues are on the horizon (e.g.hyperthyroidism, an overactive thyroid gland that produces symptoms similar to PMDD).
It is also possible to suffer from another disorder, as well as PMDD at the same time.
As observed by myself, and many other individuals, PMDD symptoms get worse with every proceeding cycle.
One thing to understand is many don’t know about, let alone understand PMDD. Many, such as I, wrote these symptoms off as just PMS for years, forcing ourselves to just toughen up even though symptoms would worsen every cycle to the point of exhaustion, after all, we just have to wait for the period. This creates a cycle of fear of your own body, and a feeling of shame for not being able to control, nor get a grasp of who you are during this phase.
Between 5–8% of women fulfill the criteria for a diagnosis of PMDD; about 20% of these women seek medical help.
— Yonkers et al., pubmed.gov
I believe more individuals who experience these cyclical episodes should not have to just toughen up and suffer. When suicidal ideation and tendencies come into play and the sufferer is thrown into what feels like an empty void where their body and mind used to be, I feel that continued ignorance of PMDD is borderline unacceptable. Any and all safe alternatives to feeling this way should be heavily researched, though the sad truth is many individuals do seek help but find themselves at yet another dead end.
Brief Exploration Into Treatment
In this section, I will cover treatments proposed to ease the individual’s suffering during this time. I will also proceed to talk about them through personal anecdotes for one reason, and it’s an important one. While listening and reading about how people respond to each treatment, results vary greatly. It seems to be a game of trial and error really, and this makes sense.
As is now known, PMDD is not a result of a hormonal or chemical imbalance that can be fixed with just one channel of medication. It comes down to an individual level, and what they respond to better. Some women find SSRIs to be all they need, while some women respond worse, and find anti-histamines work better. Some women respond well to diet tweaks and exercise and find that to be all they need.
PMDD is a Russian roulette when it comes to the individual’s sensitivity to the rise in estrogen and serotonin, and for this reason, I feel it’s wise to first incorporate the majority of non-pharmacological means of treatment first before seeking out medicine.
We will first look at recommended non-pharmacological measures by medical professionals.
Explanation, reassurance and support may be all that are required.
Try regulating carbohydrate intake: complex carbohydrates every 2–3 hours and avoidance of excess sugar and refined carbohydrates.
Reducing saturated fats and caffeine: may improve mastalgia. Good diet may correct any subclinical nutrient deficiencies (eg, magnesium and calcium) and improve symptoms.
Reducing salt intake: may reduce fluid retention.
Use of a firm, supportive bra — day and night.
Support stockings: to help aching legs.
Exercise is effective in some women.
Lessening sugar, and switching to a more low-sodium diet during this phase has helped me tremendously when it comes to physical well-being. Personally, during this phase, I tend to go through problems with digestion, so the incorporation of less inflammatory foods and cutting down on hard-to-digest foods have done wonders. Daily exercise gives me an endorphin boost, though during this time I am fatigued and unable to lift as heavy or walk as far — but I highly recommend a mix of both light resistance training and walking. As for the first point, explanation and reassurance are definitely not all that I need, but it definitely helps — and that is why this article even exists.
I will next cover the pharmacological mediums which have been proven to mitigate or eliminate symptoms altogether, as well as brief explanations for why that might be.
Selective Serotonin Reuptake Inhibitors (SSRIs) — This is what your doctor is most likely to recommend after you go in for diagnosis and have incorporated non-medicated means into your lifestyle, also known as the first-line treatment. Studies have shown that “60–90% of women [show] improvement with active treatment versus 30–40% for placebo treatments”. They have been found to suppress mood symptoms and somatic complaints. Since the effects are fast-acting, it is prescribed to limit dosage only to the luteal phase.
Birth control pills or alternative suppression of ovulation — The response rate to this method of treatment has been reported to be between 60–75%. They work for the reason you might expect them to, since ovulation is ceased, there is no reason for the brain to release luteinizing and follicle-stimulating hormones and trigger the luteal phase, thus skipping the surge of estrogen and progesterone altogether. There has been found to be little difference in results when it comes to which contraceptive brand is used, thus dosage is as recommended. However, Danazol, though effective in reducing chest pain, has been found to produce unwanted masculinization in women as well as other side effects, and is not recommended for treatment.
There lies an alternate medicine that further motivated me to write this article. Under our noses is an over-the-counter antihistamine that may just have a hidden purpose…
Pepcid for PMDD Treatment
I had never had allergies or complications with heartburn, so my first time hearing about the anti-histamine Pepcid was while scrolling through my Instagram page and happening upon a story by user ghosted_1996. Haley suffers from PMDD and has tried all the above pharmacological and general methods of coping, but saw the most significant improvements when she popped a Pepcid during a particularly bad episode.
She had just happened to have some heartburn during a much-unwanted drive to the DMV. Before taking the Pepcid, she was having severe agitation as well as thoughts of suicide and despair, and all she wanted to do was go home. However, not even a half-hour later she felt the clouds part in her brain, something unheard of for PMDD sufferers during this time. She thought hard about what had changed and remembered a follower of hers recommending Pepcid as an alternate treatment for PMDD symptoms. Knowing this couldn’t be a coincidence, she quickly spread the word to her followers, and that’s how it ended up on my feed.
Following this, she made the above video with her research into the links between histamine blockers and the suppression of PMDD symptoms, which I highly recommend watching. I will conclude with a summary of the relationship between the over-production of histamines during the luteal phase, and the role Pepcid can play by u/Odd_Maintenance_6835/, a very active contributor of the PMDD subreddit.
I don’t think this has been studied enough, but I’ll give you the ELI5 version of the mechanisms at play that could explain the role of histamine in PMS/PMDD.
You can imagine your nervous system to have many different “buttons”. These buttons are called “receptors”. For each button, there is one or several little agents who can (and do) push this button. These agents are called “agonists”. Each time a button is pressed, it sends some kind of signal through your nervous system. What signal that is depends on the button.
The central nervous system (CNS) has a powerful “off button” that’ll reduce agitation and calm a person down. That “off button” is called the GABA-A receptor. This button is very important in PMDD. In fact, there’s something wrong or atypical about it in PMDD. Pressing it while in the luteal phase, when progesterone is high, will lead to increased agitation and stress instead of having calming, stress-relieving effects.
That is because progesterone, like many other neurosteroids, leads to a change in the button. Actually, it’s not progesterone itself that does this, but something that’s made in the liver out of progesterone. That something is called allopregnanolone.
We know that histamine can also change the GABA-A button. And since some antihistamines can attach to the same things histamines can, that is probably what is happening.
Whether this is true is an educated guess and hasn’t been studied or confirmed yet. However, there are some animal studies that definitely show that famotidine and similar antihistamines do change how the GABA-A receptor works, so this guess is maybe not far off from the truth.
These facts, coupled with a small Swedish study I read sampling 95 individuals, have motivated me to seek out Pepcid as a potential PMDD treatment avenue. As an honorary mention, I also urge you to read this article about an anecdotal experience.
As mentioned, I am quite excited to report my findings in a later article and hope for good results.
Thank you for reading!
