9 September 2021

Premenstrual Dysphoric Disorder (PMDD): Does it affect fertility?

Doctor
Medical Director
Cesar Diaz-Garcia
MD PhD Assoc Prof
IVI London

 

Premenstrual dysphoric disorder (PMDD) is a more severe form of premenstrual syndrome (PMS). To some degree, PMS is familiar to many women of menstruating age, if not the majority. However, PMDD is something very different, which affects only a minority of women of childbearing age.

In this article, we’ll look at:

  • Symptoms and causes of PMDD
  • Self-help actions you can take to alleviate the symptoms of PMDD
  • How PMDD is treated and where to get help

Finally, given that this is a problem that only affects women during their reproductive years, many of whom may wish to start or extend their families, we will look at any evidence of links between PMDD and infertility.

 

What is PMDD and what are the symptoms?

Unlike premenstrual syndrome, which is very common, premenstrual dysphoric disorder is a much more extreme form which affects only around 3 to 8% of women who menstruate. With PMDD, the mild mood alterations and physical symptoms which come with PMS are magnified to the extent that they can have a detrimental impact on a woman’s work, social activities and relationships. The most debilitating symptom is an intense change of mood, which can include feelings of depression, irritability and anxiety.

Symptoms occur during the luteal phase of your menstrual cycle: the phase after ovulation and before the onset of your next period. This phase normally lasts for about two weeks. During this time, some people suffering from PMDD experience symptoms every day. For others, symptoms may only last for a few days.

According to the NHS, symptoms can include:

  • Headaches and difficulty concentrating;
  • Joint and muscle pain;
  • Fatigue and lack of energy;
  • Behavioural changes such as binge eating or disrupted sleep;
  • Loss of interest in previously-enjoyed activities and hobbies;
  • Emotional problems such as weepiness, anger and depression.

In some cases, PMDD can give rise to suicidal thoughts. If you are experiencing suicidal thoughts, there are many resources, organisations and contacts available which may help you cope if you are feeling overwhelmed. If you find you are considering acting on these thoughts, seek help immediately by calling 999 or talking to someone by calling Samaritans free on 116 123.

 

What are the causes of PMDD?

PMDD is connected to hormonal changes that occur during the menstrual cycle. This means that PMDD does not affect pre-menstrual girls, women who are pregnant or anovulatory, or post-menopausal women. The exact link between PMDD and hormonal fluctuations is still unknown, however evidence suggests that it does not necessarily result from any hormonal imbalance or dysfunction. In fact, the majority of women diagnosed with PMDD have normal hormone levels. Many authorities, including the UK mental health charity Mind, conclude that PMDD results from hyper-sensitivity to the cyclical changes in the reproductive hormones oestrogen and progesterone, the latter in particular.

Technically, PMDD is not a mental health disorder, but its emotional, physical, and behavioural manifestation can lead to symptoms such as depression. In order to distinguish PMDD from a mental health disorder such as chronic depression or bipolar disorder, it is useful to keep a diary of symptoms over the course of a few menstrual cycles. By tracking your symptoms, it can demonstrate whether it is linked to a specific phase of your cycle.

 

What can you do to alleviate symptoms of PMDD?

It is important to remember that PMDD is an endocrine disorder. If you find your PMDD symptoms are becoming disruptive or debilitating, diagnosis and treatment are essential. The first step is to make an appointment with your GP who can refer you to a specialist service. If you are referred to a specialist, tracking your symptoms alongside your cycles will be very helpful. However, if you are looking for things you can do to alleviate symptoms, some lifestyle changes commonly associated with reducing stress and anxiety have been known to be effective. These include:

  • Stress-reducing relaxation techniques such as yoga and meditation.
  • Dietary precautions such as reducing your intake of caffeine, salt, sugar and alcohol. This can be especially helpful during the days leading up to your period.
  • Exercising regularly. Due to the endorphins released during exercise, it is recommended as helpful in the management of premenstrual symptoms.
  • Quitting smoking. Stopping smoking is essential, as tobacco use has been associated with increased hormone sensitivity.
  • Knowing your menstrual cycle. If you are able to track your symptoms, it can help you to plan commitments and activities around times when you expect symptoms to appear.

If you are in urgent need of help, the NHS has a list of recommendations, including calling your GP for an emergency appointment, or dialling 111 if you need help or advice immediately. The NHS 111 phoneline is open 24 hours a day, 7 days a week.

 

What treatment is available for PMDD?

The first approach to treating PMDD is to reduce the symptoms by suppressing ovulation. This prevents the body from releasing the reproductive hormones associated with ovulation, particularly progesterone, which can trigger the onset of PMDD symptoms. This is commonly achieved by prescribing the combined oral contraceptive pill. This may be an effective strategy to alleviate symptoms, but it may not be a feasible option for women who are trying to conceive.

Selective serotonin reuptake inhibitors (SSRIs) are a type of anti-depressant which can also be used to treat PMDD symptoms. The commonly prescribed SSRIs include fluoxetine, sertraline, citalopram, and paroxetine. Many women diagnosed with PMDD also exhibit neurotransmitter abnormalities, particularly lowered central serotonin levels during the luteal phase of their cycles. SSRIs are very effective in treating PMDD by increasing serotonin levels in the brain.

At present, there is no cure to PMDD without surgical intervention. In very extreme cases, the disorder can be surgically managed through a hysterectomy with bilateral salpingo-oophorectomy. This involves the surgical removal of the uterus, ovaries, and fallopian tubes. While this offers a permanent solution, it is irreversible and only considered by most doctors and patients as a last resort.

 

Can PMDD cause infertility?

There is no evidence to suggest PMDD and infertility are connected, although abnormally low progesterone levels, commonly associated with PMDD, can also make it difficult to carry a pregnancy to full term. If this is the case, progesterone can be supplemented with medication during the course of Intrauterine Insemination or IVF treatment.

However, the more likely scenario is that your fertility is affected by the medication commonly prescribed to manage the symptoms of PMDD, such as the birth control pill or SSRIs. Certain treatments, particularly hormonal therapies like the contraceptive pill, disrupt the menstrual cycle by suppressing ovulation. If ovulation is suppressed, it is not possible to get pregnant. If you are trying to conceive, it’s important to discuss these implications with your GP or healthcare specialist so that you are aware of any risks of changing your medication regime.

Although PMDD is unlikely to affect your fertility, it is a complex condition which can have a serious impact on your life. If you are experiencing PMDD symptoms while trying to conceive or while considering fertility treatment, your condition needs to be managed very carefully. At IVI, we have experienced specialists who can talk you through your different options and answer any questions you might. You can get in touch with us here.

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