Premenstrual Dysphoric Disorder (PMDD) and Premenstrual Exacerbation (PME) are difficult to distinguish from each other. PMDD is characterized by experiencing severe mood and physical symptoms usually starting about one to two weeks before the start of one’s period each cycle (during the premenstrual, or luteal phase) with symptoms subsiding within a few days of starting one’s period. 1 The luteal phase is the time between ovulation and menstruation. PME refers to the premenstrual exacerbation/worsening of the symptoms of another disorder, such as major depressive disorder or generalized anxiety disorder. 2

Why do they need to be distinguished from each other?

Scientists need to differentiate these conditions to better understand their unique causes which may be different from each other. This is also important because about half of the women who seek treatment for PMS or PMDD actually have PME of another psychiatric disorder, like depression, and not PMDD.2 Correct diagnosis is needed for all, so that all may receive effective treatment for their experience of symptoms.

Which conditions can be exacerbated premenstrually? 2,3

Major depressive disorder

Persistent depressive disorder (dysthymia)

Suicidality

Schizophrenia

Anxiety disorders

Alcoholism

Eating disorders

And more

How can we differentiate PMDD and PME?

Researchers suggest that we can differentiate PMDD and premenstrual exacerbation of another disorder by going ‘symptom by symptom’ with daily ratings of the severity of each symptom. To do this, they explain that “symptoms of the ongoing disorder that worsen premenstrually should not be counted as symptoms of PMDD, but should instead be considered evidence for [PME]… of the current disorder. For example, depressed mood that increases premenstrually in a woman with [major depression] is considered to be evidence for [PME] of the woman’s major depression, rather than considered as a possible symptom of PMDD.” 2

You can see how this gets tricky. Depressed mood is a symptom of both PMDD and major depression. So, is depressed mood severe premenstrually because of PMDD or premenstrually exacerbated major depression? Also, could the cyclic depressed mood of PMDD have caused the now co-occurring major depression? However, despite the theoretical controversy, this method is often effective in diagnosing PMDD and PME respectively, although it is conservative and could lack some sensitivity (i.e. with this method, it is difficult to receive diagnoses of both major depression and PMDD because the conditions share some of the same symptoms). 2

So is it PMDD or PME?

If PMDD – symptoms arise premenstrually, subside within a few days of starting one’s period, and are not present in the week post-period.

If PME – symptoms are present throughout the entire cycle, but become more severe in the premenstrual phase.

If PMDD and PME – some symptoms are present throughout the entire cycle and worsen in the premenstrual phase. Some additional symptoms arise only in the premenstrual phase and subside around the time of one’s period.

How are treatments for PMDD and PME different?

Selective serotonin reuptake inhibitors (SSRIs; type of antidepressant) are considered a first-line clinically effective treatment for PMDD. Often physicians may prescribe an SSRI to be taken only in the luteal/premenstrual phase for patients with PMDD and this treatment is often effective. However, for PME, SSRIs should be prescribed to be taken throughout the entire cycle to treat the underlying disorder. Then, if symptoms persist in the premenstrual phase, physicians may prescribe an increased dose to be taken only in this phase. 3

In addition, some of the later lines of treatment for PMDD (including chemical menopause and surgical menopause) are often effective for PMDD, but do not effectively treat the underlying disorder when it comes to PME 4. This is another reason why correct diagnosis is extremely important. Before drastic measures are taken, women experiencing premenstrual symptoms should carefully track these symptoms prospectively and be open to the possibility of a diagnosis of either PMDD or PME of another condition.

What’s the bottom line?

If you experience symptoms only in the premenstrual phase, it is most likely PMDD. If you experience symptoms throughout your entire cycle, but they are more severe in the premenstrual phase, it is most likely PME of another condition. PMDD and PME may also co-exist.

All this being said, it’s important to note that while this is based on the clinical diagnostic criteria for PMDD and other conditions, you have every right to own your unique experience. You know your body. You know when you feel good and you know when you don’t. Your experience of PMDD, PME, or another condition could be somewhat different from the ‘textbook definition,’ and that is always deserving of compassion, understanding, and effective treatments. Reach out to our Peer Support Team for help navigating diagnoses and treatment plans.