Why Does PMDD Often Show Up During Perimenopause?

I am almost 39 and have been experiencing more intense PMS symptoms in the past year — migraines, anxiety, insomnia, and mood swings and irritability. I saw my doctor recently to see if this could be perimenopause. They said that this likely wasn’t perimenopause but instead suggested I may be struggling with premenstrual dysphoric disorder (PMDD).

How do hormones cause PMDD? Is it more common for this condition to appear in late-stage reproductive years? What can help with PMDD? My doctor recommended I switch my birth control to the pill (I currently have an IUD), but I’m curious if any other remedies might help too.

—KB

I understand why this is confusing. Many of the symptoms we consider symptoms of perimenopause are also symptoms of PMDD. To further confuse matters, many women are first diagnosed with PMDD in their 40s. So what is the difference between perimenopause and PMDD, and how do treatment options differ?

One of my patients describes PMDD as PMS on steroids, and that description is apt. PMDD is similar to premenstrual syndrome, or PMS, in that it occurs in the days leading up to your menstrual cycle, but the symptoms are severe enough that they interfere with your daily functioning. Another hallmark of PMDD is that at least some of the symptoms are mood-related. This can manifest as either depression, anxiety, or irritability that only occurs in the lead-up to your menstrual period, or a marked worsening of existing mood symptoms.

At 39, you are likely a little young to be in perimenopause, which is really defined by how regular your menstrual cycles are. But you could have entered the late-reproductive stage. The late-reproductive stage is characterized by regular periods, but while estrogen levels are rising and falling in the same cycle as they have throughout your reproductive life, some levels, such as estrogen, are rising higher and falling lower than they did in the peak reproductive years.

One reason women may be likely to be diagnosed with PMDD during the perimenopausal transition is that the big hormonal swings that are characteristic of the early stages of the transition can trigger PMDD. As a result, one way to treat PMDD is to take a hormonal birth control pill. Birth control pills provide a stable dose of estrogen and progesterone in each active pill. That stable level of hormones removes the hormonal fluctuations that are driving PMDD symptoms. They have the added benefit of treating perimenopausal symptoms when you do enter perimenopause.

But birth control pills are not the only option. Antidepressant medications have also been shown to be effective in treating PMDD. There are two options for treating PMDD with antidepressants. You can take them daily, the typical way they are prescribed. Or you can take them only during the 10 to 14 days before your menstrual period. The two regimens are very similar in efficacy, but you need to have a good sense of when your menstrual period will be to take medication only in the days leading up to it.

The takeaway: PMDD is common among women in the late-reproductive stage and early perimenopause. Both birth control pills and antidepressants have been shown to effectively treat PMDD.