PMDD vs PME: How to Tell the Difference and Why It Changes Treatment

[00:00:00] If you've been diagnosed with PMDD, premenstrual dysphoric disorder, but deep down you're wondering if your symptoms are something more because they don't just happen during your period, that's a distinction that matters, and we're gonna talk about that today. Because PMDD and PME, premenstrual exacerbation, can look similar, but clinically they are not the same thing, And treating them is also different.

So we wanna make sure that we are addressing the right condition and getting you the right treatments. So today, we're gonna talk about the difference between premenstrual dysphoric disorder, PMDD, and premenstrual exacerbation, PME. And this is an important clinical distinction because PMDD is a diagnosis with a specific DSM-5 criteria, while PME means an underlying condition.

As a women's health physician, this is one of the places where I see so many patients get mislabeled. They know their symptoms are cyclical, but no one has helped them figure out [00:01:00] whether this is actually a progesterone issue, something going on with just the luteal phase, or whether the hormones are actually amplifying something that is already there.

Now, if you're new here, or you're coming back, welcome to The Dr. Brighten Show. I'm your host, Dr. Jolene Brighten. I'm board certified in naturopathic endocrinology and a Menopause Society certified practitioner, and a certified sex counselor who's also a fellow of the American Board of Naturopathic Endocrinology.

And if you can take a quick second, hit the Subscribe button, like, share this with someone who needs it, or leave me a comment, I'd appreciate it. And just before we dive in, I want to remind you about the bonus PMDD workshop that is happening on June 10th for everyone who has purchased a copy of ADHD in Women.

If you go to drbrighten.com/pmdd, you can grab your ticket to the workshop when you pre-order your copy of ADHD in Women. Okay, so let's get into it. First things first, PMDD is not just bad [00:02:00] PMS. It is a depressive disorder diagnosis with a very, very specific pattern.

The symptoms typically appear in the final week before the period. They begin to improve within a couple of days of bleeding and are minimal or absent in the week after your period. So all of these cyclical patterns matter.

A key thing to know is that PMDD requires at least five symptoms with at least one core mood symptom such as mood swings, irritability, anger, depressed mood, feeling hopeless or anxious, maybe feeling on edge, and it also has to cause meaningful impairment. Work, school, relationship, daily functioning has to be impacted.

This is part of the DSM-V criteria. Now, the word I want you to remember is remission. In PMDD, symptoms are not just worse before your period, they also substantially lift once your period starts or [00:03:00] shortly after. That symptom-free or mostly symptom-free window is very clinically important when it comes to PMDD.

Now, we're also talking about PME, premenstrual exacerbation. This means that there's some underlying condition already present, and the luteal phase basically is an out-of-control hand that turns the volume up on your symptoms. So some things that we can see: ADHD, major depressive disorder, generalized anxiety, bipolar disorder, PTSD, eating disorders, migraines, IBS, autoimmune symptoms, thyroid disorders, chronic pain, and fatigue.

They all can get worse, uh, during that premenstrual window, so from ovulation until the next time you have your period. Now, with PME, the symptoms don't disappear after your period. They get easier. They may improve, but [00:04:00] there's still a baseline condition happening outside the premenstrual window. PME, one of the most common things we see is depression.

Depression's always there. Five, seven days before your period, it's really there. And this is why I don't want women just walking away with a self-diagnosis based on one bad luteal phase. We have to have a pattern. We need timing. We need severity. We need to ask what is happening in the follicular phase, too.

This is all very important information for you to bring to your medical provider so that you can talk to them about what's happening for you, get the right diagnosis, and be able to get the right treatments. With PMDD, women will say, "I feel like a different person before my period, and then I come back to myself within a few days of bleeding."

With PME- They usually say, "I struggle all month, but before my period, it becomes completely unmanageable." So these two different phrases, they're two [00:05:00] different experiences, and they're two different treatments or options of treatments for that, that you would want to talk to your provider about. So the clinical question is not only about when do you get your symptoms, but it's also about when do they resolve.

So those are the two things that you need to track. The gold standard for you getting a diagnosis is for daily symptom tracking to happen for two cycles. If you go into your doctor and you're trying to remember how you felt three weeks ago because your luteal phase was in the trenches, your brain was not working exactly right, um, you're gonna have a hard time conveying that, and at the same time, your doctor may not take it as seriously.

That's why when you go to the drbrighten.com/pmdd, I gave you a daily symptom tracker to help you and your clinician see whether this is a true luteal phase disorder like PMDD or an underlying condition with luteal phase exacerbation or [00:06:00] worsening.

Now, as I said before, the distinction matters because treatment matters, and getting the right treatment can change everything. PMDD treatment, yes, it can include lifestyle support and therapy. SSRIs are usually the standard of care, and those might be used continuously or just in the luteal phase. And so that just depends.

With PMDD, it's really common just to use it in the luteal phase. With PME, that's an exacerbation of you having depression, that SSRI is used throughout the cycle. And with PME, you need to treat the underlying condition and then build luteal phase plan support. So PMDD, we're looking at how do we support you in the luteal phase. PME, we need to support you all the time and then have a game plan for the luteal phase. So for example, if your ADHD worsens before your period, the question isn't just like, do

Is this just PMDD? It's also, is your ADHD [00:07:00] adequately supported the rest of the month? If depression worsens premenstrually- We need to ask whether depression is fully treated for the rest of the month as well. If fatigue, anxiety, constipation, hair shedding, cold intolerance, that's happening all the time, and maybe your periods are becoming irregular, and then just before your period you're like really, really fatigued, thyroid assessment is gonna be part of that workup.

And I wanna be clear in this video, this is not about you diagnosing yourself. It's about you knowing the right questions to bring to your clinician. It's about you tracking the data that gets you, you know, moving forward in that appointment towards the best treatment plan that's gonna help support you.

But let's talk about what gets missed. So when it comes to PMDD, PME, women are often told one of two things: It's just hormones, it's just mental health. And that can be incomplete because the reality is, is that it's often both for women. [00:08:00] Hormones changing and you being sensitive to those, that's not imaginary.

Mental health is also not separate from the rest of your body. So the luteal phase can absolutely expose vulnerabilities in your neurotransmitters. It certainly can make sleep a lot worse. We can see immune system shifts, so inflammation can change. We also have changes in our blood sugar regulation and our stress resilience, that may change as well.

The HPA axis, the hypothalamic pituitary adrenal axis, your stress system, can become more sensitive during the luteal phase. So while GABA can make it feel more chill, it can also become more reactive, and we've seen this in the research showing that the HPA axis may be more reactive in some women during the luteal phase.

And if you think about it, if we could potentially be pregnant, then being hyper-aware of your environment, that's not such a bad thing for your survival.

So in my clinical practice when I'm working with patients, the things I wanna know are, are symptoms cyclical? Are they impairing? [00:09:00] Are they absent after your period? Are they present outside your luteal phase and they just get worse then? Are there red flags? So we wanna look for red flags like anemia.

Maybe this is perimenopause. Maybe you have a history of trauma. We need to get you to a trauma-informed therapist. Maybe there is an underlying condition that deserves its own care plan, and we wanna make sure that we're addressing this. Now, I do wanna say in this video, 'cause we are talking about some heavy stuff, is that if you are having suicidal thoughts, thoughts of self-harm, you feel unsafe, this is not something to wait and just see if it gets better.

It's not something to try to use a supplement for or just stick to a period tracker. You need to get urgent help. You need to contact emergency services . or reach out to a crisis line in your country. And I think that sometimes we take for granted how scary PME or PMDD can be, and I don't want you to do that.

I would also encourage you to seek medical support if your symptoms are disrupting your relationships, your work, it's interfering with [00:10:00] your parenting, your sleep, if you're not able to eat, or you feel like you're overeating, and you're just not functioning overall.

Because w- I think sometimes we feel like we need to DIY everything about our lives, but mental health conditions are not something to DIY.

So PMDD, that's gonna be our cyclical mood disorder, symptoms show up in the luteal phase. PME, that's gonna be underlying conditions. Often we see anxiety, depression, they get worse happening before your period. So tracking your symptoms, we've talked about that. That's super helpful, but what else can you do?

Well, maybe you're getting lab testing with your doctor, or you're waiting to get that appointment.

Number one is physical activity. We know from the research that physical activity, regular exercise, it helps people's mental health immensely. It doesn't matter what the mental health condition is. We know anxiety, depression, PMDD, they all respond well to exercise. That doesn't mean that you can just, like, cardio your way out of a mental health disorder, but it does mean that it can help [00:11:00] you, and it's a supporting therapy.

Managing our blood sugar shouldn't be overlooked, so this is not something that you're gonna do in your doctor's office, so doing this proactively can help whatever therapies your doctor recommends you bringing on work even better. So I recommend starting your day with protein. Best time of day to have your protein is first thing in the morning, and if you're somebody who is trying to hit, like, 100 grams a day, I don't want you trying to get 70 grams of protein when you're going to bed at night.

So we wanna eat our protein earlier in the day. That helps with blood sugar stabilization, and it reinforces the growth of muscle tissue. And when we work out and we produce those myokines, those help modulate the immune system, and they can help with your brain health overall. Now, the other area we have to look at is sleep.

If you are struggling with sleep, I definitely recommend meeting with a healthcare provider to see, do you need a sleep study? You know, could this be something like you're struggling with sleep apnea or you [00:12:00] have a sleep disorder? Sometimes cognitive behavioral therapy for insomnia can be a complete game changer for people.

And then certainly having really healthy sleep hygiene, so making sure you turn off your screens. An hour before bed would be ideal, but at least 30 minutes before. Reading has been shown to help people fall asleep, stay asleep, have better quality of sleep. So reading before bed can be helpful, as can making sure that your room is dark, maybe you need an eye mask, and that your room is cool.

Taking a hot shower and then getting into a cool bed can help people get into that deep restorative sleep. Oftentimes we think about mental health disorders as being a condition where people sleep a lot, but sometimes they're not getting the quality sleep, and any brain that doesn't get quality sleep can certainly struggle.

And so if you're struggling with your sleep, yes, sleep hygiene, but also bring that up to your provider. That could be an important clue to what is going on for you. And then the [00:13:00] last thing that I would encourage you to do is reach out and find community. So whether that is maybe a Reddit board where people have shared interests,

Or maybe there's a physical community in your area where maybe you could do group fitness classes, or there's, like, a mommy and me meetup or, you know, something that gets you interacting with other people. When we're struggling with mental health disorders, we can often find ourselves isolating, feeling like we can't motivate, feeling like we're, we're just unable to get out there and meet people.

So sometimes virtual meetups might be better. But we know that when people have healthy community, they do have better outcomes in medicine overall, including those with mental health.

Now, if this episode has helped you realize that, wait, I need to track whether my symptoms actually go away after my period, and, you know, how long my symptoms last, and I need to track this for at least two months, please share this with someone who keeps getting dismissed as things are just hormonal, and bring this language of [00:14:00] PMDD versus PME to your next clinical visit so you can advocate for yourself and partner with your doctor for better treatment.

Now, as always, if you can take a quick second, like, subscribe, share this podcast. That helps it get out to all the women who need it. And as always, it's such a delight to spend every week with you. Thank you for being an active member of the Dr. Brighten Show community. I will see you next time.