Menstruation is rarely ‘just that time of the month’ for any woman.

Up to 90% of women of reproductive age experience some premenstrual symptoms. ranging from mild cramps and breast tenderness to severe mood swings, exhaustion, and depression. Premenstrual syndrome (PMS) affects around 20-40%, while 2-8% experience a much more severe form, premenstrual dysphoric disorder (PMDD).^[1]

Although PMS is well-known, PMDD is often misunderstood or misdiagnosed. Recognising the difference matters, especially if symptoms are interfering with daily life.

 

What is Premenstrual Syndrome (PMS)?

PMS usually begins in the two weeks before menstruation.

• Physical symptoms: Weight gain, abdominal pain, back pain, headaches, breast swelling and tenderness, nausea, constipation, fatigue.
• Emotional symptoms: Irritability, appetite changes, anxiety, anger, restlessness, mood swings.^[2]

 

PMS can affect any woman of childbearing age. For about 20% of women, PMS symptoms are severe enough to disrupt normal daily activities and may lead to taking time off work/studies or paying for healthcare.^[3] In most cases, symptoms improve when menstruation begins and dissipate within four days.

 

What is Premenstrual Dysphoric Disorder (PMDD)?

PMDD is a severe form of PMS that mostly impacts psychological and emotional wellbeing. It is now included in the Diagnostic and Statistical Manual (DSM-5) as a psychiatric disorder.^[4]

Symptoms usually include severe anger, anxiety, depression, changes in appetite, and a lack of interest or enjoyment in most life experiences, as well as reduced libido.^[5] Physical discomfort such as bloating and breast tenderness are also common, which can lead to a misdiagnosis of PMS.

PMDD symptoms typically emerge in the luteal phase (after ovulation, which is generally one to two weeks before menstruation) and improve by the time menstruation begins, lasting an average of six days per cycle.^[6]

 

Understanding the difference between PMS and PMDD

The key difference between PMS and PMDD is the severity and duration of symptoms.

Diagnosis of PMDD requires tracking symptoms daily for at least two menstrual cycles to accurately identify the cyclical pattern and severity of symptoms associated with the luteal phase of the menstrual cycle.^[7]

However, it is also thought that around 13-18% of women experience clinically significant interference or distress without meeting full criteria for a diagnosis of PMDD.^[8]

 

Risk factors for PMS and PMDD

While the exact aetiology of PMS and PMDD is not clear, there are risk factors associated with the development of each syndrome.

• Past trauma
  Women with PMDD are more likely to have experienced traumatic or highly stressful events in the past, including childhood abuse.^[9] Altered hypothalamic-pituitary-adrenal (HPA) axis function may be a factor, including lower cortisol levels during mental stress and higher cortisol levels during the luteal phase.^[10]
• Mood disorders
  PMDD symptoms often overlap with depression and anxiety. Around half of those with PMDD also have a coexisting mood disorder, and they are at significantly higher risk of suicidal thoughts and/or attempts.^[11],[12]
• Cigarette smoking
  Smoking is strongly linked to PMS and PMDD, even in former smokers. PMDD risk increases with the number of cigarettes smoked per day, and is higher for women who began smoking during adolescence.^[13]
• Obesity
  Higher BMI in childhood is associated with a higher risk of all premenstrual disorders, including PMDD.^[14] Women with a BMI over 27.5 are at significantly higher risk of PMS.^[15] It is suggested that excess body fat can disrupt estrogen and progesterone levels and increase inflammatory mediators, potentially intensifying premenstrual symptoms.^[16]

 

Managing PMS and PMDD

While PMS and PMDD share some symptoms, PMDD may require prescription medication such as SSRIs, whereas PMS can often be managed with lifestyle changes and over-the-counter pain relief.

• Exercise
  Exercise can increase beta-endorphin levels, which may improve PMS symptoms including mood, fatigue, cognitive dysfunction, and bloating.^[17]
• Diet
  PMS symptoms are more severe with the consumption of a high‐salt, high‐sugar diet. Minimising these foods while increasing the intake of B vitamins, vitamin D, zinc, calcium, and omega-3s may ease PMS symptoms.^[18]
  Protein and complex carbohydrates may increase tryptophan and serotonin levels, potentially improving mood. Dietary fibre may also help reduce irritability caused by fluctuating blood glucose levels.^[19]
• Supplements
  A combination of magnesium and vitamin B6 is effective in relieving PMS symptoms.^[20] Magnesium assists with nervous system function and muscle relaxation, while vitamin B6 is involved in the production of serotonin and dopamine, prostaglandins and fatty acids, which are typically reduced in those with PMS.^[21]
  Vitex agnus castus (Chaste tree) has a dopaminergic effect, and has been found to significantly improve PMS symptoms including irritability, altered mood, headache, bloating and breast pain and tenderness.^[22]
• A significant body of evidence supports the use of SSRIs dosed either continuously or during the luteal phase as an effective first-line treatment for PMDD.^[23] SSRIs are often prescribed at lower doses for PMDD than for major depression.
• John’s wort may offer an alternative for PMDD by influencing serotonin, dopamine, and norepinephrine reuptake. A case study found that supplementation with St. John’s wort improved PMDD symptoms over a five-month followup. However, further research is needed.^[24]
• Vitex agnus castus was found to provide a similar response to treatment with fluoxetine (an SSRI) in women with PMDD. However, fluoxetine was more effective for psychological symptoms, while Vitex helped more with physical symptoms.^[25]
• Changes in calcium-regulating hormones and low vitamin D during the luteal phase have been linked to physical and emotional symptoms of PMDD. This is possibly due to progesterone, which can affect the body’s ability to absorb calcium and regulate vitamin D metabolism. Clinical trials suggest calcium and vitamin D supplementation may be effective in improving symptoms.^[26]

 

Understanding the difference between PMS and PMDD is the first step toward finding effective relief. While PMS is a common experience for many women, PMDD is a severe and debilitating condition that requires proper recognition and treatment.

Tracking symptoms over multiple cycles can clarify which condition you are affected by. Lifestyle changes such as diet, exercise, and targeted supplementation may help manage PMS, while PMDD may require professional support.

If premenstrual symptoms are disrupting your life, seek help from a qualified practitioner.

 

This information is provided for educational purposes only and is not a substitute for professional medical advice. Always seek the guidance of your physician or qualified healthcare provider with any questions you may have regarding your health or a medical condition.

 

References

^[1] Gao, M., Zhang, H., Gao, Z., Cheng, X., Sun, Y., Qiao, M., & Gao, D. (2022). Global and regional prevalence and burden for premenstrual syndrome and premenstrual dysphoric disorder: A study protocol for systematic review and meta-analysis. Medicine, 101(1), e28528. https://doi.org/10.1097/MD.0000000000028528

^[2] Gudipally PR, Sharma GK. Premenstrual Syndrome. [Updated 2023 Jul 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560698/

^[3] Gudipally, P. R., & Sharma, G. K. (2023). Premenstrual Syndrome. In StatPearls. StatPearls Publishing.

^[4] Bhuvaneswari, K., Rabindran, P., & Bharadwaj, B. (2019). Prevalence of premenstrual syndrome and its impact on quality of life among selected college students in Puducherry. The National medical journal of India, 32(1), 17–19. https://doi.org/10.4103/0970-258X.272109

^[5] Hantsoo, L., & Epperson, C. N. (2015). Premenstrual Dysphoric Disorder: Epidemiology and Treatment. Current psychiatry reports, 17(11), 87. https://doi.org/10.1007/s11920-015-0628-3

^[6] Mishra S, Elliott H, Marwaha R. Premenstrual Dysphoric Disorder. [Updated 2023 Feb 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532307/

^[7] Cary, E., & Simpson, P. (2024). Premenstrual disorders and PMDD – a review. Best practice & research. Clinical endocrinology & metabolism, 38(1), 101858. https://doi.org/10.1016/j.beem.2023.101858

^[8] Halbreich, U., Borenstein, J., Pearlstein, T., & Kahn, L. S. (2003). The prevalence, impairment, impact, and burden of premenstrual dysphoric disorder (PMS/PMDD). Psychoneuroendocrinology, 28 Suppl 3, 1–23. https://doi.org/10.1016/s0306-4530(03)00098-2

^[9] Younes, Y., Hallit, S., & Obeid, S. (2021). Premenstrual dysphoric disorder and childhood maltreatment, adulthood stressful life events and depression among Lebanese university students: a structural equation modeling approach. BMC psychiatry, 21(1), 548. https://doi.org/10.1186/s12888-021-03567-7

^[10] Hantsoo, L., & Epperson, C. N. (2015). Premenstrual Dysphoric Disorder: Epidemiology and Treatment. Current psychiatry reports, 17(11), 87. https://doi.org/10.1007/s11920-015-0628-3

^[11] Prasad, D., Wollenhaupt-Aguiar, B., Kidd, K. N., de Azevedo Cardoso, T., & Frey, B. N. (2021). Suicidal Risk in Women with Premenstrual Syndrome and Premenstrual Dysphoric Disorder: A Systematic Review and Meta-Analysis. Journal of women’s health (2002), 30(12), 1693–1707. https://doi.org/10.1089/jwh.2021.0185

^[12] Mishra S, Elliott H, Marwaha R. Premenstrual Dysphoric Disorder. [Updated 2023 Feb 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532307/

^[13] Bertone-Johnson, E. R., Hankinson, S. E., Johnson, S. R., & Manson, J. E. (2008). Cigarette smoking and the development of premenstrual syndrome. American journal of epidemiology, 168(8), 938–945. https://doi.org/10.1093/aje/kwn194

^[14] Itriyeva K. (2022). The effects of obesity on the menstrual cycle. Current problems in pediatric and adolescent health care, 52(8), 101241. https://doi.org/10.1016/j.cppeds.2022.101241

^[15] Bertone-Johnson, E. R., Hankinson, S. E., Willett, W. C., Johnson, S. R., & Manson, J. E. (2010). Adiposity and the development of premenstrual syndrome. Journal of women’s health (2002), 19(11), 1955–1962. https://doi.org/10.1089/jwh.2010.2128

^[16] Itriyeva K. (2022). The effects of obesity on the menstrual cycle. Current problems in pediatric and adolescent health care, 52(8), 101241. https://doi.org/10.1016/j.cppeds.2022.101241

^[17] Daley A. (2009). The role of exercise in the treatment of menstrual disorders: the evidence. The British journal of general practice : the journal of the Royal College of General Practitioners, 59(561), 241–242. https://doi.org/10.3399/bjgp09X420301

^[18] Oboza, P., Ogarek, N., Wójtowicz, M., Rhaiem, T. B., Olszanecka-Glinianowicz, M., & Kocełak, P. (2024). Relationships between Premenstrual Syndrome (PMS) and Diet Composition, Dietary Patterns and Eating Behaviors. Nutrients, 16(12), 1911. https://doi.org/10.3390/nu16121911

^[19] Oboza, P., Ogarek, N., Wójtowicz, M., Rhaiem, T. B., Olszanecka-Glinianowicz, M., & Kocełak, P. (2024). Relationships between Premenstrual Syndrome (PMS) and Diet Composition, Dietary Patterns and Eating Behaviors. Nutrients, 16(12), 1911. https://doi.org/10.3390/nu16121911

^[20] Fathizadeh, N., Ebrahimi, E., Valiani, M., Tavakoli, N., & Yar, M. H. (2010). Evaluating the effect of magnesium and magnesium plus vitamin B6 supplement on the severity of premenstrual syndrome. Iranian journal of nursing and midwifery research, 15(Suppl 1), 401–405.

^[21] Abraham, G. E., & Rumley, R. E. (1987). Role of nutrition in managing the premenstrual tension syndromes. The Journal of reproductive medicine, 32(6), 405–422.

^[22] Berger, D., Schaffner, W., Schrader, E., Meier, B., & Brattström, A. (2000). Efficacy of Vitex agnus castus L. extract Ze 440 in patients with pre-menstrual syndrome (PMS). Archives of gynecology and obstetrics, 264(3), 150–153. https://doi.org/10.1007/s004040000123

^[23] Carlini, S. V., & Deligiannidis, K. M. (2020). Evidence-Based Treatment of Premenstrual Dysphoric Disorder: A Concise Review. The Journal of clinical psychiatry, 81(2), 19ac13071. https://doi.org/10.4088/JCP.19ac13071

^[24] Huang, K. L., & Tsai, S. J. (2003). St. John’s wort (Hypericum perforatum) as a treatment for premenstrual dysphoric disorder: case report. International journal of psychiatry in medicine, 33(3), 295–297. https://doi.org/10.2190/RERY-N6AC-NADC-EHY4

^[25] Atmaca, M., Kumru, S., & Tezcan, E. (2003). Fluoxetine versus Vitex agnus castus extract in the treatment of premenstrual dysphoric disorder. Human psychopharmacology, 18(3), 191–195. https://doi.org/10.1002/hup.470

^[26] Susan Thys-Jacobs, Don McMahon, John P. Bilezikian, Cyclical Changes in Calcium Metabolism across the Menstrual Cycle in Women with Premenstrual Dysphoric Disorder, The Journal of Clinical Endocrinology & Metabolism, Volume 92, Issue 8, 1 August 2007, Pages 2952–2959, https://doi.org/10.1210/jc.2006-2726