Last December, I attended two counselling appointments within six days of one another. The first was an emergency appointment. I hadn’t wanted to go. In fact, I didn’t want to do anything at all. I was suffering from anxiety, panic attacks, crying fits, and no appetite and was struggling with suicidal thoughts. It was one of the worst days of my life.
Fast forward to my second appointment. None of the symptoms I reported having six days earlier were there. I was cracking jokes with my counsellor and complimenting her outfit choice. I started doubting why on earth I was even attending the appointment because I felt great. My counsellor asked: ‘’Did you take any medicine since we last spoke?’’ I hadn’t. ‘’Did your personal circumstances improve in any significant way?’’ They hadn’t. ‘’Did you seek any alternative form of therapy?’’ I hadn’t. ‘’So what had changed?’’ I got my period.
PMS, as I had understood it, was the reason you might feel irritable, emotional, and be in some slight physical pain a couple of days before your period each month. I would treat it by eating chocolate and reaching for my hot water bottle. After all, it is an inconvenience all women experience. It is “normal” to feel this way. It is exactly this trivialization of PMS that led me to suffer through intense bouts of cyclical depression believing they were purely part of my personality or a result of decisions I had made. Unknown to me, I was in fact suffering from Premenstrual Dysphoric Disorder (PMDD), also referred to as severe PMS.
PMDD is characterized by overwhelming feelings of depression, anxiety, panic attacks, and hopelessness, which become severe enough to disrupt one’s ability to function in daily life. These symptoms are believed to stem from a greater sensitivity to regular hormonal changes that occur during the menstrual cycle. Essentially, it means that your mental health fluctuates predictably and intensely from being symptom-free to being unmanageable each month.
A double-blind, randomized, placebo-controlled trial published in the Journal of Psychoneuroendocrinology showed that the SAS scores (measures of problems in life and quality of life) of women with PMDD were the same as those of women with Chronic Major Depression, meaning that a PMDD sufferer and a sufferer of depression often have completely equivalent experiences, the only difference being that PMDD comes and goes, whereas Chronic Major Depression is consistent. This is why many PMDD sufferers at first think that they have depression but are left frustrated and without a diagnosis when they find that all definitions of depression depend on symptoms being consistent for over two weeks.
In 2013, the American Psychiatric Association recognised PMDD as a depressive disorder.
This did not come without controversy. Many believed its inclusion to be pathologizing what was a normal part of a woman’s reproductive life. They claimed PMDD would lead women to think that they were mentally ill and could result in mistrust of their capabilities. Jayashri Kulkarni, a professor of psychiatry, suggests that the aversion to recognising the connection between the menstrual cycle and mental health has a lot to do with the fact that, in the past, women have had to cope with dismissive views about their anger, depression, or capabilities as a result of sexism and with condescendingly being labelled “irrational” during “that time of the month.”
However, as the symptoms of PMDD and depression have been shown to be equivalent, it seems blatantly inconsistent for one to be given the legitimacy of a diagnosis and not the other. It should be possible for women to reclaim their biology without fear of being labelled irrational or incapable. A review on PMDD in the Journal of Clinical Psychiatry noted that, historically, women have been under-treated and made to believe their problems were all in their heads. They argued that formal diagnosis of PMDD would encourage greater research and investment and, most importantly, would lead to greater access to treatment for sufferers.
Ironically, the only time I felt dismissed was by a doctor who tried to empower me. She believed that women were often criticized for being emotional and suggested my desire for a diagnosis and treatment was reflective of the fact that others were simply uncomfortable with me when I was not my usual happy self. Her point represented the common argument that we shouldn’t “medicalize” a normal part of female physiology. This argument is completely valid for over 90% of women, but as with anything, there comes a point where the variation isn’t normal anymore. Suicidal ideation, panic attacks, and bouts of depression signal something a lot more serious than what my doctor wanted to “empower” me to embrace as part of the female experience.
Even though I was disheartened by her attitude, I remained certain that there was a better explanation for my symptoms. It was shortly after that I learned of PMDD. Thankfully, I had been tracking my period over a year, so it was relatively easy for me to make the connection between my changes in mood and my cycle. I spent several days matching up the dates of my cycle to any uncharacteristic or depressive episodes I could remember having. Suddenly, I had an answer for what I previously thought was inexplicable. I now understood why I felt sad at times where I should have been happy, why I could think of so many occasions in which I wasn’t behaving like myself. It was almost comical, the degree to which PMDD could predict when I would fall out with my friends and family, or when I would get stressed out over things that typically wouldn’t faze me. Everything began to match up perfectly. Eager to get a second opinion, I took this information to a specialised women’s health doctor. I began my treatment for PMDD that day.
Things felt bittersweet. I felt an immense sense of relief to finally understand what was causing these changes to my mental health. However, this was coupled with disappointment as I looked back at the many times things could have been better had I known earlier. Living undiagnosed put a huge amount of strain both on my own mental well-being and that of those closest to me.
Two things in particular made it difficult for me to notice any relationship between my menstrual cycle and my mental health. Firstly, I was of the assumption that in order to be related to PMS, I would have to have my period within a few days of experiencing any fluctuations in my mood. This was a complete misconception. Symptoms of PMDD are present throughout the luteal phase of the cycle, which is the time between ovulation and menstruation. Therefore, symptoms can be felt anytime from 6 days up to 2 weeks before you actually have your period.
The second was the seemingly unpredictable and short-lived changes in my mood, leading me to believe that their source was external to me, a result of my personal circumstances and relationships. However, it is not necessary that you feel constantly mentally unwell during the luteal phase of your cycle for it to be PMDD. It is possible to still have good days during this time. In fact, a common pattern for women with PMDD is to experience a few bad days around ovulation, followed by a settling of symptoms, which then flare up again closer to when their period is due.
Although knowledge of PMDD has not brought an end to my struggle with it, management of my symptoms has become significantly easier. If you believe there could be link between deteriorations in your mental health and your menstrual cycle, seek a medical professional’s advice, whether that be in the form of counselling or a doctor’s appointment. However, as there is no formal test that can be carried out for a PMDD diagnosis, it is entirely dependent on the information provided by the patient. Therefore, it is advised that you continuously track both your periods and changes in mood, information which you should then present to your doctor. Apps such as Clue are specifically designed to track the menstrual cycle and allow you to track a wide range of symptoms from cramps to tearfulness to your level of anxiety.
I cannot stress enough how important it was to let others know I was struggling. Telling my friends was arguably the hardest thing for me to do. I felt that once I admitted to someone what I was going through, I was admitting defeat. Looking back, it was one of the bravest things I have ever done. A more unexpected source of help came online. I managed to connect with support groups filled with women from all over the world having the same experiences. These complete strangers have ended up being one of the greatest sources of support for me. The Gia Allemand Foundation is a nonprofit organization that provides both education and advice to women with PMDD.
There should be absolutely no shame in receiving treatment and getting the help required. Nobody should have to resign their mental health difficulties to simply being part of who they are. Plenty of treatment options are available that can help greatly improve the quality of life of sufferers. Importantly, whether it is PMDD or common, moderate PMS, and whether it’s a formal diagnosis or simply a better understanding of what’s going on, knowing about how hormone fluctuations can impact our wellbeing is always empowering. More accurate knowledge is always better than less.
PMDD is believed to affect 3-8% of women of a reproductive age, and yet I only learned of it through my friend who coincidentally happened to be suffering from it as well. Given both its severity and prevalence, awareness of PMDD should be far greater than it is. We should be informed of how important it is to track our periods. We should be made aware of the influence our menstrual cycles can have on our mental health. We should stop trivializing PMS as just “that time of the month.” If we don’t, we run the risk of dismissing or delegitimizing the experiences of women who are suffering from serious mental health difficulties. Spreading awareness of PMDD could lead to such a positive change in someone’s life. In my case, struggling as I was with suicidal thoughts, the information was potentially life-saving.
If you urgently require help in relation to the issues raised, call Samaritans on 116 123
For further help contact –
TCD Counselling: (01) 8961407
TCD Health Centre: (01) 8961591
The Well Woman Centre: (01) 872 8051