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Premenstrual Dysphoric Disorder

Dr. Vered Bar, Hava Center, Director of the Fertility Psychiatry Unit, Sheba Medical Center
4 February 2026

Premenstrual syndrome (PMS) is a common condition that causes physical and emotional symptoms before menstruation, such as mood swings, fatigue, and irritability. Premenstrual dysphoric disorder (PMDD) is a more severe condition, affecting about 7% of women. The disorder is defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as a mental disorder that causes significant functional impairment or extreme distress.

Diagnosis of premenstrual dysphoric disorder

To be diagnosed with premenstrual dysphoric disorder, there must be significant functional impairment or distress, along with at least 5 characteristic symptoms (e.g., irritability, low mood, fatigue, changes in sleep or appetite). Symptoms should begin about a week before the onset of menstruation and last a few days after, for most cycles over the past year. Keeping a symptom diary can help with the diagnosis.

Treating and coping with premenstrual dysphoric disorder

Treatment includes dietary and behavioral recommendations, such as reducing caffeine and an adapted diet, along with lifestyle changes: Adequate sleep, exercise, relaxation, and more. Drug treatment with antidepressants from the SSRI family can provide relief, and taking birth control pills (sometimes it is recommended to take them continuously). In any case of taking medication or pills, a physician should be consulted. Psychotherapy (CBT) and open communication with close people can also help.

For those who already struggle with depression, anxiety, or another mental disorder, the days before your period can make your feelings worse. It is important to know that there are ways to adjust your regular treatment to make it easier during these times as well.

Women of reproductive age undergo cyclical hormonal changes. The first phase is the follicular phase, where there is an increase in hormone levels that leads to ovulation. After ovulation, the luteal phase begins (the yellow body phase) and if fertilization does not occur – hormone levels decrease until the onset of menstrual bleeding.

Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) appear in the luteal phase, and pass with the onset of menstruation or shortly after. In addition, some women who deal with mental disorders may experience a worsening during the menstrual phase.

One of the goals of this article is to validate what you are feeling. Even if sometimes you are not believed to have "period pains", or are mockingly told "she is on her period", these are real pains that disrupt life and affect your functioning. Many women walk around with the feeling that they do not understand what is happening to them. Just understanding that it is related to the hormonal changes of the menstrual cycle can be very comforting.

The difference between premenstrual syndrome and premenstrual dysphoric disorder

Premenstrual syndrome (PMS) is a condition that many women experience, and it is manifested by a series of physical and mental symptoms that appear in the days before menstruation. During these days, there may be mood swings, fatigue, irritability, tension, the blues, changes in appetite and breast tenderness. The phenomenon can occur in varying degrees of intensity, but in about 7% of women it is the appearance of a large number of symptoms, very severe in intensity, to the point of significant impairment of social, occupational and personal functioning.

In these cases, in which there is significant impairment in functioning, it may be premenstrual dysphoric disorder (PMDD). While premenstrual syndrome is considered a common phenomenon, premenstrual dysphoric disorder is recognized as a distinct mental disorder that requires medical treatment.

Unlike other disorders, such as postpartum depression or postpartum psychosis, which are themselves considered characteristics of existing disorders, premenstrual dysphoric disorder is the only one in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) that is related to hormonal changes. That is, it is a diagnosis that stands on its own and gives validity and recognition that it is a unique disorder.

Diagnosing premenstrual dysphoric disorder

The main condition for diagnosing premenstrual dysphoric disorder is significant distress or impairment in functioning due to symptoms related to mood changes. To diagnose the disorder, at least five symptoms from a specific list in the DSM-5 are required. Symptoms should begin within a week before the onset of menstruation and pass within a few days after it begins. In addition, symptoms should occur in most menstrual cycles over the past year. It is useful to keep a detailed record of symptoms for two cycles, including their impact on daily functioning. Symptoms include:

  • Irritability, anger, or oversensitivity
  • Depressed or anxious mood
  • Fatigue or lack of energy
  • Changes in appetite, including cravings for sweets and carbohydrates
  • Difficulty sleeping or sleeping too much

Treating and coping with premenstrual dysphoric disorder

There are several ways to reduce symptoms and their severity:

Getting enough sleep, practicing relaxation techniques such as mindfulness, and being physically active. If you do not exercise regularly, try to find a type of exercise that you enjoy and can stick with.

Reducing caffeine and alcohol intake, avoiding certain foods, and following specific diets that are tailored to the different phases of the menstrual cycle.

Taking SSRI medications only on days when symptoms appear. When treating depression, these medications are expected to show results within a few weeks, but in treating premenstrual dysphoric disorder, the response is faster, and without the appearance of abrupt withdrawal symptoms. If this practice does not help, it is recommended to take the medication regularly throughout the month.

Note: In any case of taking medications or pills, it is important that you consult your physician and undergo a comprehensive examination before starting treatment. A particular medication that helped your friend may not necessarily help you, and it is important that the medication is tailored to you. In addition, even if a particular medication did not help you, another medication may prove to be helpful.

Cognitive behavioral therapy may help some women or at least make it easier to cope with the symptoms of the disorder.

It is important that you maintain open communication with those close to you, such as your spouse, family, and close friends. They can help you and support you emotionally. Try to relieve yourself of unnecessary loads during challenging times and ensure that you have time to rest and a stable routine.

Important to know

Important to know

PMS can appear for the first time after childbirth or change following it – getting worse or actually getting better. In addition, women who suffered from PMS before childbirth are at higher risk of postpartum depression.

Women who have existing mental disorders

Women who are diagnosed with depression, anxiety, bipolar disorder, schizophrenia and OCD, who are stabilized with medication and experience worsening symptoms in the days before their period – will be defined as suffering from premenstrual disorder. It is advisable to consult with the treating physician about the possibility of adjusting the treatment in the days before your period. In any case, only professional physicians whose field of expertise is this determine a change in dosage; do not change the dosage on your own.

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