Venita Currie (Host): Welcome to another episode of Flourish, the podcast where we delve into the latest health and healing advice from trusted experts from PRISMA Health. Today, we're joined by Dr. Neha Hudepohl, Director of the Women's Mental Health Program and the Department of Psychiatry in the upstate of South Carolina.

We're going to talk about the often severe and debilitating symptoms of premenstrual dysphoric disorder, or PMDD which can cause physical and emotional discomfort. But don't worry, we're going to talk about options to help you find some relief. Welcome to the show, Dr. Hudepohl.

Neha Hudepohl, MD: Thank you. Thanks for having me.

Host: Can you first tell us what premenstrual dysphoric disorder is and how is it different from PMS?

Neha Hudepohl, MD: Absolutely. So premenstrual dysphoric disorder or PMDD, as we like to call it, is a psychiatric condition that affects women in the premenstrual days prior to getting their menstruation. So what it can be characterized by is pretty significant symptoms of depression or mood lability. What I mean by that, is ups and downs in mood. People can feel numb, detached. They can feel anxious, feel overwhelmed by things or even have a sensation of feeling out of control. They can often have changes in concentration and appetite and sleep. Sometimes those thoughts can be really severe to where people actually start to have self-deprecating thoughts or even thoughts of wanting to harm themselves.

And all of that happens in the context of other physical symptoms that we often attribute to our menstrual cycles, things like abdominal bloating, appetite changes, cravings for food, joint pains and muscle tenderness, headaches and other things like that. So what's unique about this illness, unlike depression or other illnesses, is that it specifically happens in the week or two weeks prior to getting your period.

And then once you get your period or your menstrual cycle, symptoms start to get better and they completely resolve within about a week of getting your menstrual cycle. So it is very tied to this cyclical pattern of hormones that women experience.

Host: I wanted to just jump in and say, it sounds like this could really impact someone's life too.

Neha Hudepohl, MD: Absolutely. So actually one of the criteria for this condition is that it has to have what we call clinically significant distress or impairment in functioning. So it has to be affecting your job performance or your school performance or your family life or your interpersonal relationships with other people in order to meet the criteria for this diagnosis.

And that's really what makes it different from PMS, which a lot of people talk about and is a very common condition. I think the majority of women experience some forms of PMS or premenstrual syndrome symptoms. And those can also include some mood changes, some anxiety, sleeplessness, food cravings, physical changes, like breast tenderness and appetite changes. But what's different about them is the severity in which people experience them.

Host: So how do you diagnose this? What are some things that patients who fear they may have this, what are the things I'll have to go through to confirm if they have it or not? 

Neha Hudepohl, MD: The majority of the diagnosis is made based on a clinical interview. So if a patient or a person feels that they might have this condition, the first step is really to spend some time tracking their mood symptoms and their other physical symptoms that might happen around their periods, because that's going to be the most important thing is seeing that this is a pattern across multiple cycles. So this is a condition that would happen with roughly every menstrual cycle, it wouldn't pick and choose or be here and there, it would be there all the time. So if they're seeing the, a pattern of that nature, then the next step would be to talk to your healthcare provider about that pattern. 

Most patients are going to require a thorough medical, gynecologic, and psychiatric history to be able to confirm the diagnosis. And the majority of times what we would ask a person to complete is a mood chart over their menstrual cycles, over a period of potentially several months. So that they're tracking daily mood symptoms and physical symptoms, and there are some standardized ways to do this.

There are some standardized forms for this, so people don't have to create this themselves. We have the tools to make this happen. But over time with that information, we're able to see these patterns unfold. And that's really when a diagnosis can be made.

Host: And do you know if there's any specific risk factors or certain women who are more likely to have this problem than others?

Neha Hudepohl, MD: Absolutely. So, unfortunately, PMDD is not a very well studied condition, so we don't have a lot of information about it, but what we do know, at least in the United States, is that it seems to be more common in white women compared to other races and ethnicities, and it does seem to be more common in people who have risk factors for obesity or other types of metabolic conditions that would be at risk for obesity. So those are some conditions that we know can be associated. We also know probably more than anything that premenstrual dysphoric disorder is probably a genetic illness. So it is heritable.

It happens in families. And so there are many studies that see higher prevalence rates in siblings and in twins and things like that. So we know that there's definitely a genetic component to this condition. And there are likely some other risk factors, things like stress in your life, trauma history, things of that nature that we also think contribute. But those are really the primary things that we understand at this point in time. 

Host: So how can women find relief? What kind of therapies or medications or daily changes to their life do they need to make?

Neha Hudepohl, MD: Yeah, that's a great question. So I think the most important first step is when you identify your symptoms, to talk to your healthcare provider about that and work towards making a diagnosis. This, as you mentioned, can be a debilitating condition, but it is also a treatable condition, and that is really good news.

So once a diagnosis is made, there are a variety of things that can be done. First and foremost is good self-care. That's the most important thing. This is a predictable illness. We know when this is going to happen. We know that we can time this to the onset of someone's menstrual cycle. So making sure in those times, that people are taking good care of themselves, that they're getting adequate sleep and nutrition and exercise, that they have good support systems around them to help them through those tough periods is step one.

Step two is to talk to your healthcare provider about medication options. There are a variety of things that have been studied to treat this condition. First and foremost, what we typically use are antidepressant medications, and that might seem a little odd sometimes because this isn't depression that exists chronically, but those same medications seem to affect some of the underlying biologic conditions that we think drive PMDD. So sometimes using an antidepressant, even just in those weeks prior to the period, or just using it continuously, can be very effective to lower the risk or mitigate these symptoms.

The other option sometimes can be oral contraception or birth control pills which are often used to help regulate someone's hormonal cycles so that they're not having these fluctuations as significantly as they might without the use of oral contraception. But of course, these are personalized decisions that have to be taken into the context of someone's personal medical history and psychiatric history.

One of the key drivers, we think, of the cause of PMDD are these hormonal changes in a person's brain. And we think that there are some women that are susceptible to the changing concentrations of our reproductive hormones, things like estrogen and progesterone, that puts you at risk for having this. And so sometimes really targeting and attenuating those changes is what we can do to help these symptoms.

There have been some other things studied, some other complementary and alternative treatments, particularly vitamin supplementations, but unfortunately we don't have a lot of evidence to back them up. But there is emerging information about things like calcium and vitamin D, vitamin E and some other things, that you can talk to your healthcare provider about in more detail.

Host: Well, for those who are watching our interview today, what can they do if they know of a loved one, a sister, a wife, a colleague at work, how can we be supportive of someone who's dealing with this health problem? 

Neha Hudepohl, MD: I think the first thing to acknowledge is that PMS and PMDD are tough things to talk about. I think as a society, we often label women as hormonal or they're acting sort of crazy around their periods. And I think that kind of language and that stigma can really make it difficult for people to seek care and to be willing to talk about these things openly with their health care providers.

So I think the first step for anyone is to de-stigmatize those things and for us to move towards language that's more accepting and more reassuring and more compassionate, because it isn't just about being hormonal. This is definitely a brain-related change, and these symptoms are really disabling for some people, and so I think that if you have a loved one or a friend or a family member or colleague who you are concerned about, the first step is just to compassionately, express your concerns and ask them if they're okay. Make sure that they know that you're there to support them and not to make them feel judged.

I think the next step would be to help them get to their health care provider and feel comfortable discussing these symptoms. Not a lot of people realize that this is an illness. I think a lot of people attribute this to PMS. Or as I mentioned before, sort of being quote unquote hormonal. But this is really a diagnosed condition. It's a medical condition. And so I think really being able to normalize and validate that, so people are feeling more comfortable talking to their healthcare providers about these conditions, is the next step.

And then finally, knowing that we can sort of predict when these symptoms happen, being able to provide the additional support or perhaps the additional resources so those people can engage in some self-care during these times. So if it's, you know, a loved one or a family member, maybe let them take a nap or have them have a little alone time or a little extra support or a little extra TLC during those weeks where they're feeling more symptomatic. I think that can go a long way.

Host: All wonderful and great advice. Thank you so much. I hope our viewers who have or may have this problem, feel empowered to protect their physical and mental health. Thank you so much for joining us today. This has been an episode of Flourish. For more information, head over to prismahealth.org/flourish.

This is Flourish, a podcast brought to you by PRISMA Health.