How we think and feel, at core, is based on our neurotransmitters, the biological chemicals that our brains use to transmit electrochemical signals. These can be affected by life circumstances, neurological conditions, medications, illness and our hormones. Important to both PMT (pre-menstrual tension) and PMDD (Pre-Menstrual Dysphoric Disorder) are how sex hormones affect our neurotransmitters. This affects our thinking, mood and how we feel about ourselves.

People with functioning ovaries experience a spectrum of PMT, from minimal effects to PMDD. If you find that your life becomes very difficult during your PMT, then you may be experiencing PMDD.

General Practitioner Doctors are not Specialists

Most GPs, unless they have done extra study, will have only a rudimentary knowledge about the reproductive system. Surveys have shown that most GPs downplay any abdominal related pain or discomfort in people who present female or are AFAB (Assigned Female at Birth [on their birth certificate]).

If your GP is not taking your experience seriously, then ask for a referral to a gynaecologist. If your GP doesn’t do so, see a new GP.

Understanding PMDD

What is PMDD?

This article is a snapshot of PMDD (Pre-Menstrual Dysphoric Disorder). For all of the nitty gritty details, go to our main PMDD page.

PMDD is a somewhat controversial diagnosis. It is well known that most women experience PMT (Pre-Menstrual Tension, or PMS for Pre-Menstrual Stress) during the week prior to menses (blood flow). Some women continue PMT symptoms (cognitive and mood drop) for a few days into their menstrual flow.

History of the PMDD Diagnosis

Doctors would often notice the significant dysregulation in some menstruating teens and prescribe contraceptive medication to help regulate the sex hormones Oestrogen and Progesterone to minimise the strength of the dysregulation. Although doctors did not have a formal name for this prior to 2013, they frequently recognised the problem and had a treatment plan.

PMDD is a recent controversial addition to the DSM 5 (2013), and the ICD 11 (2022), with many patients and psychiatrists advocating FOR the addition, while psychologists and some feminist scholars campaigning against its addition. The fear was that the condition would be over diagnosed to invalidate women’s health and silence women or that Big Pharma was just out to make more money selling drugs.

I think the critics are wrong. Enough of my clients have a level of reaction to the time of their menstrual cycle that clearly is an order of magnitude more severe than what is described by PMT. PMDD helps to differentiate between the two experiences and helps us to consider therapeutic strategies to address PMDD. Most medical therapies are already pre-existing medications that are already available, and often already used when someone recognises the condition (see the GP’s above treating dysregulated hormonal teens). Having an official name for this symptom / treatment pairing makes it easier for doctors to recognise that this is what is happening and do something about it.

The PMDD, ADHD and Bipolar Link

ADHD and PMDD

ADHD is a condition where your brain either does not make and deliver enough Dopamine to your pre-frontal cortex (the bit of brain just behind your forehead), and or does not well retain the Dopamine so that you can use it. ADHD medications either increase the production of Dopamine by a few percent, or slow down how quickly Dopamine is moved on to the next part of the equation – making Noradrenaline for your Amygdala (middle brain in the limbic system). We have an extensive section on ADHD here to really understand this.

Remember when we said above that the amount of Dopamine that you make is directly proportional to your blood Oestradiol? During PMT, as seen on the graph, your Oestradiol is at its lowest – and so is Dopamine production. With low Dopamine, you struggle to make enough Noradrenaline – which makes it hard for your middle brain to tell you when you are safe, causing Anxiety and or Aggression [there are other forms of ADHD]. With low Dopamine making it hard to think rationally, and your Noradrenaline being out of the Goldilocks Zone (too little or too much, rather than “good”), you are very likely to make bad decisions because.

The general background level of ADHD in people is around 5 to 10%. If we select a group due to a particular demographic, such as Cis Women, we should find that 5 to 10% of them have ADHD.

In a study of 209 participants diagnosed with PMDD, 143 (68.4%) participants took medication for ADHD. That is 68.4% of the participants in this particular study [Link to the Study].

While ADHD is not just low Oestradiol, low Oestradiol can exacerbate ADHD.

If you want to understand the neurology behind why the two are strongly connected, read this next section. Below it, we continue on to talk about Bipolar.

Bipolar and PMDD

Bipolar Affective Disorder is supposed to have no biological sex distinction – that is, it should be just as common with cis males as it is with cis females [cis means the person identifies as the same gender as what their biology at birth suggests]. Despite this expectation, we find that around 80% of people diagnosed with Bipolar Affective Disorder are female.

One of the forms of ADHD is that Dopamine is too quickly converted to Noradrenaline, leaving the person feeling agitated and hypervigilant due to this excess Noradrenaline (the too much in the Goldilocks Zone), and with low cognitive function due to the low Dopamine.

For these ADHDers, in the peak Oestradiol phase of their menstrual cycle, they may be synthesising normally good quantity of Dopamine, but they are quick converting too much of the Dopamine to Noradrenaline, flooding the Amygdala. This leads to cognitive confusion and hyperactivity. The high Oestrogen and Progesterone can trigger a euphoric feeling that channels the feeling from the Amygdala to over the top behaviours, extreme happiness, and thus odd behaviours.

Again, for these ADHDers, during the trough PMT phase, they will make only a little Dopamine, which can’t be converted easily into Noradrenaline, which leads to low production of Adrenaline. This leaves you feeling cognitively confused, sad, depressed and absent of any energy to do any tasks.

As the Menstrual Cycle is … a cycle, this then leads to high and low cycling, which can look like Bipolar.

Just a few quick things on Bipolar and PMDD

• Not all Bipolar is actually PMDD / ADHD
  • A way to test this is if a neuronal Noradrenaline suppressant like Clonidine drops your manic phase, then this is PMDD
• Some people have naturally low Oestrogen, which means that if you have this form of ADHD, you can have several depressed cycles, occasional “normal” and infrequent mania.
  • A way to test this is to get two blood tests for Oestradiol.
  • The first is when you first start menses (day 1)
    • that should be your lowest, and ideally is should be 300+ – some people are fine with 200, but that isn’t common.
  • The second is around day 12 +/- 2 days, when you feel your best around a week after menses finishes
    • that should be 1000+ pg/mL
    • If you are below 600 pg/mL, your Oestradiol is likely low, leading to lots of depression
    • If you experience mania, you can get a third blood test during your manic phase (get a helper to remind and assist you). If you are 2000+ pg/mL, then this may be why you are manic / hyperactive
  • If your Oestradiol is out, get a referral to a sex hormone endocrinologist
    • It is also worth checking your thyroid function, as this can cause all of this (rare, but it happens)
    • Oestrogen receptor modulators exist (like Tamoxifen), which can tamp down the Oestrogen and thus Oestradiol peaks. Talk to your endocrinologist about what is best for you.

This is Not Medical Advice, it is guidance

Not all menstrual cycles are regular, 28 days long, or have the same level of expected hormones. This information is a guide for people who are experiencing symptoms that strongly affect their lives and informs you of what may be going on, and thus gives you additional information to discuss with your specialist for diagnostic and treatment strategies.

If you want to talk to me directly about the contents here and your life, you can book an appointment with us.

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