Not It's Just in Your Head: PMDD, Hormone Literacy, and Finding Real Relief
- Amanda Woolston, LCSW, CCTP, CT
- 6 days ago
- 9 min read
When Erin’s period came this month, she knew the drill: the crash, the rage, the sobbing that came out of nowhere. She’d tried everything—three different birth controls, two SSRIs, therapy, supplements, yoga. Her gynecologist had once told her, “You just have bad PMS,” while another shrugged, “This isn’t really my specialty.” The psychiatrist she saw next said her mood swings “didn’t sound hormonal.”
Every cycle felt like a betrayal. A week or two of stability, followed by the slow unraveling—like watching herself through glass, powerless to stop the distortion.
When Erin finally asked about hormone replacement, her doctor frowned. “That’s more for menopause,” she said. “You’re too young.” Erin was thirty-eight.
Later that night, Erin read medical articles on her phone until 2 a.m., realizing what no one had told her: hormones treatment can actually be considered PMDD who reacted poorly to SSRIs and birth control. She felt furious that no one had mentioned it. Furious that she’d been left to put the pieces together herself. But for the first time in months, she felt like she had a plan.
"Amanda, it's not the flu or food poisoning because it wasn't food poisoning or the flu last month, the month before, or any of the other months before that," my best friend replied to my monthly why-do-I-feel-like-I-am-dying? text. "You know you ask me what the symptoms are for food poisoning like once a month. It's never food poisoning."
She was right. For years I had fallen into an increasingly bad cycle of feeling low for 1-2 weeks (2-3 days of which were horrendous), every single month. Yet I would rebound, forget about it, and find myself bewildered at my "failure" to stay feeling well yet again the very next month. Exhaustion. Brain fog. Upset stomach. Headaches. Depression. Whole-body-anxiety. It couldn't be PMDD, I told myself. I was already on the highest dose of an SSRI - what more was there to do? It wasn't until I started perimenopause, where those 2-3 horrendous days started lasting for at least 7, that I became desperate to do something.
If you’ve tried birth control, antidepressants, or just pushed through the monthly spiral of PMDD symptoms only to be told ‘it’s normal,’ this post is for you. Whether you’re a teenager just trying to understand your cycle, a midlife woman feeling hijacked by hormones, or someone in perimenopause wondering why you feel like you’re losing yourself... I want you to know that you can seek medical care and find relief. Knowing how to advocate for yourself is key.
What is PMDD?
Premenstrual Dysphoric Disorder (PMDD) is both a neuroendocrine disorder and a depressive disorder. It is a biological sensitivity to normal hormone changes in the body that causes uncomfortable physical and mental health symptoms that alter your functioning or quality of life. Typically, these symptoms begin during the luteal phase of the menstrual cycle and end once menstruation starts. In some cases, the symptoms can last throughout menstruation. In rarer cases, the hormone shift during the follicular phase can also trigger mild symptoms.
Similar Premenstrual Conditions
These conditions are similar to PMDD. Although much of the advice throughout this post can apply or be useful for these conditions, this post will focus on PMDD.
Premenstrual Syndrome (PMS) is an uncomfortable but normal response to hormonal shifts in the body. While it can cause mood changes, fatigue, bloating, or irritability, it is not experienced by everyone who menstruates, and it doesn’t cause significant functional impairment. Because of this, PMS is not considered a disease or mental health disorder, but rather a common physiological response to the hormonal changes of the luteal phase. Premenstrual Exacerbation (PME) is a clinical phenomenon where someone has a pre-existing mental health condition (such as GAD, MDD, ADHD, Borderline Personality Disorder, or Bipolar Disorder), and experiences a worsening of symptoms in response to normal hormonal fluctuations — especially during the luteal phase. The key difference from PMDD is that in PME, the underlying condition is present throughout the cycle, but symptoms intensify premenstrually.
Perimenopause is the transitional phase leading up to menopause, during which hormone levels (especially estrogen and progesterone) become erratic and unpredictable.
Other Conditions with PMDD-like or PME-like Symptom Patterns
You may experience PMDD-like or PME-like emotional symptoms in response to abnormal or erratic hormone levels caused by other medical conditions. These include (but are not limited to):
Polycystic Ovary Syndrome (PCOS)
Postpartum hormone shifts
Thyroid dysfunction (hypo- or hyperthyroidism)
Adrenal disorders or chronic stress states
Endometriosis or adenomyosis
Peripuberty (adolescence)
Gender-Affirming Hormone Therapy (GAHT) if you are already hormonally sensitive
In these cases, the nervous system may be highly sensitive to hormonal instability, even when it’s outside of a typical menstrual cycle. The symptoms may not meet diagnostic criteria for PMDD or PME, but they often respond to similar tracking, stabilization, and care strategies.
Getting Diagnosed with PMDD
Getting diagnosed requires at least two months of symptom tracking that demonstrates the minimum symptom criteria. To meet the criteria, you need:
At least one of these symptoms:
Mood swings
Irritability/anger
Depression/hopelessness
Anxiety/tension
Additional symptoms:
Decreased interest in usual activities
Difficulty concentrating
Fatigue
Appetite changes
Sleep issues
Feeling out of control or overwhelmed
Physical symptoms (breast tenderness, bloating, joint/muscle pain)
Your symptoms must interfere with at least one area of life: work, school, parenting, socialization, self-concept, self-care, or relationships. PMDD needs to be the best explanation for your symptoms. Your symptoms need to occur in a cycle rather than be constant. If your symptoms are constant but are significantly worse in a way that seems tied to your menstrual cycle, PMDD may still be part of the picture or PME (Premenstrual Exacerbation) may be the culprit. This self-screening tool may be helpful in understanding if you are experiencing PME vs. PMDD.
Tracking tools to aid diagnosis include:
Apps:
Printable Chart:
Common Roadblocks in the Medical System
Systemic issues within the medical system can make getting proper diagnosis and treatment frustrating and difficult. These include:
Medical gaslighting — "It’s just stress." "Everyone gets moody." "You're overreacting."
Lack of empathy — e.g. "Your hormones aren't abnormal and you need to get used to handling the sensitivity on your own rather than being 'dependent' on medication."
Over-pathologizing or under-treating.
Offering SSRIs or birth control without understanding the hormonal driver.
Failing to match the treatment type to the symptoms bothering you most.
Lack of provider knowledge — Especially around hormone-sensitivity or perimenopausal PMDD variants.
Bias — Focus on fertility or contraception over mental health and quality of life.
Common Treatments (Why they Help and Sometimes Might not Help)
Many people with PMDD or hormone-sensitive mood symptoms are first offered SSRIs or hormonal birth control. These can be helpful for some. For others, they fall short or even backfire, especially when the root issue is sensitivity to hormonal fluctuations, not a classic mood disorder or hormonal deficiency.
SSRIs (Selective Serotonin Reuptake Inhibitors)
Examples: fluoxetine, sertraline, escitalopram
How they can help:
Reduce mood symptoms like anxiety, rage, or depression
Work relatively quickly when taken only in the luteal phase ("intermittent dosing")
Effective for about 60% of people with PMDD (per clinical studies)
Why they might not help:
They don’t address the hormonal trigger—just the mood symptoms
May not prevent the cycle of monthly mood crashes
Can cause side effects (emotional blunting, GI symptoms, sexual dysfunction)
Less effective for those whose symptoms are triggered by hormone withdrawal or fluctuation, especially in perimenopause
Bottom line: SSRIs can reduce the emotional response, but don’t stop the hormonal rollercoaster driving it.
Hormonal Birth Control (Combined Oral Contraceptives – COCs)
Examples: Yaz, Junel, Lo Loestrin, generics
How they can help:
Suppress ovulation and flatten hormonal fluctuations
May help you by creating a steady hormone environment
Certain formulations (like Yaz) are FDA-approved for PMDD
Why they might not help (or can worsen symptoms):
Most contain synthetic progestins, which can worsen mood in progesterone-sensitive individuals
If you react negatively to hormone withdrawal during the pill-free week
May cause or worsen anxiety, depression, or emotional dysregulation in sensitive users
Effectiveness varies dramatically by individual
Hormonal IUDs
Examples: Mirena, Kyleena
Why they’re sometimes offered:
Provide long-term contraception
Thought to act mostly locally in the uterus
Why they may worsen PMDD or mood symptoms:
Release levonorgestrel, a potent progestin with systemic effects
Can trigger or worsen depression, anxiety, or irritability in sensitive individuals
Do not reliably suppress ovulation, so hormonal fluctuations often continue
Bottom Line: IUDs are often mistakenly recommended for PMDD, but can worsen symptoms in those sensitive to synthetic progestins or ovulatory fluctuations.
The Case for HRT or Hormone Suppression
HRT (Hormone Replacement Therapy) in perimenopause is often overlooked in favor of antidepressants or birth control even though hormone instability is the core driver.
Progesterone sensitivity: Micronized progesterone (bioidentical, not synthetic progestin) can sometimes stabilize mood, but in some, it worsens it.
Estrogen dominance or fluctuations (common in perimenopause) can drive PMDD-like symptoms.
Estrogen patch + cyclical or continuous progesterone may offer more stabilization than OCPs or IUDs, especially if tailored.
Self-Advocacy Roadmap
What to Ask Providers
“Could my symptoms be PMDD or hormone-sensitivity?”
“Is there a hormonal suppression approach (like GnRH agonists, HRT, or continuous BC) we could try?”
“Can we use symptom tracking alongside hormone testing (e.g., estradiol, progesterone across the cycle)?”
“Would you consider a referral to a reproductive psychiatrist or endocrinologist?”
What Kind of Providers to Look For
Reproductive psychiatrists (ideal for PMDD)
Gyns familiar with perimenopause or who offer HRT beyond fertility/contraception
NAMS-certified menopause practitioners (for midlife)
Endocrinologists (hormone mapping)
Integrative or functional medicine (with caution – vet for evidence-based practice)
When to Seek a Second Opinion:
If you’re told “you’re too young for perimenopause” (many start in their 30s!)
If you're told “the IUD has no systemic effects”
If providers dismiss mood symptoms as “just stress” or offer only SSRIs with no hormone discussion
How Therapy can Help
PMDD is biologically driven, but that doesn’t mean therapy isn’t useful. In fact, for many people, therapy becomes essential. Although therapy cannot “fix” the symptoms directly, it can help to reduce their impact and help you live with more stability and self-trust.
Symptom Tracking and Diagnostic Clarity
Helping you track symptoms daily, identify cyclical patterns, and distinguish hormonal triggers from baseline mood states
Using structured tracking tools (e.g., DRSP) and integrate insights into clinical conversations with your medical providers
Collaborating with you to spot hormonal vs. non-hormonal patterns, especially when perimenopause or irregular cycles complicate the picture
Differential Diagnosis and Comorbidity
Helping differentiate PMDD from other mental health conditions like:
Major depressive disorder
Generalized anxiety disorder
Borderline personality disorder (which is often misdiagnosed when PMDD is the issue)
ADHD or PTSD (which can interact with PMDD)
Cyclical mood disorders (e.g. Bipolar)
Clarifying whether symptoms are cyclical (PMDD) or constant with premenstrual worsening (PME).
Identifing overlapping or comorbid conditions (e.g., OCD, trauma-related disorders, disordered eating, personality disorders, neurodivergence) that may be contributing to distress
Cognitive and Emotional Tools
Identifying PMDD-related thought patterns (e.g., intrusive thoughts, catastrophic thinking)
Learning self-compassion techniques to reduce guilt or shame during flare-ups
Practicing distress tolerance and grounding skills for intense mood spikes
Navigating Medical Trauma & Gaslighting
Processing past experiences of not being believed
Reclaiming trust in your own body and intuition
Practicing advocacy language for future appointments
Planning Around the Cycle
Therapists can help you build a "luteal phase safety plan" with supports in place for the hardest days
Learning how to track emotional windows of vulnerability
Exploring cycle-based scheduling for rest, productivity, and relationships
Relationship & Identity Support
Repairing damage in relationships affected by PMDD symptoms
Exploring grief, identity confusion, or self-perception changes that arise during the cycle
Addressing PMDD's impact on parenting, partnerships, and work life
Services and Resources
In addition to the apps and chart noted above, there are services and providers available that are already focused on helping you suffer less through PMDD. This is not a comprehensive list or an official endorsement. These are a few resources of which I am aware because I have interacted with them either personally or professionally.
Midi: Midi delivers virtual care by clinicians who specialise in midlife women’s health (including perimenopause and hormone-related mood swings). They offer prescriptions (hormonal and non-hormonal) through a personalised “Care Plan”, and accept many major insurance plans for both visits and prescriptions (though check your plan’s specifics).
Allara Health: Allara Health is a membership-based telehealth program for women with complex hormonal, metabolic and gynecological issues. They provide virtual visits with board-certified OB/GYNs, endocrinologists and dietitians, comprehensive lab testing, personalized lifestyle + nutrition plans, and medication management.
Behavioral Wellness for Women: Helmed by Brianna Dawson, PMHNP-BC, Behavioral Wellness for Women is a virtual women’s mental health clinic licensed in PA and NJ, accepting Aetna (for Pennsylvania residents) and private-pay for others. They specialize in issues like mood fluctuations, anxiety and depression in the context of hormonal transitions (including PMDD) and offer tailored care for high-achieving women navigating perimenopause and similar life-stage changes.
Wrapping it all up
If you’ve ever been dismissed with “it’s just PMS,” or cycled through birth control and antidepressants that only made things worse , you are not overreacting, and you are not alone.
PMDD can show up in adolescence, your mid-20s, or during the hormonal chaos of perimenopause and it's real. It’s not a character flaw or emotional weakness. When the usual treatments don’t work, it doesn’t mean you’re broken or have to suffer forever.
Learning to track your symptoms, name what’s happening in your body, and ask the right questions is how you stop getting lost in the system. You do not need anyone’s permission to take your symptoms seriously. The medical system is often behind on this. You don’t have to be.
Disclaimer: I have no affiliation or financial relationship with any of the apps, products, medications, providers, or services mentioned in this post. Nothing shared here is sponsored or endorsed. Please use your own judgment and consult a qualified medical provider before trying anything discussed as every body responds differently.
Important Note: The information shared here is for educational purposes and is not intended to replace professional mental health advice, diagnosis, or treatment. If you’re facing challenges with your mental health, please reach out to us or another a licensed mental health professional who can support you. The stories in our posts are fictional and created to help explain important concepts. They are not based on client cases. Protecting the privacy and dignity of those we work with is central to our practice, and we do not use client experiences in our content.
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