Understanding the Spectrum of Premenstrual Disorders

For decades, premenstrual changes were dismissed as moodiness or exaggeration. Today, research has made it clear, premenstrual disorders are real, neurobiological conditions that affect millions worldwide. Yet, even now, terms are often confused. Many people know about PMS, fewer have heard of PME, and most have only recently encountered PMDD.

Understanding how these conditions differ, and overlap is essential for accurate diagnosis, compassionate support, and effective treatment.

PMS Is More Than Just Mood Swings

Premenstrual Syndrome (PMS) describes a recurring set of physical, emotional, and behavioural symptoms occurring during the late luteal phase of the menstrual cycle, typically within five days before menstruation and resolving within a few days after bleeding begins. Symptoms vary widely and may include bloating, cramps, breast tenderness, irritability, sadness, and difficulty concentrating ("brain fog").

What distinguishes PMS is the reversibility of symptoms with the onset of menstruation. While most individuals experience mild to moderate symptoms, about 20–30% meet clinical criteria for PMS severe enough to interfere with daily functioning. Biologically, PMS is linked to hormonal fluctuations after ovulation, specifically rising progesterone and declining estrogen, that affect neurotransmitter systems like serotonin and GABA, influencing mood, sleep, and stress response.

The luteal phase also impacts fluid retention and pain sensitivity, contributing to physical discomfort.

Importantly, PMS is not classified as a psychiatric disorder but rather a syndrome of symptoms. This contrasts with Premenstrual Dysphoric Disorder, a formal mood disorder differentiated by severity and diagnostic criteria.

Premenstrual Exacerbation of Existing Conditions

Premenstrual Exacerbation (PME) refers to the worsening of an underlying condition during the luteal phase. Unlike PMS or PMDD, PME is not a standalone disorder. It is a hormonal amplification of conditions such as:

• Major depressive disorder

• Generalized anxiety disorder

• Bipolar disorder

• ADHD

• Migraine or epilepsy

  
  

For example, someone with ADHD may find their executive dysfunction unbearable in the week before menstruation, or someone with bipolar disorder may experience more intense depressive episodes pre menstrually.

PME is often misdiagnosed as PMDD, but the two are distinct:

• PMDD symptoms are only present in the luteal phase and remit after bleeding begins.

• PME involves baseline symptoms that are present throughout the cycle, but they worsen premenstrually.

  
  

Why does this happen? Research suggests it’s linked to how the brain responds to certain hormones, called neurosteroids. When progesterone breaks down, it creates a byproduct called allopregnanolone (ALLO). ALLO usually helps calm the brain by working on its natural ‘relax switches’ (GABA-A receptors).

But in some people, their brains are extra sensitive, so instead of feeling calm, ALLO can actually trigger anxiety or low mood. This helps explain why some people experience stronger mood symptoms or worsening PME before their period.

Premenstrual Dysphoric Disorder

PMDD (Premenstrual Dysphoric Disorder) is the most severe end of the spectrum, affecting 5–8% of menstruating people. It is now recognized in both the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition) and ICD-11 (International Classification of Diseases, 11th Revision) as a mood disorder.

Symptoms

PMDD goes beyond PMS, it involves disabling emotional, cognitive, and physical symptoms, including:

• Sudden, intense mood swings

• Hopelessness, depression, or suicidal thoughts

• Explosive anger or irritability

• Heightened rejection sensitivity

• Cognitive impairments (“PMDD brain fog”)

• Severe fatigue or physical pain

  
  

Diagnosis

Unlike PMS, PMDD requires symptom tracking for at least two cycles, using tools such as the Daily Record of Severity of Problems (DRSP). Symptoms must:

1. Be present in the luteal phase,

2. Disappear shortly after menstruation begins, and

3. Not be explained by another condition (to rule out PME).

This cyclical pattern is the hallmark of PMDD.

Biological Mechanisms

Current research shows that PMDD is not a hormone imbalance, but an abnormal sensitivity to normal hormonal fluctuations. Neuroimaging shows altered activation in the amygdala and prefrontal cortex during the luteal phase. At the molecular level, PMDD is associated with dysregulated serotonin signalling and altered GABA-A receptor response to ALLO.

This explains why SSRIs are the frontline treatment,  and uniquely, they can work within hours in PMDD (unlike weeks in major depression).

Living With These Conditions

Understanding whether you’re experiencing PMS, PME, or PMDD is the first step toward relief. Once you can name what’s happening, you can begin to map support strategies that actually fit your experience instead of trying to “push through.” At the Feminine Rhythm this is how we support women with PMDD:

• Peer connections: Support Group (peer support for PMDD, PMS +PME) — sharing lived experiences reduces isolation and normalises what can feel overwhelming or confusing.

• Personalised coping: 1-1 PMDD Coaching (personalised coping strategies for PMDD support) structured, individualised approaches help you create routines and rituals that work with your cycle rather than against it.

• HPA and Nervous system regulation: Somatic Course (healing through body practices → PMDD support) body-based tools can re-train stress responses and build resilience during hormonal shifts.

• Education + stories: Podcast on my PMDD story, When the Cycle Feels Like a Storm: My Journey with PMDD hearing how others navigate these conditions can spark recognition and practical insights you may not find in medical descriptions.

For many, simply tracking and naming the condition is liberating, it shifts the inner narrative from “I’m broken” to “My brain and body are responding in patterned, predictable ways.” 

This reframing creates space for self-compassion, clearer conversations with doctors or partners, and more intentional choices about treatment or lifestyle support. Over time, awareness becomes a tool of empowerment, you’re no longer waiting for the storm to hit, you’re learning how to read the weather.

Related Reads

• Period Insomnia and PMDD: How Hormones Affect Sleep Before Your Period

• PMDD and ADHD: Understanding the Connection and How to Manage Both

• Binge Eating Before the Period

• Attachment Styles & PMDD

How These Conditions Change in Perimenopause

PMS, PME, and PMDD don’t remain static. As estrogen and progesterone decline in the 40s and 50s, premenstrual conditions can worsen, shift, or resolve entirely.

Continue reading: How PMS, PME, and PMDD Change During Perimenopause

References

• American College of Obstetricians and Gynecologists. (2023). Premenstrual Syndrome (PMS).

• National Institute of Mental Health. Premenstrual Dysphoric Disorder.

• Schiller CE, et al. (2014). Neurosteroid regulation of GABA-A receptors and affective switching in PMDD. Frontiers in Neuroscience.

• Yonkers KA, et al. (2008). Epidemiology and treatment of premenstrual disorders. Journal of Clinical Psychiatry.

• Rapkin AJ & Lewis EI. (2013). Treatment of Premenstrual Dysphoric Disorder. Women’s Health.

• International Association for Premenstrual Disorders (IAPMD). Clinical guidelines.