In perimenopause, hormone shifts can make the days leading up to your period more intense and unpredictable. Mood swings hit harder. Minor frustrations trigger full-blown rage. Deep anxiety and sadness can settle in. If PMS feels like it’s taken on a life of its own in your 40s, it might not be PMS at all—it could be premenstrual dysphoric disorder (PMDD). This severe condition is often overlooked, but for many women, perimenopause is when it first appears or worsens.
For Melissa Sawyer,* PMS was once an annoyance—cramps, bloating, moodiness, irritability. But as she entered perimenopause, her symptoms became something else entirely. “I’d yell over small things—yelling at my husband if he left a cup on the counter or losing it at my daughters’ teenage eye rolls. My mood sank so low it felt like the depression I experienced in college. I didn’t want to interact with anyone.”
Around eight percent of women experience PMDD in perimenopause, although symptoms often begin during their reproductive years (1). The condition can last through the menopause transition but ends when your hormone levels stabilize and your periods have entirely stopped (2).
Still, PMDD is a serious condition that can even shorten your health span: A 2017 study found that women with untreated PMDD lose about three years of good health over their lifetime due to severe premenstrual symptoms (3).
About the Experts
Taniqua Miller, M.D., is a board-certified OB-GYN and nationally certified menopause practitioner.
Katrina Furey, M.D., a board-certified reproductive psychiatrist specializing in PMDD and mood and anxiety disorders related to menopause.
What is PMDD and Why Can It Worsen in Perimenopause?
Premenstrual dysphoric disorder (PMDD) is a severe form of PMS that causes intense and sometimes debilitating mood swings, depression, irritability, tearfulness, and difficulty concentrating.
PMDD symptoms overlap with perimenopause, but they follow a distinct pattern: they hit during the luteal phase—the week or two before your period—when estrogen and progesterone take a nosedive, then typically ease up once bleeding starts (4). For women who are sensitive to hormonal shifts, the extreme estrogen and progesterone fluctuations during perimenopause make PMDD worse.
Women with a family history of PMS or PMDD—or a history of depression, postpartum depression, or other mood disorders—are more at risk of developing the condition (2). Genetics may also play a role. “It seems like there’s some genetic difference in certain estrogen and GABA receptors that makes some women more vulnerable to hormonal fluctuations,” Furey says. “It’s not that their hormone levels are off; it’s that their brains are just more sensitive to the fluctuations.”
How are PMS and PMDD different?
Unlike PMS, PMDD is a diagnosed mental health disorder with symptoms that can disrupt daily life, relationships, and emotional well-being. In 2013, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the guide for diagnosing mental health conditions, added PMDD (1).
Another key difference? When symptoms start. PMS can begin as soon as you get your first period, while PMDD tends to develop later. While some women develop PMDD in their 20s, new research indicates that it often tends to flare up later as women approach the onset of perimenopause (6, 7).
PMDD symptoms and diagnosis
To be diagnosed with PMDD, a woman must experience at least five of the following symptoms that interfere with normal functioning for at least two consecutive cycles (1).
Mood swings, sudden sadness, or increased sensitivity to rejection
Irritability, anger, or increased interpersonal conflicts
Depression, hopelessness, or self-critical thoughts
Marked anxiety or feelings on edge
Loss of interest in usual activities (work, school, friends, hobbies)
Changes in appetite (overeating or specific food cravings)
Insomnia or hypersomnia (sleeping too much)
Feeling overwhelmed or out of control
Tracking symptoms for at least two to three cycles helps rule out other conditions, says Taniqua Miller, MD, a board-certified OB-GYN. “A lot of things are blamed on hormones, so we want to rule out other causes, like thyroid disease,” she says.
A PMDD diagnosis can take years due to a lack of awareness among patients and providers.“If society doesn’t know this stuff is real, and then the doctors and the providers aren’t being educated either, no wonder it’s so hard to get a diagnosis,” Furey says.
The difference between PMDD and menopause mood swings
About 40 percent of women have mood swings during perimenopause that are similar to PMS— you might feel irritable, moody, or tearful. These symptoms tend to be manageable and end shortly after your period starts.
PMDD is an entirely different experience, with extreme mood swings that can make women feel out of control.
Beyond yelling at children or screaming at your spouse, the consequences of untreated PMDD can be severe. In a 2022 study published in BioMed Central Psychiatry, 70 percent of nearly 600 women with confirmed PMDD said they experienced a prevalence of lifetime self-injurious thoughts and behaviors (8).
Why Does PMDD Get Worse During Perimenopause?
PMDD worsens during perimenopause because of erratic hormone fluctuations, mainly drops in estrogen and progesterone, which disrupt mood-regulating neurotransmitters. These shifts intensify mood swings, anxiety, and depression, making PMDD symptoms more severe and unpredictable.
Researchers believe that as estrogen declines in perimenopause, the hypothalamus releases norepinephrine, a neurotransmitter that regulates your fight-or-flight stress response. This norepinephrine surge can trigger depression, anxiety, and hyperactivity disorder (research shows that menstruating women with Attention Deficient Hyperactive Disorder are 30 percent more likely to have PMDD) (9, 10).
Norepinephrine also suppresses dopamine and serotonin, two key neurotransmitters that govern your moods. When levels of these hormones drop during perimenopause, it can make depression and mood swings feel more extreme (11).
Acetylcholine, a neurotransmitter that affects sleep and mood, also contributes to the development of PMDD in perimenopause (12). Lower acetylcholine levels can contribute to brain fog, and difficulty concentrating, which often worsens in perimenopause (13).
Hormones aren’t the only factor. Perimenopause is also often a time of significant life stress. In their late 40s and early 50s, many women juggle careers, parenting, and caregiving for aging parents, all of which can amplify PMDD symptoms (4).
Another challenge? The irregular cycles that are a hallmark of perimenopause make PMDD harder to track. “The cycles aren’t as regular, so it gets harder to predict when you might be experiencing a PMDD episode, and then it can get harder to treat,” Furey says.
Because PMDD symptoms overlap with major depressive disorder (MDD), misdiagnosis is common. “In midlife, you have an increased risk of being susceptible to depression and anxiety because of life, right?” says Miller. Recognizing PMDD’s cyclical pattern—rather than assuming it’s just perimenopause or depression—is key to getting the proper treatment.
A combination of lifestyle factors and medication is often needed to treat PMS and PMDD in perimenopause. “Some patients with milder symptoms may respond to lifestyle modifications alone, but many will need medication management, Furey says. There’s no shame in that.”
Medication
The most common and effective options to reduce PMDD symptoms include antidepressants, birth control, diet and exercise, supplements, and HRT (4).
Selective serotonin reuptake inhibitors (SSRIs)
SSRIs (the most prescribed type of antidepressant) are the first-line treatment for PMDD. “They work quickly (within days), whereas it takes several weeks for SSRIs to kick in for other disorders like major depressive disorder,” Furey says.
Your doctor might suggest cyclic SSRI therapy, where the medication is taken in the two weeks before you get your period. However, since perimenopause makes cycles unpredictable, continuous SSRI use is often recommended.
Birth Control
Whether you’re interested in contraception or not, your doctor might suggest taking hormonal birth control to treat PMS or PMDD, Miller says. Research shows that oral contraceptives containing ethinyl estradiol and drospirenone (some common ones include Yasmin, Yaz, Gianvi, and Jasmiel) are particularly effective at managing PMDD symptoms (14).
HRT
Hormone replacement therapy, or menopause hormone therapy (MHT), can help perimenopausal women who have PMDD alongside symptoms like night sweats or low libido.
“Using menopause hormone therapy (MHT) in a medically supervised, clinically appropriate manner can ease symptoms, which can include irritability, mood disruptions, and cognitive dysfunction,” Furey says.
Diet and Exercise
A balanced diet containing lean protein, complex carbohydrates, and plenty of fruits and vegetables can support hormone (estrogen) and neurotransmitter function. However, consider reducing sugar, salt, caffeine, and alcohol, as these can increase blood sugar and cause irritability, fatigue, and anger (15, 16).
There aren’t specific workouts to relieve PMDD, but regular aerobic exercise can help regulate mood and reduce stress. Aim for 150 minutes of moderate-intensity weekly activity, such as a brisk walk or swim (15).
Supplements
Certain supplements or vitamins may help ease PMDD symptoms. Lower Vitamin D levels have been associated with depression (17). The National Institutes of Health recommends 600 IUs of the vitamin every day (18). One study linked 250 mg of magnesium to reduced PMS severity (19). There is also evidence that calcium may relieve depressive symptoms (20). The recommended daily allowance for women in perimenopause is 1200 mg per day (21).
*The name in this story has been changed to protect privacy.
The Bottom Line
PMDD is not just severe PMS—it’s a clinical mental health condition that causes intense mood swings, depression, and anxiety, often severe enough to disrupt daily life. Symptoms tend to worsen in perimenopause due to erratic hormone fluctuations, but effective treatments exist. A combination of medication (SSRIs, birth control, or hormone therapy) and lifestyle changes can help manage symptoms.
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