by Josephine Machado

Graphic design by Jinny Moon

Somehow, the sunlight seeping through Katie’s linen curtains brings on feelings of disdain. She reaches for her phone to find text messages that cause her to feel a profound sense of loneliness and isolation that she herself cannot understand. She then snaps at her partner for uttering a simple “good morning” and spends the remainder of her day failing to concentrate on her experiments in the lab. She lacks the energy to take her dog on his evening walk, experiences intense joint pain, and has lost all interest in the book she has been reading. To the average person, these symptoms would be alarming, but to Katie, it is a recurring monthly experience; she suffers from premenstrual dysphoric disorder (PMDD). 

PMDD is a chronic, cyclical mood disorder that affects an individual’s emotional and physical health in the days that lead up to their menstrual cycle.¹ The symptoms of PMDD are much more extreme than commonly experienced premenstrual symptoms. Though tied to reproductive health and hormonal changes, PMDD is classified as a mental health disorder.² A recent meta-analysis found the prevalence of PMDD to be 1.6%—affecting 31 million girls and women globally; however, this statistic is restricted to community-based studies that followed strict Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnostic criteria and does not reflect provisional diagnoses.³ According to the DSM-5, diagnosing PMDD requires that symptoms (1) occur in the luteal phase of one’s cycle (the final week before the onset of menstruation), (2) interfere with the individual’s work, school, or social life, and (3) should not be considered an exacerbation of an underlying psychiatric disorder.¹ The individual must also experience at least five hallmark symptoms in most menstrual cycles over a single year, including at least one of the  “core symptoms” pertaining to emotional distress.¹ Core symptoms include marked (1) affective lability, (2) irritability, (3) depressed mood, and (4) anxiety. Additional hallmark symptoms include decreased interest in usual activities, poor concentration, lethargy, marked change in appetite, sleep changes, a sense of feeling overwhelmed, and physical symptoms such as joint pains.¹ Diagnosis should also be confirmed with daily symptom tracking throughout at least two symptomatic cycles.¹ 

PMDD significantly impacts an individual’s physical, psychological, social, and economic well-being, underscoring why underdiagnosis is such a pressing issue. In 2013, the American Psychiatric Association made the decision to include PMDD as an official stand-alone diagnosis in the depressive disorders section of the DSM-5. This decision has led to an influx of research, interest, and research funding for the condition over the last decade.¹   

A globally distributed, survey-based study conducted between January and March 2020 reported that individuals with PMDD experience serious distress in various aspects of daily life. Of the 3600 participants, 47% were reported to have engaged in self-harm at least once during a PMDD crisis; 82% experienced suicidal thoughts during their luteal phase at least once, with 40% experiencing suicidal thoughts at some point monthly.⁴ Moreover, 26% of participants reported attempting suicide during a PMDD crisis.⁴Additional burdens include depressive episodes, which can include feelings of hopelessness and worthlessness, alongside self-critical thoughts, and frequent or sudden tearfulness. These symptoms can exist alongside anxiety, irritability, and difficulties with concentration.¹ As a result of studies such as this one, the serious nature of this condition is becoming increasingly evident. 

Despite its severe consequences, PMDD remains underdiagnosed, undertreated, and misunderstood—both in practice and at a societal level. A study by Osborn et al. which interviewed 17 women diagnosed with PMDD found that an average of 20 years elapsed between initial PMDD symptom onset and obtaining a correct diagnosis and treatment, exemplifying the difficulty of diagnosis.⁵ The ramifications of PMDD on an individual’s social functionality and quality of life are similarly profound and extensive. A 2025 study based in the United Kingdom examined the impact of PMDD on life and relationship quality. The study found that PMDD patients had a significantly lower perceived quality of life across all World Health Organization (WHO) domains including physical health, psychological health, social relationships, and environment, in comparison to controls. Partners of PMDD patients also reported a significantly lower quality of life in most of the Adult Carer’s Quality of Life Questionnaire domains (support for caring, caring choice, caring stress, personal growth, sense of value, ability to care, and carer satisfaction), when compared to the partners of healthy controls. Both patients and partners also reported significantly lower relationship quality in their romantic relationships compared to healthy controls and their respective partners .⁶ 

According to individuals diagnosed with PMDD, one of their most life-altering experiences includes enduring the barriers to diagnosis.⁷ A study exploring diagnosis and treatment of PMDD in 32 patients who identified as having PMDD in the U.S. healthcare system reported that almost 30% of participants experienced misdiagnoses including those of bipolar disorder, borderline personality disorder, and post-traumatic stress disorder, in addition to adverse effects from inappropriate treatments and medications.⁷ Pre-existing medical and structural barriers to diagnosis alone include limited health-provider knowledge, nonadherence to diagnosis and treatment guidelines, a lack of insurance, and limited access to healthcare services. For example, an 87-participant survey-based study of physicians by Craner et al. found that most physicians (98.9%) used clinical interviews as a component of their practice when diagnosing PMDD, yet only 11.5% of these physicians reported adhering to diagnostic guidelines.⁸  

Some individuals have even reported instances of medical gaslighting, and dismissal of symptoms. The aforementioned medical barriers can further manifest in the form of internalized individual obstructions such as medical trauma, mistrust, fear, and shame, as well as cultural barriers such as reproductive and mental health stigma, gender and cultural norms, and cultural preferences for alternative medicine.⁸ In terms of cultural norms, the stigma surrounding the psychotropic and hormonal interventions that are often used to treat PMDD led to a decreased utilization in many non-Western contexts.⁸ These factors can lead to diagnostic delay, ultimately leading to an increasingly negative experience for this group of individuals.  

The stigma surrounding women’s reproductive health can be debilitating. Many individuals internalize PMDD patients internalize their condition as a personal flaw⁴ or when it is simply a medical diagnosis. Individuals with PMDD have described a deep sense of shame and worthlessness, which was reinforced by repeated dismissal from professionals and society.⁷ Many patients delay seeking help due to internalized stigma and the belief that menstrual suffering is “normal.” ⁶  

Treatment options are available to alleviate such suffering including selective serotonin reuptake inhibitors (SSRIs), hormonal therapies (e.g. oral contraceptives), and surgical options in severe and treatment-resistant cases. Complementary therapies such as cognitive behavioral therapy, mindfulness-based interventions, as well as lifestyle modifications can also be of benefit, but are often underutilized.¹ Routine screening for cycle-related mood symptoms in gynecological and primary care settings may also help identify PMDD cases earlier. 

Overall, PMDD is a serious and commonly misunderstood condition that highlights critical gaps in the diagnosis, recognition, and treatment of conditions surrounding women’s reproductive health. Addressing women’s health concerns requires not only a systemic shift towards improved diagnosis and treatment, but a socio-cultural shift in the prioritization of women’s mental health as a crucial component of healthcare.  

References 

1.Cary E, Simpson P. Premenstrual disorders and PMDD – a review. Best Practice & Research Clinical Endocrinology & Metabolism 2024;38:101858. https://doi.org/10.1016/j.beem.2023.101858.  

2.Mishra S, Elliott H, Marwaha R. Premenstrual Dysphoric Disorder. StatPearls, Treasure Island (FL): StatPearls Publishing; 2025.  

3.Reilly TJ, Patel S, Unachukwu IC, et al. The prevalence of premenstrual dysphoric disorder: Systematic review and meta-analysis. Journal of Affective Disorders 2024;349:534–40. https://doi.org/10.1016/j.jad.2024.01.066.  

6.Hodgetts S, Kinghorn A. Examining the impact of premenstrual dysphoric disorder (PMDD) on life and relationship quality: An online cross-sectional survey study. PLoS ONE 2025;20:e0322314. https://doi.org/10.1371/journal.pone.0322314.  

4.Brown D, Smith DM, Osborn E, et al. Women with Premenstrual Dysphoric Disorder experiences of suicidal thoughts and behaviours: a mixed methods study. Front Psychiatry 2024;15:1442767. https://doi.org/10.3389/fpsyt.2024.1442767.  

7.Chan K, Rubtsova AA, Clark CJ. Exploring diagnosis and treatment of premenstrual dysphoric disorder in the U.S. healthcare system: a qualitative investigation. BMC Women’s Health 2023;23:272. https://doi.org/10.1186/s12905-023-02334-y.  

8.Nayak A, Wood SN, Hantsoo L. Barriers to Diagnosis and Treatment for Premenstrual Dysphoric Disorder (PMDD): A Scoping Review. Reprod Sci 2025. https://doi.org/10.1007/s43032-025-01861-3.  5.Osborn E, Wittkowski A, Brooks J, et al.. Women’s experiences of receiving a diagnosis of premenstrual dysphoric disorder: a qualitative investigation. BMC Women’s Health 2020;20:242. https://doi.org/10.1186/s12905-020-01100-8.