You get depressed around the time of ovulation because of a decreased serotonin uptake along with decreases in steroid levels. It goes by the name of Premenstrual Dysphoric Disorder (PMDD). PMDD is a more severe subtype of Premenstrual Syndrome (PMS) that involves more emotional symptoms characteristic of depression, such as sadness, anxiety, mood swings, irritability, and loss of interest in things once found pleasurable. It occurs during the 1-2 weeks prior to the onset of menstruation (usually around the time of ovulation) that resolves after the menstrual cycle is complete. The frequency of PMDD in women of reproductive age is estimated at 3–8%. It responds well to SSRI antidepressants and oral contraceptive pill (Sadock, et al., 2017).
The average menstrual cycle takes about 28 days, with a normal range of 25-35 days. The monthly cycle occurs in phases: the follicular phase, the ovulatory phase (ovulation), the luteal phase, and the menstrual phase. The follicular phase slightly overlaps with the menstrual phase. It begins on the first day of your period and ends when you ovulate. During the follicular phase, estrogen levels start to rise as eggs start to grow. The ovulatory phase, or ovulation, occurs about day 14. The luteal phase begins after ovulation, post-day 14, and continues until the first day of your period.
Signs and Symptoms of Premenstrual Dysphoric Disorder
The premenstrual dysphoric disorder requires at least five symptoms in the final 1-2 weeks before the onset of menses which start to improve a few days after the onset of menses and are either minimal or absent in the week following menses.
One or more of the following symptoms must be present:
- Emotional lability
- Irritability/anger/interpersonal conflict
- Depressed mood/hopelessness/self-deprecating thoughts
- Anxiety/tension/keyed up or on edge
In addition, at least one of the following symptoms must be present:
- Decreased interest in things once found pleasurable
- Concentration difficulties
- Fatigue/low energy
- Appetite changes
- Excessive sleep/sleeplessness
- Feeling overwhelmed/out-of-control
- Physical symptoms: include breast tenderness, abdominal discomfort, and a feeling of distension
The symptoms must be severe enough to interfere with functioning or cause clinically significant distress (Sadock, et al., 2017).
Causes of Premenstrual Dysphoric Disorder
The cause is not definitively established. Biological explanations based on ovarian hormones (excess estrogen, lack of progesterone), pituitary hormones, and disturbed fluid and electrolyte balance have not been proven. Possible associations of the syndrome with neuroticism or with attitudes towards menstruation have led to other unproven psychological explanations (Harrison, et al., 2018).
Some studies have shown that decreased uptake of the neurotransmitter (a natural chemical messenger occurring in the brain) serotonin with premenstrual decreases in steroid levels have been correlated with the severity of symptoms (Sadock, et al., 2017).
Treatment of Premenstrual Dysphoric Disorder
For PMDD, SSRIs and oral contraceptives are considered the treatment of choice, with the latter primarily improving the physical symptoms. Cognitive-behavior therapy and lifestyle modifications also have a role.
The SSRIs and venlafaxine (Effexor), all originally used to treat depression, have been approved by the FDA for the treatment of PMDD. SSRIs, particularly fluoxetine (Prozac), have demonstrated efficacy, and as many as 50 percent of women may respond to fluoxetine administered only in the second half of each cycle. The doses of venlafaxine therapy range from 50 to 200 mg/day.
Improvement of symptoms of PMDD with SSRIs may be seen during the first week of treatment. Mood, irritability, and anxiety improve. Physical symptoms, such as swelling, bloating, and breast tenderness, are less responsive to treatment. Treatment is often started at 10 to 20 mg of fluoxetine per day. The dose is adjusted upward as needed. SSRI sertraline is usually started at 50 mg per day given daily or during the 2 weeks of the luteal phase. Individual patients may respond at lower doses. Some may require an upward titration of the dose (Sadock, et al., 2017).
A variety of hormonal therapies have been tried in PMDD, and the ones with the best efficacy are gonadotropin-releasing hormone agonists, compounds that reversibly suppress pituitary secretion of the gonadotropins (hormones) FSH and LH and hence turn off ovarian steroid secretion. This works in about two-thirds of women with PMDD, the same percentage (although not necessarily the same individuals) as are successfully treated by SSRIs. This therapy should be considered for those women who do not respond to SSRIs, particularly if they have severe symptoms (Sadock, et al., 2017).
Several studies have found that alprazolam (Xanax) is more effective than a placebo for the treatment of premenstrual dysphoric disorder.
Another FDA approved treatment for PMDD is the oral contraceptive with ethinylestradiol and novel progestin drospirenone taken on a 24-4 schedule (24 active pills, 4 inactive pills). The idea behind using oral contraceptives is to suppress ovulation, therefore suppressing sex hormone fluctuations.
Cognitive-Behavioral Therapy (CBT) has been shown to be effective in treating the symptoms of PMDD. CBT is an evidence-based approach for treating depression and focuses on the link between mood, thoughts, and actions to help patients address current issues and symptoms. Through the practice of CBT, patients can better recognize and modify recurrent issues as well as thought and behavior patterns that interfere with functioning well or that make depressive symptoms worse.
Alternative and Lifestyle Therapies
Nutritional supplements such as calcium carbonate have been shown to relieve the symptoms of PMDD. Herbal treatments that seem to work in PMDD include ginkgo (Ginkgo biloba), St, John’s wort (Hypericum perforatum), and chasteberry (Vitex agnus castus).
Exercise can improve symptoms of depression, fatigue, and trouble concentrating. Be active for at least 30 minutes a day for at least 5 days a week, including even a daily walk through your neighborhood. Managing stress can alleviate the symptoms of PMDD to some extent. This can be done through deep breathing exercises, yoga, and meditation, which calm both your mind and body.
Harrison, P., Cowen, P., Burns, T. & Fazel, M., 2018. Shorter Oxford Textbook of Psychiatry. 7 ed. Oxford: Oxford University Press.
Sadock, B. J., Sadock, V. A. & Ruiz, P., 2017. Kaplan and Sadock’s Comprehensive Textbook of Psychiatry. 10th ed. Philadelphia: Wolters Kluwer.