PMDD and chronic stress or trauma: what we know (and what it means biologically)

What is PMDD?

Premenstrual dysphoric disorder (PMDD) is a cyclical mood disorder: severe mood, behavioural and physical symptoms that appear in the luteal phase of the menstrual cycle and ease once your period starts. 

The link between PMDD, stress and trauma

Over the last decade, researchers have repeatedly found a strong and clinically important association between stressful life events - especially childhood adversity and trauma - and both the risk and severity of PMDD.

So what does the evidence show us, and what’s the biological explanation behind this?

 

Evidence that stress and trauma are linked to PMDD

• Multiple large studies and systematic reviews report that women with PMDD have higher rates of childhood maltreatment and lifetime trauma than controls.
• One recent analysis found a very high prevalence of early-life trauma among people diagnosed with PMDD. (1)
• Meta-analyses and multilevel reviews show an association between traumatic stress and worse premenstrual symptoms (both PMS and PMDD), and point out that trauma is a reproducible risk factor. (2)
• Stress exposure is not only a historical risk factor—chronic everyday stress and acute stressful events can worsen PMDD symptoms and predict greater luteal-phase impairment.

Bottom line: trauma and chronic stress are over-represented in PMDD populations and appear to make premenstrual mood symptoms more likely and more severe.

 

How trauma and chronic stress might produce neuro-sensitivity to menstrual hormones

T here isn’t one single cause of PMDD, but research suggests a “multi-hit” process. Early trauma or ongoing stress can create long-lasting changes in the brain and stress systems. Later, when normal hormone changes happen before a period, these changes can make the brain more sensitive, leading to the mood and physical symptoms seen in PMDD.

1. HPA-axis (stress hormone) dysregulation

Experiences of trauma or ongoing stress can change how the body handles stress hormones like cortisol. In people with PMDD, research shows that cortisol levels and responses to stress are often different in the week before a period. (3) This may reflect the long-term effects of past stress or trauma. These changes can make it easier for mood and emotions to feel out of control when normal hormonal shifts happen before a period

2. Neuroactive steroid signalling (allopregnanolone & GABA-A receptor sensitivity)

Progesterone, a hormone that rises before your period, is turned into a substance called allopregnanolone (ALLO), which normally helps calm the brain. In some people, however, this rise can have the opposite effect, causing mood swings, irritability, or anxiety.

This isn’t because hormone levels are too high or too low, but because the brain’s “calming system” may be more sensitive or respond differently. (4) Early-life stress can alter neurosteroid signalling and GABAergic function, which could prime the brain to respond abnormally to the cyclic ALLO surge.

3. Circuit-level effects: amygdala, prefrontal cortex, and emotional reactivity

Brain scans show that during the week before a period, women with PMDD often have stronger activity in parts of the brain that process emotions, like the amygdala, which can make feelings more intense. (5)

Experiencing trauma can make this part of the brain even more sensitive and can reduce the brain’s ability to calm these strong emotions. When this happens together with changes in stress hormones and other brain chemicals during this time, it can lead to stronger emotional symptoms that happen mainly in the days before a period

4. Neuroinflammation & epigenetic programming (emerging evidence)

Recent research suggests that experiences of trauma or ongoing stress can cause subtle, long-lasting changes in the brain and body. These changes can include low-level inflammation and modifications to genes that control how we respond to stress.

Together, these changes can make the brain and hormone systems react more strongly to the normal hormonal shifts that happen before a period.

In simple terms: early trauma or chronic stress can “prime” the brain and body so that normal hormonal changes during the menstrual cycle feel much more intense, which may explain why some women experience the severe, cyclical emotional and physical symptoms of PMDD.

 

Assessment and treatment considerations for PMDD

1. Talk about past stress or trauma

Many people with PMDD have experienced childhood adversity or trauma. Understanding this helps guide treatment, and combining trauma-focused therapy with PMDD care can be very helpful.

2. Address trauma directly if needed

If trauma or PTSD symptoms are present, therapies like trauma-focused CBT or EMDR are recommended. Treating trauma can reduce overall symptoms and improve response to PMDD care.

3. A team approach works best

Coordinating care between gynaecologists, mental-health professionals, and therapists -along with support from friends, family, or support groups - often gives the best results.

Where to get help

• See your GP or family doctor: first step for assessment, medication (SSRIs), and referral to specialist menstrual or mental-health services. NHS Talking Therapies pages explain routes to mental-health and talking-therapy services.
• NHS Talking Therapies (IAPT) or local psychological-therapy services: self-referral is often possible for CBT and other evidence-based talking therapies. These services can provide trauma-focused CBT where indicated.
• Charities and peer support: organisations such as the PMDD Project provide information, signposting and local support for PMDD and trauma (including helplines and guides).
• If you’re in immediate crisis or thinking of harming yourself, call emergency services or crisis lines. In the UK, Samaritans are available 24/7 on 116 123 (free) for immediate emotional support.

References:

1. Kulkarni, J., Leyden, O., Gavrilidis, E., Thew, C. & Thomas, E. H.-X. (2022). The prevalence of early life trauma in premenstrual dysphoric disorder (PMDD). Psychiatry Research, 308, 114381. https://doi.org/10.1016/j.psychres.2021.114381
2. Van den Akker, O., & Stein, D. J. (2021). Associations between premenstrual symptoms and (traumatic) stress: A systematic review and three multilevel meta-analyses. The British Journal of Psychiatry, 219(6), 629–639. https://doi.org/10.1192/bjp.2021.128
3. Csenkei, Z., Kirschbaum, C., & Dutz, J. (2023). Altered hypothalamic–pituitary–adrenal axis functioning in premenstrual dysphoric disorder: a systematic review. Psychoneuroendocrinology, 154, 106192. https://doi.org/10.1016/j.psyneuen.2023.106192
4. Hantsoo, L., & Epperson, C. N. (2020). Allopregnanolone in premenstrual dysphoric disorder (PMDD): Evidence for dysregulated sensitivity to GABA A receptor modulating neuroactive steroids across the menstrual cycle. Neurobiology of Stress, 12, 100213. https://doi.org/10.1016/j.ynstr.2020.100213
5. Baller, E. B., et al. (2008). Toward a functional neuroanatomy of premenstrual dysphoric disorder. Journal of Affective Disorders, 108(3), 223–231.
6. Pilver, C. E., Libby, D. J., Hoff, R., & Stein, M. B. (2011). Post-traumatic stress disorder and trauma characteristics are correlates of premenstrual dysphoric disorder. Journal of Affective Disorders, 135(1–3), 373–376. https://doi.org/10.1016/j.jad.2011.06.057
7. Martínez, P. E., Rubinow, D. R., Nieman, L. K., Koziol, D. E., Morrow, A. L., Schiller, C. E., & Schmidt, P. J. (2022). The prevalence of early life trauma in premenstrual dysphoric disorder (PMDD). Archives of Women’s Mental Health, 25(2), 405–412. https://doi.org/10.1007/s00737-021-01189-1
8. Eisenlohr-Moul, T. A., Girdler, S. S., & Schmalenberger, K. M. (2020). Childhood trauma and premenstrual symptoms: The role of emotion regulation. Journal of Psychiatric Research, 130, 427–434. https://doi.org/10.1016/j.jpsychires.2020.08.012
9. Bublatzky, F., Stein, D. J., & Van den Akker, O. (2024). Pain sensitivity and depressive triad mediate the relationship between trauma and stress, and symptoms of premenstrual disorders.

 

Author: Dr Anna Cantlay  BMBS BMEDSCI MRCGP DFSRH DROCG DOCCMED
Role: Head of Medical at Evelyn and GP specialising in Women’s health
Dr Cantlay specialises in women’s mental health, PMDD, and hormone-related mood disorders.

Disclaimer: This content is for informational purposes only and is not intended as medical advice. Always speak to a qualified healthcare professional about any health concerns.

Last updated: Nov 2025