PMS, PMDD and our relationships - the effects and how to talk about it

You’ve probably heard of Premenstrual Syndrome (PMS), but what it means isn’t always so clear. 

‘PMS is a huge umbrella term,’ explains Dr Tory Eisenlohr-Moul, associate professor of psychiatry at the University of Illinois at Chicago and the chair of the clinical advisory board for the International Association of Premenstrual Disorders. ‘Is it physical or emotional, severe or mild? It’s not very specific.’ 

Most people who menstruate experience mild PMS at some point in their lives. While PMS won’t be the same for everyone, some of the most common symptoms are mood swings, anxiety, insomnia, breast tenderness, and headaches. You might also find yourself with oily hair, spots, and changes in your appetite and sex drive.

For 3-8% of people who menstruate, these symptoms are disruptive enough to meet the criteria for Premenstrual Dysphoric Disorder (PMDD) - a depressive disorder in the Diagnostics and Statistical Manual of Mental Disorders (DSM).

Both PMS and PMDD occur during the second half of the menstrual cycle (aka the luteal phase), which occurs after ovulation and before our period. People with PMDD often experience severe mood swings, anger, anxiety and depression, as well physical symptoms like brain fog and exhaustion. Once your period begins, the symptoms usually go away within a few days.

There are a couple of main theories as to why PMS and PMDD occur are, the most prominent being that people with PMS/PMDD may be more sensitive to natural changes in the levels of estrogen and progesterone, or one of the metabolites of progesterone, allopregnanolone. Read here for more information on the theories behind the causes of PMS and PMDD.

So how exactly are PMS and PMDD different? ‘Although PMDD can include some physical symptoms, the emotional symptoms have to be there in order to diagnose the disorder, which isn’t true of PMS,’ says Dr. Eisenlohr-Moul. ‘PMDD is also a way to specify that [the condition] is very severe’.

Whether it’s mild or severe, managing PMS can leave you tired, grumpy and emotionally drained. If finding the energy to keep up with your normal routine feels like a challenge, you’re not alone.

In a survey of more than 4,000 women*,35% described PMS as having a moderate-to-severe impact on their everyday life. A 2016 study found that 58% of women* with severe PMS reported lower productivity, with 36% experiencing disturbances at work and school. Evelyn’s own research showed that 51.7% of people had to take time off work or school because of PMS or PMDD.

It’s no surprise that a monthly rollercoaster of symptoms can also take a toll on relationships. Nearly half of all women* report an impact on socialising and family relationships. This might manifest with us turning down a night out with friends or finding ourselves pushing our partners away. It’s not uncommon for us to end up thinking ‘PMS is ruining my relationship’.

The same study reported that half of women* with PMS felt less satisfied with their relationship during the lead-up to a period and enjoyed fewer positive experiences with their partners. Partners of those experiencing PMS or PMDD also reported feeling less satisfaction in their relationships, compared with couples where the female individual didn’t experience PMS.

For people with PMDD, symptoms can be especially challenging in relationships.

‘The experience of PMDD varies really widely,’ says Dr Eisenlohr-Moul, ‘but for the average person, PMDD has at least some impact on their personal life. It's very typical to experience lost relationships due to the symptoms.’

Dr Eisenlohr-Moul’s patients with PMDD often experience extreme irritability. While not everyone with PMDD will be irritable, this common symptom can put a strain on relationships. 

‘They're reacting to things in ways that they don't feel in control over and they don't see as normal for the rest of the time,’ she says. ‘Even small acts of interpersonal aggression, like snapping at people, can really have an impact on relationships.’ 

It’s important to remember that PMDD is a medical condition and irritability is a well-recognised symptom. But the effect can still leave friends and partners walking on eggshells for part of the month. 

The good news is that growing awareness of premenstrual disorders means that there are more resources than ever before to help support each other.

It isn’t always easy to open up about what’s troubling you, especially when it touches on periods and mental health - topics that some people are still uncomfortable talking about.

Dr Eisenlohr-Moul recommends thinking about how you’d approach any other physical illness.

‘Imagine how you would tell a friend that you've been diagnosed with diabetes,’ she says. ‘PMDD is not completely different. You can say something like, I just wanted you to know that I have this and if you notice that I'm not myself that might be what's going on.’

There’s no right or wrong way to start the conversations, but being honest about what you’re going through will help the people you care about offer support.

You might want to consider where the best place is to talk to someone. Do you want somewhere private or will you feel more relaxed in a busier atmosphere, chatting over coffee?

It can also be helpful to think about what you want to say in advance. Maybe there are examples you want to share or specific pieces of information that will help someone understand what you’re experiencing.

Having a list of resources is useful if the person you’re talking to has questions or wants to learn more. A good place to start is the International Association for Premenstrual Disorders (IAPMD). Its website includes a brilliant overview of the disorder as part of a toolkit for patients and their families.

You might also want to consider what you’re hoping for from the conversation. Do you want help working on a specific issue, or are you hoping for empathy and understanding? Let the person you’re speaking to know if you have suggestions for what they can do.

Remember, you don’t need to tackle everything all at once. If the person doesn’t react like you’d hoped, it can help to give them space to think about the conversation. Talking about your experience is an important first step, and one that you can build on over time.

If you’re talking to children, try to make sure they feel safe and at ease. Choosing self-empowering language is a good technique - like describing how you’re doing everything you can to understand your body and get the support you need to feel better. You can still be honest about your experience, but using language like this will help children know that you’re going to be okay.

Learning more about the disorder is one of the most important ways that you can help someone with PMDD. There’s evidence that having a supportive partner who understands PMDD leads to a more satisfying relationship and can even make the symptoms less severe.  

‍One study showed that individuals in same-sex relationships managed symptoms more effectively than individuals in opposite-sex couples in comparable situations. The women* who took part in the study pointed to open communication and awareness as important strategies for supporting each other.

But awareness can’t exist without understanding where your partner or friend with PMDD is coming from.

‘Some partners are aware of PMDD as a neurobiology problem,’ says Dr Eisenlohr-Moul. ‘They know that their partner's brain is sensitive to these cyclical hormone fluctuations and so they're trying their best to anticipate and give support. That’s a different experience than someone who's completely unaware of what's happening and just experiences their partner as very unpredictable.’

A good understanding of PMS and PMDD means that you can work on strategies to manage issues together. This might mean talking through how you can support each other at difficult times or finding ways for both partners to work on self-care.

‘Have a conversation about what's helpful,’ says Dr Eisenlohr-Moul. ‘Do you need to go away into your room and not be bothered for a day or do you want more affection and support? Depending on the person, that's going to differ so much.’

You can also offer practical support to your friend or partner with PMDD. That might mean advocating for them at medical appointments or extra help with childcare for part of the month. Every person and every relationship is different, so it’s helpful to talk honestly about what works best.

One of the major sources of tension in relationships can be a breakdown in communication. Studies suggest that PMS makes communication between partners harder - and the worse your PMS symptoms are, the bigger the impact on communication.

But that doesn’t mean effective communication is impossible, it might just take some extra effort.

Dr Eisenlohr-Moul recommends having a conversation about managing tensions during the phase of your menstrual cycle when you’re not experiencing PMDD symptoms.

As the person in a relationship who doesn’t experience PMDD, talking to someone who does, she suggests framing any concerns in a caring way. Gently pointing out that your partner or friend doesn’t seem like themself is much more constructive than telling them they’re acting weird or irrational.

‘When you frame it as ‘not yourself’ there's an understanding that something is going on in their brain that’s different from what's normal for them,’ Dr Eisenlohr-Moul says. ‘There's also an understanding that we need to support that person and keep them safe.’

Because PMDD was only added to the DSM (the standard classification of mental disorders) in 2013, there still haven’t been large clinical trials looking at psychotherapies to ease relationship issues like extreme irritability.

But Dr Eisenlohr-Moul suggests that some people with PMDD may benefit from Dialectical Behavioral Therapy, which is based on Cognitive Behavioural Therapy (CBT) - a skills-based talking therapy for people who experience intense emotions.

DBT teaches you to understand and identify difficult emotions while learning skills to help manage them.

‘We're not saying you need to learn all these skills to manage your irritability because the irritability is your fault,’ Dr Eisenlohr-Moul says. ‘The irritability comes from a biological place, whether it's the menstrual cycle or something else. But we do want people to feel empowered to learn skills that can reduce the impact on relationships.’

If you’re still having a difficult time communicating, couples therapy can also be a good option to explore your relationship.

If PMS or PMDD is affecting your relationships, you may want to talk to your doctor about what treatment options can help. Your GP might recommend lifestyle changes, like getting more sleep and eating a healthy diet. They may also suggest combined oral contraceptives or selective serotonin reuptake inhibitors (SSRIs), a common type of antidepressant, which provide effective symptom relief for up to 70% of people with PMDD.

The National Institute for Health and Care Excellence has detailed guidelines about how PMS and PMDD are diagnosed and what help you can access through the NHS. The National Association for Premenstrual Syndromes, a UK-based charity, is another useful source of information.

You might also want to join the Evelyn community to talk about your symptoms with people who understand what you’re experiencing. Communities like ours are a helpful opportunity to explore issues like PMDD and relationships. 

While PMS and PMDD can bring challenges to a relationship, open communication, empathy, and awareness will help you find ways for everyone to feel supported.