Official diagnostic criteria for PME don’t exist - patients are diagnosed and treated based on the underlying disorder. Photo / 123RF
More than half of women with depression might experience a phenomenon called premenstrual exacerbation of depression, or PME.
One in six women in the United States has depression, according to the Centers for Disease Control and Prevention. And new research seems to confirm what many suspect - the symptoms often can get worse just before your period.
It’s called premenstrual exacerbation of depression (PME), and as many as 58% of people with depression who menstruate might have it, studies suggest.
“It could be they’re experiencing premenstrual worsening of depressed sadness, or feelings of guilt or worthlessness, or loss of interest or pleasure,” said Jaclyn Ross, a licensed clinical psychologist at the Chicago Premenstrual Disorders Clinic.
Most recently, a study published in BMJ Mental Health found that mood ratings were lowest from three days before until two days after their period in women with depression who tracked their symptoms.
Premenstrual exacerbation of depression differs from the more commonly known premenstrual syndrome (PMS), which is characterised by physical symptoms such as aches, bloating and cramping, and emotional symptoms such as anxiety and mood swings, leading up to your period.
However, both PME and PMS fall under the same “umbrella of premenstrual emotional symptoms”, said Tory Eisenlohr-Moul, an associate professor of psychiatry and psychology at the University of Illinois Chicago College of Medicine, and a co-author of a study about PME published in the journal Biological Psychiatry in May.
PME is easily confused with premenstrual dysphoric disorder (PMDD), a mood disorder that can also cause depression, anger and irritability around the middle of the menstrual cycle. The latter has been better studied: in 2013, PMDD was included in the Diagnostic and Statistical Manual of Mental Disorders, or DSM-5, the reference book used by clinicians to define mental health conditions.
The more important distinction, experts said, isn’t so much symptom type or severity (both PME of depression and PMDD can be severe), but “what happens during the follicular phase of the cycle”, said Susan Kornstein, a professor of psychiatry and obstetrics & gynecology at Virginia Commonwealth University.
With PMDD, a person probably has no depressive symptoms in that follicular phase, which lasts from the first day of the new cycle until ovulation. Then, “the symptoms turn on like a light switch”, Ross said, and, within a few days of menstruation, “they turn off like a light switch”.
On the other hand, PME “is more like a dial”, she said. Because there’s a preexisting condition - in this case, depression - “symptoms are there all the time, but they turn up”.
Official diagnostic criteria for PME don’t exist - patients are diagnosed and treated based on the underlying disorder. “Basically, PMDD was the cleaner alternative to create the diagnosis,” Eisenlohr-Moul said, “but we know we have a lot of work to do to be more inclusive for people with messier symptom patterns.”
Unlike PMDD, she said, PME “is harder to see because you also have background things going on”. Just to make it all more complicated, Eisenlohr-Moul pointed out that a person might have PMDD, then eventually develop chronic PME of depression. It’s also possible to have both conditions, or symptoms that resemble PME but are something else entirely.
Formally recognising PME as a separate condition is a matter of some debate among experts, but its inclusion could open up more treatment options for patients, Eisenlohr-Moul said.
People with other psychiatric diagnoses may have symptoms that are exacerbated by the menstrual cycle. It’s possible to experience PME “of pretty much any mental health disorder”, Ross said, including obsessive-compulsive disorder, eating disorders and generalised anxiety disorder.
With PME of depression, your symptoms tend to get worse during the luteal phase, seven to 14 days before your period, Eisenlohr-Moul said.
You might feel intensely sad, or more fatigued or withdrawn than you do at other times in your cycle, according to the International Association for Premenstrual Disorders (IAPMD), a nonprofit that advocates for people with premenstrual conditions. Thoughts of self-harm and suicidality can also increase during this time.
Symptoms usually return to their baseline after you get your period. The exact timing of symptoms can vary from month to month, though, “which is so frustrating for scientists, clinicians and patients”, Ross noted. “We want it to be neat and tidy.”
Not all women with depression experience worse symptoms before their period. Researchers have also found you can have symptoms even if you’re taking antidepressants.
A common misconception is that PME is caused by hormonal imbalances. “It’s actually that you have an abnormal brain sensitivity to normal hormone fluctuations that happen across the menstrual cycle,” Ross said. “The way I think of it is that your brain is allergic to your menstrual cycle.”
Track your symptoms
If your depression seems worse leading up to your period, start by writing down how you feel daily over the course of two menstrual cycles to look for patterns. Reporting back on symptoms from memory “is not always reliable”, Kornstein said, “which is why prospective daily charting is needed”. Eisenlohr-Moul recommended downloading the free symptom tracker worksheet on the IAPMD website.
Connect with a provider who listens
Your doctor should believe you if you tell them you’re experiencing heightened depression around your period, then help monitor those symptoms to understand the impact they’re having on your life. “If a provider dismisses you or turns you away, find a new provider,” Eisenlohr-Moul said.
Consider working with a therapist
Ross recommended acceptance and commitment therapy (ACT), dialectical behaviour therapy (DBT) or cognitive behavioural therapy (CBT) - “all three of those contain elements that can be really useful for managing premenstrual symptoms”. Ideally, your therapist will work with you on tailoring coping skills to your cycle, she said, so you’re better equipped on days you’re most vulnerable.
Ask about medication options
Serotonin reuptake inhibitors (SSRIs) and birth control pills that contain drospirenone or ethinyl estradiol are approved to treat PPMD, but PME may require a different approach. Still, “the frontline treatment for premenstrual emotional symptoms is SSRIs”, Ross said, so this can be “a good place for people to start”. Some clinicians might prescribe an increased dose for high-symptom days. Oral contraceptives are also “worth exploring as a potential treatment option” for PME, Ross added, “although there’s not a one-size-fits-all approach here”. (On the other hand, if you’ve already been taking oral contraceptives and are having exacerbated symptoms around your period, sometimes changing them may help, said Veerle Bergink, a professor in psychiatry and the director of Mount Sinai’s Women’s Mental Health Center.)
On good days, follow a routine
Sleep, diet and exercise aren’t going to cure depression, experts stressed. (And implying that “can be really discouraging and invalidating for people”, Ross noted.) But establishing positive lifestyle strategies might make harder days easier to manage. “One of the things I hear patients talk about a lot is going into ‘rotting’ mode in bed,” Ross said. “Maybe when I feel good in my follicular phase, maybe I run every day. That’s not going to happen during the high-symptom phase, but could I still go for a 20-minute walk?”
Catherine Monk, a clinical psychologist and the Diana Vagelos Professor of Women’s Mental Health in obstetrics & gynecology at Columbia University, suggested making a list of calming activities you love, then trying to do at least one on high-symptom days: “Not that it’s going to make you feel fantastic, but it can help.”
Establish a safety plan
While not everyone with PMDD or PME of depression will have life-threatening thoughts, studies show that women with premenstrual disorders may have a higher risk of self-harm. In a 2024 study published in the American Journal of Psychiatry, Ross, Eisenlohr-Moul and other researchers found that the menstrual cycle could worsen suicidal ideation and planning among psychiatric outpatients who’d had suicidal thoughts in the month prior. If your symptoms become severe, work with your medical team to put a safety plan into action on high-symptom days, Monk said.
Most importantly, no one experiencing depression should suffer in silence, they said. Regardless of whether your depression is chronic, then gets worse around your period, or only appears leading up to menstruation, help is available.
“We don’t want to contribute to this idea that all women have PMS, or all women with depression are depressed because of their hormones,” Eisenlohr-Moul said. “Having said that, if you are a woman with depression, you are at greater risk of having these hormone sensitivity changes, and it makes sense to track and see if you are one of those people.”