By: Jackie Piasta, DNP, WHNP-BC, MSCP

By Jackie Piasta, DNP, WHNP-BC, MSCP

Many women already know a truth medicine is only recently starting to acknowledge: hormonal changes can profoundly affect mood, energy, sleep, cognition, and overall functioning. Yet conditions such as Premenstrual Disorders (PMD), Premenstrual Dysphoric Disorder (PMDD), and perimenopausal mood disturbances are still misunderstood, minimized, or brushed aside as “normal PMS” or “just getting older.”

At Monarch Health, we want you to understand what’s happening in your body—and remind you that your symptoms are real, valid, and treatable.

In this article, we’ll explore:

What PMD and PMDD actually are
How hormonal sensitivity affects mental health
Why perimenopause often intensifies mood symptoms
The connection between PMDD and perimenopause
Treatment options, including when menopausal hormone therapy (MHT) can help

What Really Happens in Premenstrual Disorders (PMD)?

Premenstrual Disorders (PMD) include a range of emotional, physical, and cognitive symptoms during the luteal phase (the 1–2 weeks before your period).

Why symptoms appear

Your hormone levels are usually normal—but your brain’s sensitivity to natural hormonal shifts varies. Estrogen and progesterone heavily influence neurotransmitters such as:

Serotonin (mood, impulse control, sleep)
GABA (calming, stabilizing)
Dopamine (motivation, reward)
Norepinephrine (stress response)

When these hormones rise and fall, some women experience outsized neurological responses—leading to:

Common PMD symptoms

Low mood
Irritability or sudden anger
Brain fog
Anxiety
Fatigue
Bloating or headaches
Sleep disruption
Emotional sensitivity

For many, these symptoms are unpleasant but manageable. For others, they interfere with work, relationships, and daily functioning.

PMDD: When Premenstrual Symptoms Become Debilitating

Premenstrual Dysphoric Disorder (PMDD) affects an estimated 3–8% of menstruating women—some studies suggest up to 10%.

Unlike PMS, PMDD is a severe neurobiological condition tied to hormonal sensitivity, not hormonal imbalance.

How PMDD differs from PMD

PMDD is not “worse PMS.” It is a biochemical sensitivity to normal progesterone fluctuations, which disrupts:

Serotonin activity
GABA pathways

Symptoms may include:

Intense anxiety or panic
Rage or severe irritability
Hopelessness or depression
Social withdrawal
Feeling “out of control”
Difficulty concentrating
Suicidal ideation (in severe cases)

These symptoms appear cyclically—starting after ovulation and improving once bleeding begins.

Why certain treatments work

SSRIs

Work quickly in PMDD (often within days)
Target serotonin dysregulation caused by progesterone sensitivity
Can be taken only during the luteal phase—a unique advantage

Hormonal contraceptives

Reduce symptoms by suppressing ovulation, smoothing hormone fluctuations
Effective for some—worsen symptoms for others due to synthetic progestin sensitivity
Drospirenone-containing pills may be more helpful for hormone-related mood symptoms

Why treatment varies so much

PMDD is driven by sensitivity, not hormone levels.
The key is identifying where in the cycle the sensitivity occurs and matching treatment to the underlying neurochemical pattern.

Perimenopause: A Midlife Hormonal Transition That Affects Mood

Perimenopause is often called “puberty in reverse”—and for good reason. Hormones fluctuate dramatically for 4–10 years leading up to menopause.

What happens during this transition?

Estrogen levels spike, crash, and become unpredictable
Progesterone production becomes inconsistent
Ovulation becomes irregular
Neurotransmitters lose their stable hormonal support

Common perimenopausal mood symptoms

New or worsening anxiety
Mood swings
Irritability or emotional volatility
Depression or emotional flatness
Feeling overwhelmed
Brain fog or memory issues
Sleep disruption

These symptoms are biologically driven, not personal failings—and they are extremely common.

PMDD & Perimenopause: How Are They Connected?

For women with a history of PMDD—or severe PMS, postpartum depression, or mood sensitivity—perimenopause often intensifies symptoms.

Why?

Perimenopause causes dramatic hormone fluctuations
Women with PMDD are already sensitive to monthly shifts. Perimenopause multiplies these fluctuations.
Estrogen decline impacts serotonin
Low estrogen = less serotonin support → anxiety, depression, mood instability.
Progesterone decline removes its calming GABA-enhancing effect
Less progesterone = less natural neurological calm.
Research suggests PMDD is linked to earlier menopause
Some studies show women with PMDD may reach menopause slightly earlier.
Vasomotor symptoms worsen mood symptoms
Hot flashes and night sweats disrupt sleep → worsening anxiety and depression.

The good news

Once you reach menopause (12 months without a period), the PMDD cycle stops.

But support during perimenopause is crucial.

Treatment Options: What Works and Why

✔️ 1. Lifestyle & Behavioral Support

These approaches help stabilize the neurological foundation:

Regular exercise (boosts serotonin, endorphins)
Stable sleep-wake rhythms
Protein-rich meals and stable blood sugar
Limiting caffeine and alcohol
Cognitive Behavioral Therapy (CBT)

They are not “fixes,” but they strengthen every other treatment.

✔️ 2. SSRIs & SNRIs

Highly effective for:

PMDD
Anxiety
Depression
Perimenopausal mood changes

SSRIs can be used luteal-phase only for PMDD or daily during perimenopause.

✔️ 3. Hormonal Contraceptives

Helpful when:

Ovulation triggers symptoms
PMDD symptoms worsen with progesterone fluctuations
Smoothing cyclical rises and falls is the goal

Not ideal if:

You are sensitive to synthetic progestins
Or struggle with libido

✔️ 4. Menopausal Hormone Therapy (MHT)

MHT can be extremely helpful for perimenopausal mood symptoms.

Why estrogen helps

Enhances serotonin and GABA activity
Improves sleep
Reduces hot flashes and night sweats
Stabilizes brain responsiveness to stress

Transdermal estrogen (patches, gels) provides gentle, steady levels—ideal for mood stabilization.

Progesterone matters

If you have a uterus, you need progesterone
Micronized progesterone is often the most mood-friendly
Some synthetic progestins can worsen mood in sensitive individuals

Important:

MHT does not treat PMDD, since PMDD is ovulation-sensitive.
But it does help stabilize perimenopausal hormone fluctuations, which can significantly improve mood for women with a history of PMDD.

✔️ 5. Non-Hormonal Options

For women who cannot or prefer not to take hormones:

SSRIs/SNRIs
Non-hormonal medications for hot flashes
Low-dose anxiolytics
Newer neuro-modulating medications

Supplements such as magnesium, vitamin B6, and calcium may help some women—but research is mixed.

✔️ 6. Surgical Menopause (Only for Severe, Treatment-Resistant Cases)

In rare situations, a hysterectomy with ovary removal may be considered. This stops ovulation and the hormone fluctuations that trigger PMDD—but initiates surgical menopause.

This is never a first-line option.

When to Seek Help

If your symptoms are:

Disrupting your work or relationships
Causing hopelessness, anxiety, or panic
Occurring in a predictable cyclical pattern
Worsening during perimenopause
Interfering with sleep, memory, or daily functioning

…it’s time for an evaluation.

Final Takeaway

Hormonal changes are never “just in your head.”
PMD, PMDD, and perimenopausal mood shifts arise from real biochemical processes—and with the right support, women can feel balanced, steady, and well throughout every stage of life.

You deserve care that understands the interplay of hormones, mood, and your lived experience.

Your symptoms are real.
Your experience is valid.
You do not have to suffer silently.

Understanding PMD, PMDD, and Perimenopause-Related Mood Changes