Premenstrual syndrome is something many women are familiar with. From painful cramps and mood swings, lots of people experience PMS - but for some, the symptoms are debilitating. Around one in 20 women have symptoms severe enough to stop them living their normal lives, which can be the result of premenstrual dysphoric disorder - or PMDD - which can have a serious impact on mental well-being.
Olive Mackintosh-Lowe, 26, says her PMDD causes depression, lethargy and mood swings in the two weeks before her period.
"At its worst, it has led to the breakdown of a loving relationship; it has caused me to spend days unable to get out of bed to work or even to do smaller things like brush my hair," she says.
"I would be overwhelmed with despair as if my heart had been filled up with cement. For me, the mood swings are certainly the worst but there are many people who suffer physically or experience completely different symptoms around their period.
"The mood swings were how I spotted something was wrong - I am a passionate person but it is rare that I experience real rage," Mackintosh-Lowe adds. "However, without medication, I can be happily pottering through my day one minute and be consumed with a visceral, righteous anger the next."
What is PMDD?
Nick Panay, spokesperson for the Royal College of Obstetricians and Gynaecologists and chair of the National Association for Premenstrual Syndrome, says PMDD is a 'severe' form of PMS and affects 5-10% of women.
"The symptoms of PMDD are similar to those of PMS, but are more exaggerated and often have more psychological symptoms than physical ones. These can include feelings of hopelessness, persistent sadness or depression, extreme anger and anxiety, decreased interest in usual activities, sleeping much more or less than usual, very low self-esteem and extreme tension and irritability," he says.
"PMDD and severe PMS can have a profoundly negative effect on a woman's daily life. It is diagnosed when mood symptoms seriously affect relationships and stop women from functioning properly in their daily lives."
Is it PMDD?
Panay says that while it's normal for a woman to experience mild PMS symptoms, such as feeling upset, irritable or tired, you should see your GP if the symptoms are making everyday life difficult.
It can be helpful to take the PMDD treatment guidelines with you to your GP appointment. You can download guidelines from The National Institute for Health and Care Excellence (NICE) and the National Association for Premenstrual Syndrome (NAPS), which explain what the condition is and treatment options.
Sometimes people with PMDD can be wrongly diagnosed with other mental health problems such as depression because they share some of the same symptoms. It can also be helpful to ask to speak with a doctor who specialises in gynaecology or mental health.
What can help
Keep a symptom diary
Dr Shazia Malik, a consultant obstetrician and gynaecologist, recommends keeping a symptom diary.
"The first step is to keep a diary of your symptoms over two-three menstrual cycles - often getting the diagnosis can be the biggest hurdle. Once other causes for your symptoms have been ruled out, you should see a specialist who can help with specific symptoms," she says.
Your GP may recommend medication to treat feelings of depression.
"Finding the right medication has given me some relief from these awful symptoms but I had to drive my treatment every step of the way," Mackintosh-Lowe says.
Your GP may also recommend taking the pill - oral contraceptives - to help reduce the symptoms of PMDD by controlling or stopping your periods.
Although this helps some people, though, it may not necessarily work for everyone. Taking the pill may make some people's symptoms worse.
Some people may benefit from gonadotropin-releasing hormone (GnRH) analogues, which come as injections or a nasal spray and reduce the symptoms of PMDD by bringing on a temporary menopause.
Side effects include loss of bone density, which can lead to osteoporosis (weak or brittle bones), so treatment is often combined with hormone replacement therapy - which relieves symptoms of the menopause and reduces bone density loss.
In very severe cases and when all other treatment options have been exhausted, your GP may talk to you about surgeries such as a hysterectomy. This involves the removal of the uterus, which carries risks and is non-reversible.
Making some lifestyle changes can sometimes help improve your mental and physical health generally, which may help with the symptoms of PMDD.
Getting regular exercise can help because physical activity releases brain chemicals such as endorphins, which help boost our mood. A 2017 study by the Black Dog Institute found regular exercise can help prevent depression - and just one hour a week can help. Exercising can also help you sleep better too.
The charity Mind also recommends eating a healthy, balanced diet, reducing the amount of alcohol you drink, quitting smoking and reducing your caffeine intake too.
Self-care may help reduce the impact PMDD has on your life. You could try to manage your stress levels with relaxation techniques, such as yoga, meditation or mindfulness, which can help with unwanted thoughts.
Know your cycle
It can help to know your cycle, including dates and common feelings or thoughts. Mind recommends rearranging stressful events for different times, planning relaxing activities and even creating a self-care box.
A self-care box contains things which help you through difficult periods, such as your favourite book, photographs, mindfulness colouring books and other items.
Your doctor may recommend talking treatments to help manage the psychological symptoms of PMDD, such as depression and anxiety. Talking therapies give you a safe space to speak to a professional without judgement and may help you make more sense of things.
Talk to someone
Reproductive health and mental health should never been seen as taboo subjects and it's important to speak with other people if you are struggling.
Speaking to someone, whether it's a friend, family member or your GP, is often the first step you can take towards getting help.
Peer support can help alleviate feelings of isolation by connecting you with other people who have experienced PMDD.
The Gia Allemand Foundation provides more information about online peer support available for women with PMDD around the world, including links to online groups. You could also try Mind's Elefriends community, an online space for people with mental health problems.