Neha Pathak, MD, FACP, DipABLM: Welcome to the WebMD Health Discovered podcast. I'm Dr Neha Pathak, WebMD's Chief Physician Editor for Health and Lifestyle Medicine. While many of us have heard of or experienced PMS linked to our menstrual cycles, today, we're going to discuss a lesser-known condition that impacts about 1.6 percent of the population, or 30 million people worldwide—PMDD, or premenstrual dysphoric disorder.
Very few of us know about the way this intense form beyond PMS symptoms can impact our daily lives. So it's hard to know how to manage it, treat it, or even discuss it with our doctors. So if you've consistently felt like your time of the month is more than just PMS—where overwhelming mood swings, irritability, or intense fatigue take over so dramatically that it leaves you feeling unrecognizable—it's important to learn more about PMDD.
We'll explore why sudden drops in estrogen can amplify everything from irritability to brain fog, and how it impacts our relationships, jobs, and sense of self. We'll also tackle the big questions many of us are likely asking: How do I know if it's PMDD, severe PMS, or a different mood disorder altogether?
How do life's other hormonal shifts—for example, postpartum mood changes or mood shifts during perimenopause—interact with PMDD? And most importantly, if you do have this condition, what are the treatment options, hormonal or otherwise? We'll look at everything from continuous birth control to lifestyle strategies and symptom-tracking methods that can help us take back control of our lives. If you've ever suspected your body's monthly rhythms were throwing your entire world off track,
this conversation is for you. But first, let me introduce my guest, Dr Heather Hirsch. Dr Hirsch is the founder of the Menopause and Midlife Clinic at the Brigham and Women's Hospital and also served on the faculty at Harvard Medical School.
She's board-certified in internal medicine and completed advanced fellowship training in women's health at the Cleveland Clinic. She's now the CEO and founder of a private telemedicine practice, The Collaborative, by Heather Hirsch MD, which provides care for women in midlife.
She's also the author of her first book, Unlock Your Menopause Type, which hit shelves in 2023. Her specialty practice focuses on menopausal hormone therapy, perimenopause, breast cancer survivorship, sexual dysfunction, bone health, and other conditions common to women in midlife. Welcome to the WebMD Health Discovered podcast, Dr Hirsch.

Heather Hirsch, MD: What a pleasure to be here. There's so much I'm looking forward to talking about.

Pathak: Me too. So before we jump into our conversation, I'd love to start with your own personal health discovery around how you became interested in the topic of PMDD and women's health. You are an internal medicine doc. I'm an internal medicine doc. But it seems like you have really dived into this world, specifically around women's health.
So can you tell us a little bit about that journey? And was there an aha moment working with your patients that led you down this path?

Hirsch: Yeah, absolutely. I always wanted to take care of women, and so I thought that that meant OB-GYN. So I did spend a year and a couple of months in OB-GYN residency, but I quickly realized I really loved helping women make complex decisions, and I would much rather talk all day than do surgery. So I transitioned to internal medicine and became board-certified in internal medicine.
And during that transition—because I stayed at the same training hospital—so many of my internal medicine colleagues knew me as the former OB-GYN resident. So I would get so many questions about women's health. It really surprised me, and I realized there was kind of this gray area between OB-GYN, where these doctors are trained very intensely on gestation, pregnancy, surgery—and internal medicine.
Whereas internal medicine residents, you spend so much time learning about the whole body, but it's kind of easy to skip over some of the gynecologic conditions because, well, that's for the gynecologist. But they're not learning it either.
So I then did a two-year fellowship at Cleveland Clinic that was focused on hormonal health. I spent the majority of my time learning about perimenopause, PMDD, and menopause. And I really just had my aha moment that there was this really big gap in women's hormonal health that no one was really doing with just the intensity that's actually really needed. And that just became my mission, my passion, and my focus for the last decade plus.

Pathak: Let's just take a step back. We hear these terms in common parlance—PMS, PMDD. So can you take a step back and help us define what these terms are?

Hirsch: I always say PMS is a physiologic process, not a social construct. Certainly you cannot get away from seeing some movie or TV show where they're kind of poking fun at that time of the month. What's really happening each and every cycle is the estrogen is declining before menstruation and progesterone is rising.
This helps us so that we can potentially have to get pregnant every month—not that in today's society that's what we're necessarily always aiming for. When the estrogen declines, women can feel this, oftentimes closer to perimenopause. This can bring about symptoms of low estrogen like hot flashes before your period, or brain fog, or vaginal dryness.
And as progesterone increases, that can make us think of bloating, or maybe salt and chocolate sweet cravings, the formation of acne—as both estrogen is declining and progesterone is increasing.
So every month there is this physiologic process, and that is premenstrual symptom or syndrome, or PMS. PMDD, which stands for premenstrual dysphoric disorder, is kind of taking that PMS up on steroids a little bit. It's really when patients feel this shift so intensely that it really impacts their function and their quality of life.
So they may have severe brain fog, huge amounts of irritability, anger, and hostility—and that's the estrogen declining, because actually estrogen increases serotonin in the brain. So it acts like a natural antidepressant.
Bloating, water retention, weight gain, can't get your rings on and off. Women with PMDD—as the nickname for premenstrual dysphoric disorder—will really find that their quality of life suffers so immensely that it disrupts relationships not just at home, but also at work. And they find themselves very, very disarmed and struggle during this time of the month.

Pathak: Can you talk a little bit about how you go about diagnosing PMDD? And I say this because—I'm sure you experience this personally and amongst your patients—is that we are really great at forgetting and not recognizing patterns. Sometimes it's sort of like when you're over that phase and you're back to your normal, you may not even recognize how hard things were. So how do you go about making the diagnosis?

Hirsch: Wonderful question. You know, the same thing exists for perimenopause—and we’ll talk about that—because PMDD can really, really flare in late thirties and early forties, as women are also experiencing perimenopause. But these are both clinical diagnoses.
The way I say that is—I’m the clinician, so I decide. So there is no lab test, which for clinicians, we—you know, that can sometimes make it easier. We can clearly diagnose hypertension or diabetes because we've got clear cutoffs, but this is really a clinical diagnosis.
So therefore, what I like to do is—if I have a patient who is either describing what sounds like severe PMS or potentially PMDD, or thinks they have it—I like to, in an ideal world (we don’t live in one necessarily), have her journal and track for three or four months. That gives her three or four cycles to really journal and track and see how bad those symptoms are and how much they affect her quality of life.
Now, you can also do this retrospectively if they've been doing that. Or, for me, people tend to come to me by the time they've seen several other clinicians. It can take on average five or six visits with a clinician or healthcare provider—your OB-GYN, a psychologist, a psychiatrist, a sleep doctor, your internist—to get the diagnosis of PMDD.
So it's really up to the clinician to decide. But when they say keywords like, I have almost gotten fired several times during this time of the month. There's a cyclic pattern to this mood. I've almost tried to divorce my husband. I've gone off on my children—any type of pattern where you see this repeated type of extreme behavior that they feel just is not like their normal self—you can really cinch that diagnosis.
And then—we'll probably continue to talk in this episode—but what else is actually very helpful is, sometimes treatment is not only therapeutic but diagnostic. If you do treat with hormonal support and they feel like they function much better, that's going to also cinch that diagnosis pretty clearly for you.

Pathak: That’s really helpful. And how do you differentiate PMDD from other mood disorders like major depression?

Hirsch: Great question. So you’ll tend to see this cyclic pattern. If anything, I want to tell you a story about a patient that I had, because this will put this in clear perspective.
When we think about the cycle—although not every woman has a beautiful 28-day cycle—you've got the first two weeks after menstruation, which is your follicular phase, and then the last two weeks of the menstrual cycle, which is the luteal phase.
So during the follicular phase, estrogen tends to rise. And estrogen helps increase serotonin in the brain. Not always—some women certainly react slightly differently to hormones. Some women don't really seem to be impacted on a day-to-day basis. But let’s go through the cycle for learning purposes.
As that estrogen is increasing—typically around day 14, or ovulation—women tend to feel pretty well. They'll say they feel energized, cognitively really sharp, maybe their libido goes up because there should be a testosterone spike a few days before ovulation.
So they're feeling really good. Then we go into the luteal phase, where that estrogen tends to decline and the progesterone is increasing. So as progesterone rises, there can be irritability, low mood, sometimes heat intolerance, bloating, water retention, exhaustion—because progesterone can make you feel a little tired—cravings, migraines, or acne.
So when you see this kind of cycle, it can really help when you look at their different behaviors. With something like major depressive disorder, there's going to be more of a persistent low mood that doesn’t have such an almost predictable variation.

So my one patient said to me:
"After my period, for the next seven days, I want to eat fruits and vegetables, and I'm starting to feel really good and motivated.
The next week, I am so happy. It’s all lollipops and cotton candy, with a dash of chickpeas and hummus, and I'm just feeling great.
The week after that, I start to feel really moody. I'm getting a little more irritable. I'm starting to eat the snacks in my house—lots of carbohydrates, junk food.
And then the next week—oh my gosh—it’s pizza, Coke, I’m laying in bed. I’m miserable. I’m snapping at everyone. I don’t want to go to work. I won’t get out of bed. I won’t put my clothes on.
Then the next week—boom—I’m right back to eating well and feeling good and starting to get back into exercise."

And so I tell that story because—even though it’s a little exaggerated—that can really help you see that there is this cyclic nature to the mood swings. And again, when they really impact life, when a patient can say just like that—that’s how I feel each week out of the month—you’ve probably got PMDD on your hands.

Pathak: Wow. I don't think you could have painted a better picture. That was really helpful. What are some of the risk factors? What are some of the pieces of information that might suggest that this is going to be something that a certain population is going to be at higher risk for than others?

Hirsch: You know, again, this is such an area ripe for research because so much of this is still coming out right now—as women are learning about it, as we're teaching it.
So any type of history of mood disorder could be a risk factor. It's not a definite risk factor, because there is a difference between generalized anxiety disorder—which is more of that low-level anxiety around things like remembering your to-do list, paying bills, or squabbles with your neighbors—that's going to be fairly consistent.
Major depressive disorder, of course—anhedonia, the lack of joy—all of that is going to be a little different. But any type of mood disorder could increase the risk that you could have or develop PMDD.

In my decade-plus of treating women for hormonal imbalances—I don’t love the word imbalance, but there's no better word—I do seem to see that it tends to be more of a quality-of-life factor as they get into their thirties and forties. And I think that's when there's even more natural hormonal disruption, which is perimenopause leading to menopause.

Another risk factor we can look at is postpartum or peripartum mood disruptions. Those, again, are associated with big swings in hormonal changes.
During the first trimester of pregnancy, there is a lot of progesterone. In fact, progesterone’s main role in the body is to sustain a first-trimester pregnancy until the placenta is formed. That is why—if anyone listening has ever had a first-trimester pregnancy—you feel so exhausted and tired during that time. You’re not even really big yet, right?
And it’s interesting—second trimester, we tend to get a lot more energy even though our body is changing even more. That again is the impact of progesterone.

So sometimes when women say first trimester pregnancy, I felt horrible, I’m thinking—okay, there’s definitely a sensitivity to progesterone, which causes that rest, that sedation, and sometimes water retention. Progesterone is also going to slow the digestive tract because it's trying to absorb all the nutrients for the growing fetus.
And then postpartum depression—when you have this massive drop in estrogen—could also be a risk factor for developing PMDD as that estrogen declines.
Of course, if you've had a baby, you can see the temperature irregularities, the shivers, and even not being able to feel comfortable in your skin for a little while after delivery. Mood changes, night sweats—those kinds of things—and those can put you at increased risk for PMDD.

Pathak: So you have this patient that you are working with, and you're very confident about the diagnosis—or at least you're confident enough that you want to do something that can potentially help you confirm the diagnosis. So then let's get into what we can do about it.

Hirsch: I think treatment is so individualized because the first treatment that we could offer would be some type of contraception that's going to stop ovulation. Now, I'm gonna come back to this again and again. I'm also gonna talk about how there are other ways besides just stopping ovulation, actually, for me.

But this could be selection bias for the women who come to see me. Sometimes I use low-dose postmenopausal hormone therapy, and some women prefer that by the time they're in their late thirties or forties—if they've had bad experiences with any type of oral contraceptives in the past, or they don't want to use one for whatever reason they may have.

So let's go back to the example of my patient. She actually did not want to use birth control. But again, if you did use birth control—let's sit here on that for a moment. If you're gonna use a traditional combined ethinyl estradiol and progestin birth control—so your standard estrogen-progesterone birth control pill—if you give that to someone with PMDD, if it's stopping ovulation, then really, they're going to be getting more of a steady state of hormones every day, be it in the pill. And that should therefore stop both the good stuff that comes from the follicular phase and the disruptive stuff that comes from the luteal phase.

Now, a big caveat here is that women with PMDD should not be using placebo pills because placebo pills can disrupt the treatment. So if you're going to use birth control pills for a woman—we're, again, going to use our traditional combined oral contraceptives—I would write these pills to be taken one active pill daily. Do not take placebo pills, and make sure you're prescribing three months at a time. Another way to do this would be something like a 91-day pill pack.

For any clinicians listening—if women really can't tolerate continuous usage because they continue to get breakthrough bleeding—then it is best to stop it for just a few days and then restart it. The more continuous or steady the levels of those combined oral contraceptives that they're taking, the better.

So that's how you could use birth control pills. You could also use any other type of contraception—the IUDs—because the IUDs do not stop ovulation, so not necessarily any of the intrauterine devices. But you could also do the same concept of overriding the woman’s hormonal system by using something like the NuvaRing or even something like a Nexplanon, which is the long-acting birth control that goes in the arm, or high doses of progesterone like the Depo-Provera injection.

However, it's still important to talk to those women about side effects, and so they'd really want to make sure that they also want to be using that type of contraception to help treat their PMDD, if that makes sense. But I'll actually give you a little second to ask me any questions—I might go into also how I use postmenopausal hormone therapy.

Pathak: Yes, that is exactly what I wanted to ask you next.

Hirsch: So what we do a lot of times with my patients who are getting a PMDD diagnosis in their late thirties, early forties, mid-forties—but they don't want to take birth control pills for whatever reason—sometimes what I do is I will use a postmenopausal estrogen patch the week before their period.

When that estrogen is really declining and they really start to feel it—that estrogen drop triggers the mood disruptions, the short fuse, the irritability, the anger, the hostility, the sleeplessness, the hot flashes—I will actually support that drop using a postmenopausal dose of estrogen.

Now, it doesn't have to be necessarily a patch. There are many ways to use postmenopausal estrogen. Without getting too nuanced in this episode, sometimes a patch is really easy for women who have busy lives at this time—usually during this decade. They can put a twice-a-week patch on or a weekly patch on, let’s say the week before they're about to menstruate or two weeks before they're about to menstruate, and see if even just something as simple as that can support them. And oftentimes it really does.

Pathak: So let's talk a little bit about lifestyle interventions. Is there data around nutrition, exercise, stress management techniques that can help stabilize moods during the luteal phase in particular?

Hirsch: Absolutely. So let's start with lifestyle. For example, let's go back to my patient. She would start to work from home the week before her period, and that helped so much—just so that she didn't feel as though there was so much stimulus that was triggering the anxiety.

When it comes to exercise, this is really important. We want to do some exercise that's a little bit gentler and that will stimulate the parasympathetic nervous system. So it's maybe not the best time for high-intensity interval training, but maybe more yoga, or walks or hikes, or even just some gentle stretching, flexibility, and mobility exercises.

So that can be very, very important. And they also know to be really cognizant of their diet during that time. So trying to avoid over-caffeinating, overstimulating. You know, I gave you the example of my patient who felt like all she wanted to do was sit in bed and eat junk food during the week. Well, now she actually knows how important it is not to do that—because maintaining a nice glucose level, not having those spikes in glucose and drops, is going to keep her brain happier as well.

So we've got her on a really nice, actually clean diet, and what she does is she meal preps a week before when she's ovulating and she feels great. She meal preps, she puts everything in the freezer so that she's ready to go. So the lifestyle changes are really, really important. Treatment, of course, with medications is—but nothing can really help to support a woman through this more than knowing that this is coming and knowing how to best function and live and treat her body during that time.

Pathak: So for the person who's listening, who suspects that they might have PMDD or someone that they love has it, what do you think is the best way to start opening up, start asking questions, start introducing this idea to your clinician? Because to your point, not all clinicians may be super familiar or comfortable in making this type of diagnosis. And then how do you suggest fighting the stigma around it—or even this internal dialogue where we, as women, often think, “Well, I’ve just got to power through this”?

Hirsch: I'll tackle that first—because there is no medal for powering through it. And truthfully, it can derail your long-term health goals. It can derail your personal and family and work goals. As I think about what luxury is in 2025, I do think it's health and wellness. I love the corner that we're turning here.

And so for anyone listening—there is no medal here. In fact, it's going to derail your personal health goals, because there is great treatment for you. You're going to feel and function so much better—and everyone around you is. And that might not even include needing pharmaceutical treatment. That just may mean getting the diagnosis and really being able to better set your life up for success. But it certainly could include treatment.

So what do you do if this sounds like it could be you? Start journaling and tracking. That is the very first thing you gotta do. Journaling and tracking for as many months as you can is going to be the clinical gold—that is how someone's going to actually make the diagnosis.

Just like I did, you could get a calendar, you could do it on your phone, and you can really see: What is your mood like? What are the things that you're craving? How are you sleeping? How is your productivity?

You can start to see if you have this rainbow-like effect, where you get this peak mid-cycle and then this drop before your period. Then note: How is it really affecting your quality of life? Because that really makes the difference.

Then what you want to do—if you think this is you—is start with your internist or your OB-GYN. And I always say start here because when you do—and your doctor may not be sure—it is going to trigger in them, time and time again, as women keep coming and asking, the realization that they really need to seek out this education. So this is going to be helpful for everybody.

And then you want to make a problem-focused visit. Go and talk to your doctor with all of your beautiful data and really synthesize it for them in a few minutes: “Look, I’m noticing that I have this cyclic pattern that goes right along with my cycle. My first week’s this, during ovulation I’m like this, and then I’m like this during my luteal phase. And it's affecting my quality of life in one, two, and three ways. I heard about this, and I’m wondering if treatment is right for me.” Because one of the things about trying treatment is it might help you realize if you actually do have this diagnosis.

And if that doctor’s not sure—look for a second opinion. And keep on going until you get the answers you deserve.

Pathak: That is really concrete and super helpful. So we're coming close to the end of our time together, and I'd love to hand it over to you for some final action items. If you could really talk to someone listening right now, what are some of the key takeaways and the key things you'd like them to do?

Hirsch: The key takeaway, I think, is that as women, we are so strong—and we don't give ourselves enough credit for the ways our bodies change every single day. The hardest thing that men physiologically and hormonally go through is puberty, whereas women’s bodies change from day to day.

Give yourself some grace if you feel totally different on Monday versus Tuesday, because there is such a huge physiologic change in our cycles. I think just picking up a pen and spending two or three minutes a day at the end of the day thinking about how you felt that day—and starting to look for any patterns—could be helpful.

Talk to your family. Talk to your mom, maybe, if you have any sisters, any female cousins. Because as you continue to talk, if you learn—even if you're just asking questions—you’re going to start to stimulate dialogue and conversation and normalize the fact that women have massive hormonal disruptions. Yes, I don’t know if you want to say “changes” on a nearly daily basis. And knowing that should give you a lot of superpower—that we really, really are amazing, amazing creatures and we do so much.

But at the same time, I feel as though the medical educational system really has to increase the education that we give to young doctors-in-training, medical students, and residents so that we can all do better—not only for ourselves, because many clinicians are women—but for each other. That’s my main takeaway from today.

Pathak: Love it. So important, and I’ve learned so much in this conversation. I feel like I understand myself better. It's so important, to your point, to give ourselves grace for how much we do do every single day. I think the way that you have framed it is just so important—that we don’t need to accept things that are disrupting our lives as normal, that we can seek help, and that it’s really, really important that we do. So, so, so thankful for your time today, Dr Hirsch.

Hirsch: Thank you so much for having me.

Neha Pathak: Thanks so much for joining us for this discussion about PMDD. We learned why common ideas around PMS don't do justice to a condition that can trigger drastic mood swings, irritability, and physical symptoms like bloating and fatigue. Dr Hirsch stressed the importance of noticing patterns across our cycle and across our lives—especially if you feel like an entirely different person during the luteal phase of your menstrual cycle—and how journaling for even a few months can reveal a clear story that most lab tests won’t be able to capture.

We also discovered that PMDD is treatable—whether through targeted hormonal approaches that treat hormonal turbulence or through carefully timed medications. And for all of us, thinking about how our lifestyle plays a role is also critically important—thinking about ways that we can lower our stress, thinking about optimal times to switch up our workout, whether that means less of an intense workout during those periods where we feel really, really fatigued. All of that can make a real difference as well.

Most of all, we heard that there’s no reason to suffer in silence. If these monthly ups and downs are affecting your relationships, job, and mental health, it’s time to reach out to a healthcare professional. Understanding your unique hormone patterns can be the key to breaking the cycle of challenging symptoms and reclaiming a sense of balance throughout the month.

To find out more information about Dr Heather Hirsch, visit heatherhirschmd.com. We'll also link to more information about how to connect with her in our show notes.

Thank you so much for listening. Please take a moment to follow, rate, and review this podcast on your favorite listening platform. If you’d like to send me an email about topics you’re interested in or questions for future guests, please send me a note at [email protected].

This is Dr Neha Pathak for the WebMD Health Discovered podcast.