Effects of Premenstrual Symptoms on Bipolar

How Premenstrual Symptoms and PMDD Can Worsen Bipolar Disorder

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Bipolar Disorder and PMS. Jessica Lindahl / EyeEm / Getty Images

What are the effects of premenstrual symptoms (PMS) or premenstrual dysphoric disorder (PMDD) on bipolar disorder?

Let's take a look at what studies tell us about premenstrual symptoms superimposed on bipolar disorder, how these symptoms can be distinguished from one another, some testimonies from women who have experienced this dreaded double duo of symptoms, and what can be done to manage the symptoms.

As a final question, is the diagnosis of bipolar disorder ever missed, and the symptoms mistakenly attributed to premenstrual dysphoric disorder?

Effects of Premenstrual Symptoms on Bipolar Disorder

Living with bipolar disorder alone should be enough, yet recent studies tell us that many women with bipolar disorder have a worsening of symptoms during the premenstrual period.

While it may seem obvious that the irritability of premenstrual tension would accentuate the symptoms of bipolar disorder, researchers have been able to demonstrate specific ways in which these monthly symptoms may exacerbate bipolar disorder. Women who report significant premenstrual symptoms:

  • Have more episodes related to their bipolar disorder, most commonly depressive episodes
  • Experience less time between episodes
  • Have episodes which are more severe (including depressive, manic, and hypomanic episodes)

Overall, women who have premenstrual symptoms which exacerbate their symptoms of bipolar disorder have a worse course of illness, a shorter time to relapse, and more severe bipolar symptoms.

How Common is PMS and PMDD in Women with Bipolar Disorder?

A large meta-analysis (a study that compares the results of several different studies) found that 44 to 68 percent of the women with bipolar disorder had some premenstrual-related mood changes, 22 to 77 percent of women with bipolar disorder met the criteria for premenstrual dysphoria, and 15 to 27 percent met the criteria for premenstrual dysphoric disorder (PMDD.)

Premenstrual Symptoms vs Premenstrual Dysphoric Disorder

Premenstrual symptoms, when they occur, usually occur during the luteal phase of a woman's menstrual cycle. This usually corresponds to the two week period between ovulation (which generally occurs mid-cycle) and the time menstruation begins.

The different terms used to describe these symptoms are based primarily on the severity of symptoms. Premenstrual syndrome (PMS) is used to describe the very common irritability and emotional lability in women before their periods. Premenstrual dysphoric disorder has specific criteria, yet it comes down to PMDD being present when premenstrual symptoms significantly affect your quality of your life.

It's important to note that there may be overlap as a woman's premenstrual symptoms can vary month to month.

Can Bipolar Disorder be Misdiagnosed as PMDD?

The answer to whether or not someone can be erroneously be diagnosed with PMDD when they really have bipolar disorder is yes. This is one reason it is important for women with PMDD to track their symptoms (see below.)

Accessing the Role of PMS in Bipolar Disorder - Tracking Your Periods

It can clearly be helpful to determine if PMS or PMDD are exacerbating your bipolar disorder, but unfortunately, this isn't very easy.

There are no blood tests or hormonal tests, and the only way to figure this out is to track your symptoms daily for at least two months.

Some women keep a journal, making a note each day. A somewhat objective way is to write down symptoms such as irritability and energy level, giving each of these symptoms a number between one and ten. For example, you could rate your irritability level as one, meaning you barely feel irritable, or a ten, referring to irritability that is as bad as it ever gets.

There are other tools which can help you follow your symptoms such as PMDD symptom tracker, or one of the phone apps available such as Clue Connect,

Tracking periods can also be helpful for those who have been diagnosed with PMDD but are concerned that they may actually have bipolar disorder.

Testimonies About the Effect of Premenstrual Symptoms on Bipolar Disorder

Sometimes hearing the words of others describing the relationship between PMS and bipolar can be helpful. You may see yourself in some of these testimonies. It is also helpful in reminding women with bipolar disorder that they are not alone.

Here are the testimonies of four women:

Rider: "This hit home for me. I can tell you that premenstrually, I’m a mess with my bipolar! I would be full of rage and anger about a week before my period. Nothing helped that feeling until after I got my period, and then I’d be down in despair again. The yoyoing was exhausting. I would throw things, cry uncontrollably, not sleep. All the depressive symptoms came back, and I thought, “Here I go again.” I added Abilify to my meds, and it seemed to keep me more level for about a month. It boosted my confidence - and then everything fell apart again. One morning, I had an episode so bad it seemed impossible to get out of the funk. The physical side effects of Abilify added to my depression and made me want to get off the med, so it’s back to the doc for more advice."

Sam: "Yes, things definitely got worse premenstrual. My cycles were only 23 or 24 days long, and for a week before and three days after I was awful, a total basket case. So for 10 out of every 23 days living was hell for me and my partner. I was agitated, angry, argumentative. It was miserable."

Geri: "I am so glad to see this addressed. I was diagnosed Bipolar II in my late 30s. Before that, I just figured I had raging PMS. My bipolar symptoms (mostly depression with a few days of hypomania rapidly cycling monthly. With journaling and my psychiatrist’s help, we were able to distinguish the bipolar symptoms from the premenstrual symptoms, because they didn’t completely match together. It’s a bit like the bipolar cycles on a solar scale (12 months/year) and the menstruation is on a lunar cycle (13 months/year). So, kind of like an eclipse, when they both happen together, it’s a mild explosion. I’m so glad to know I’m not alone. (Now, I won’t even get into what the type 2 diabetes and the fibromyalgia do to this dance.)"

Troya: "Most definitely, every month there is another dent in the dishwasher from me kicking it! My meds seem to manage the depression pretty well but I do notice that I feel quite low when I’m pre-menstrual. Like most women, I tend to be a bit teary and moody, but what is most frightening is that my anger gets out of control and I go into a full blown rage. I am normally a very placid person, but I seem to get so wound up over nothing, spit venom at everyone—even strangers on the telephone—and become very violent towards my furniture. Even my dogs seem to know and stay away. It really does scare me, and it takes me ages to come down from all that dark energy, leaving me totally exhausted afterward. Not fun at all."

Treatment/Management of PMS/PMDD with Bipolar Disorder

Since premenstrual symptoms and PMDD can significantly worsen bipolar disorder, it's important to control PMDD symptoms as well as possible. Treatment options for PMS/PMDD include:

  • Lifestyle changes - Avoiding alcohol and caffeine can be helpful, and exercise is critical. Dietary changes can make a difference and include eliminating high glycemic index carbohydrates as much as possible. A glycemic index chart can be helpful to figure out which foods this includes.
  • Alternative treatments - It is important to talk to your psychiatrist before trying any alternative therapies, though nutritional supplements such as chasteberry and calcium carbonate may help some people.
  • Relaxation therapy including activities such as meditation and yoga may help some people and have a low risk of side effects.
  • Birth control pills may help some people, though this approach is most effective for those with mild symptoms and can sometimes worsen symptoms. Estrogen patches, oral progesterone, and gonadotropin releasing hormones are second line treatments that may offer some relief.
  • Selective serotonin reuptake inhibitors (SSRIs) such as Prozac (fluoxetine) are often used for women without bipolar disorder but should be avoided for those with bipolar disorder (due to the risk of precipitating a manic episode.) If these medications are used they should most often be used along with a mood stabilizer or antipsychotic medications, and then only with extreme caution. Since SSRIs are used very commonly for people with PMS/PMDD, this is an important reason why it's important to distinguish between PMDD and bipolar disorder.


Dias, R., Lafer, B., Russo, C., Del Debbio, A., Nierenberg, A., Sachs, G., and H. Joffe. Longitudinal Follow-Up of Bipolar Disorder in Women with Premenstrual Exacerbation: Findings from STEP-BD. American Journal of Psychiatry. 2011. 168(4):386-94.

Teatero, M., Mazmanian, D., and V. Sharma. Effects of the Menstrual Cycle on Bipolar Disorder. Bipolar Disorder. 2014. 16(1):22-36.