Premenstrual Exacerbation: When Your Period Can Be Life-Threatening

4 min read

Feb. 24, 2023 – Most women are aware of the emotional ups and downs that can occur before their monthly period, known as  PMS, or  premenstrual syndrome. Some women's PMS symptoms are so severe that they may receive a diagnosis  of  PMDD, or premenstrual dysphoric disorder, which often  comes with severe mood swings. But a lesser-known condition might be the worst of all: premenstrual exacerbation, or PME. 

PME occurs when there are hormonal changes in the luteal phase of your cycle, between ovulation and menstruation. One or 2 weeks before a woman's period, PME can cause the symptoms of a preexisting disorder, like major depression, generalized anxiety disorder, schizophrenia, bipolar illness, or other mood disorders, to flare. One study found that 58% of women with depressive disorders also have PME, raising their risk of suicide during this premenstrual phase. 

“PME, PMS, and PMDD are all related to mood problems before your period,” says Lauren M. Osborne, MD,  vice chair for clinical research in the Department of Obstetrics and Gynecology at Weill Cornell Medicine and New York-Presbyterian Hospital in New York City. “The difference is, women with PMS and PMDD don’t have a mood disorder. PME causes really significant mood symptoms 2 weeks before a woman’s period if she has an underlying mental health condition.”

Women with PME show an abnormally heightened sensitivity to fluctuating sex hormones during their menstrual cycle, which appears to be its trigger, according to German researchers

What Are the Symptoms of PME? 

PME can manifest itself through “premenstrual breakthrough." This means that symptoms of a mental health condition that can be controlled when a woman isn’t premenstrual become more obvious when she is. For example, if a woman takes medication for bipolar disorder, she may find that the dose that normally works well suddenly isn’t preventing her from having mood shifts. 

“The difference between PMS, PMDD, and PME is often a different symptom quality,” says Monica Rosen, MD, an obstetrician-gynecologist at University of Michigan Health Von Voigtlander Women's Hospital in Ann Arbor, MI. “You can feel anxiety before your period with PMS or PMDD, but with PME, you’ll have a full panic attack.”

According to the International Association for Premenstrual Disorders (IAPMD), symptoms of the following conditions can also worsen due to PME:

  • Alcoholism
  • Attention deficit hyperactivity disorder
  • Borderline personality disorder
  • Schizophrenia
  • Eating disorders 
  • Posttraumatic stress disorder
  • Persistent depressive disorder
  • Psychosis
  • Substance use disorders

How Is PME Diagnosed? 

PME is not yet a recognized diagnosis on its own. Rather, it is linked to the diagnosis of an underlying mental health condition.

“It’s much harder to manage a depressive episode or anxiety attack when it comes on seemingly out of nowhere,” says Sabrina Romanoff, PsyD, a clinical psychologist in New York City. “In PME you have the advantage of time, which affords knowledge of the days which might be more difficult.”

But “many women who have PME haven’t recognized that they have a mood disorder,” says Osborne. “They may have undiagnosed depression, and seeking help for PME symptoms is often the way they get that diagnosis.”  

According to the IAPMD, about half of women who seek medical help for what they believe is either PMS or PMDD discover they actually have PME, or a psychiatric condition they were unaware of. 

To confirm PME, a doctor will most likely ask the patient to note how they feel right before their period.  

“It’s important to be self-aware of what specific symptoms trigger you,” Rosen says. “Many of my patients use a tracking app, which is very helpful in identifying how you feel on any given day.”  

How Is PME Treated? 

PME is primarily addressed by treating the mental health condition that causes your symptoms to worsen.  

“For women who do have a diagnosis and are using antidepressants, bumping up the dose during their premenstrual period may stop their symptoms,” says Osborne. “Sometimes when we properly treat depression, PME goes away.”

If not, stepping up other forms of treatment can make a difference. 

“Talk therapy is always helpful,” says Rosen. “Also, medication to help with hormone cycling such as birth control pills or rings can work for many women.” As a last resort, some women may elect to have surgical menopause to stop extreme PME symptoms.

It’s important to know that self-help can also make a big difference in gaining relief from PME. 

For instance, it might be helpful for women who have PME to rearrange their schedule the days before their period to lighten the workload and avoid excess stress as much as possible. 

Those struggling with PME should also avoid isolating themselves from others.  

“Schedule time with your friends in advance,” suggests Romanoff, as this sense of connection can help lessen symptoms. Patients can also find PME support groups online, to talk with other patients who can offer great advice.

The bottom line: “PME is controllable," says Romanoff. 

Take PME seriously, but don’t focus on fear. Instead, seek out the help you need, and look forward to feeling better.