Misdiagnosed and misunderstood: premenstrual dysphoric disorder

On this episode of the CMAJ Podcast, Dr. Mojola Omole and Dr. Blair Bigham explore Premenstrual Dysphoric Disorder (PMDD), a debilitating condition affecting 5% of people who menstruate, yet it is often misdiagnosed or misunderstood. The conversation builds on insights from the CMAJ article, “Five things to know about…: PMDD,” co-authored by Dr. Erin Brennand, an associate professor at the Cumming School of Medicine in Calgary.

Abhi Bala shares her lived experience with PMDD, describing the profound impact of cyclical depressive symptoms, suicidal ideation, and emotional dysregulation on her life. Her journey from misdiagnosis to awareness highlights the importance of tracking symptoms and recognizing patterns linked to the menstrual cycle, which can lead to earlier diagnosis and treatment.

Dr. Brennand explains how PMDD is frequently mistaken for depression or bipolar disorder, delaying accurate diagnosis and treatment. She highlights the importance of recognizing that PMDD's cyclical symptoms align specifically with the luteal phase—the final two weeks of the menstrual cycle. Dr. Brennand also discusses evidence-based treatments, including SSRIs, oral contraceptives, and, in severe cases, GnRH agonists.

This episode provides valuable insights into diagnosing and managing PMDD, helping physicians better support their patients.

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Transcript

Dr. Mojola Omole:
I'm Mojola Omole.

Dr. Blair Bigham:
I'm Blair Bigham. This is the CMAJ podcast. Jola, today we're looking at a condition that affects a lot of people, but I have never heard of it, and it's so dramatic that a lot of people go undiagnosed or misdiagnosed and suffer for a long, long time.

Dr. Mojola Omole:
And honestly, I actually heard about it because I was doing a history in a patient for something completely unrelated, and they're like, I had this. And I was like, what is that? And then they told me, and then I ended up Googling it after.

Dr. Blair Bigham:
Shall we reveal it?

Dr. Mojola Omole:
Yes, we should do the big grand reveal. It is called PMDD or Premenstrual Dysphoric Disorder. And honestly, from speaking to people and after reading the article, it's really disruptive in people's lives to the point where they can't work, they can't parent because of this cyclical mood disorder.

Dr. Blair Bigham:
And like we said, it can go on for decades and not get diagnosed, even though it's treatable. And some people even get misdiagnosed as having depression or bipolar or just, I guess, bad PMS symptoms.

Dr. Mojola Omole:
Yeah, and I think that one thing I really want to tease out is, and I am coming from a personal perspective, is like, well, what is PMS? And what is PMDD? Because I think oftentimes we are not taught that. It's the same as when we talk about painful periods. I learned two years ago, periods aren't always painful for people, that some people don't have painful periods. And I'm like, I was shocked. So I also would want to know, how do you know what is PMS and what's PMDD?

Dr. Blair Bigham:
Right? What's sort of a variation of normal and what is pathological?

Dr. Blair Bigham:
Yeah, well, we're going to find out. We're going to speak to the co-author of the article in CMAJ, titled “Five things to know about premenstrual dysphoric disorder”.

Dr. Mojola Omole:
But first, we're just going to get a firsthand experience from someone who's living with this condition. 

Dr. Blair Bigham:

Abhi Bala’s going to share her story. That’s up next.

Abhi Bala:
Usually, it starts with a buzzing sensation that happens in the body before the onset of other symptoms. The symptoms just kind of progressively get worse from there. So you start to experience the brain fog. Sometimes formulating simple thoughts feels really difficult. Because of the brain fog, I'm not able to articulate myself well enough as opposed to if I wasn't experiencing my symptoms. You start to experience feelings of unworthiness and severe depression and hopelessness, and it doesn't matter what you do or what you try to tell yourself, but you believe that you're inherently unlovable and that you're a burden. And this depressive voice is telling you that you're not good enough and there's no point to continuing life, and that's where the suicide ideation comes in.

It's like clockwork. Every month I would experience it. The last episode was actually quite mild compared to two months ago. I had a really terrible breakdown. I was feeling this overwhelming sense of hopelessness, and it starts with feeling like you're feeling crushed. I don't know how else to explain it. You feel like you're feeling crushed under some type of pressure. And then the anger, the fear, the shame, the guilt, all these repressed emotions just come to the surface, and you're forced to experience it and express it. And so I remember I was just in my room crying for hours and hours, until the point where my energy was completely depleted.

And this experience sort of started with me, particularly with my awareness around the diagnosis or when I got the diagnosis. I think I was 28 years old, and it was after I was taken to the hospital for a really bad mental health breakdown. So I was having severe panic attacks, and I wasn't able to control what was going on.

And then my family wasn't aware of what was happening either, so they just drove me out to Sunnybrook, and that's where I received the diagnosis. But I think for so many years I was experiencing dysregulation in my nervous system and this heightened anxiety. And every month I was having these terrible, just complete emotional breakdowns. And I thought maybe it had something to do with more of my lifestyle, or maybe it was work stress or relationships, family trauma. There were so many other things that it could have been that it never occurred to me that it was a hormonal disorder.

I had gone to the doctor and told him I was experiencing severe depression and that I was feeling suicidal. And the response to that kind of was like, well, you should go see a therapist. And I was like, yeah, I should. And I did see a therapist, and I would talk to them about it, and nobody assumed that it was PMDD. People were just kind of like, oh, well, you need to change your work lifestyle. You have to change your relationship or everything else.

The one thing I didn't tell anybody—or that because I wasn't aware of it—was that it was cyclical. So I was experiencing it on a monthly basis, but it never occurred to me that it coincided with my menstrual cycle, and it never occurred to me to look into that further also. So even when I received my diagnosis at 28, I assumed that this was just another example of medical misogyny and that my feelings were being dismissed.

And then I started actually journaling my symptoms and keeping track of my cycle, and I was like, oh, there's a pattern here. This is real. And it just felt like I received this missing puzzle piece to just everything in my life. Everything else just started to make sense.

I feel like if somebody had just probed about what was going on with me by asking me these questions and bringing into my awareness that maybe it had a link to my menstrual cycle, that would've given me enough insight to start doing the symptom tracking so that I could discuss it with a physician further in terms of treatment plan.

I think it's really important for physicians to just start asking people, especially menstruating people, if they've started tracking their suicidal ideation with their menstrual cycles. I think even just asking that simple question would make a huge difference in how people reach their diagnosis.

As I said, it took me a really bad mental health breakdown to receive a diagnosis, and I don't think it should take that long. I think the intervention should happen a lot earlier, and it could happen a lot earlier.

Dr. Blair Bigham:

Abhi Bala lives in Toronto, and thank you so much for sharing your story.

Dr. Mojola Omole:

Premenstrual Dysphoric Disorder, or PMDD, is a subject of Five things you need to know in the CMAJ. Dr. Erin Brennand is a co-author of the paper. She's an associate professor in the Department of Obstetrics and Gynecology and Community Health Sciences at the Cumming School of Medicine in Calgary. She's also the founder and director of the Sex, Gender, and Women's Health Research Unit within the O'Brien Institute for Public Health. Erin, thank you so much for joining us today.

Dr. Erin Brennand:
Thanks for having me.

Dr. Mojola Omole:
So just to start off, because when I was reading everything, I'm like, wait, do I have PMDD or did I have PMDD before I started an antidepressant? How would you describe it?

Dr. Erin Brennand:
I would describe PMDD as a cyclic disorder where people's mood, their affect, their actual visceral sensations in their body fluctuate over the course of the month in relation to the menstrual cycle. The difference between PMDD and other menstrual symptoms is the level of distress that it causes people.

Dr. Mojola Omole:
I think one thing that I find confusing, and this was also, I think, recently when we're talking more about how painful some people's periods are, is that I think I assumed that everyone felt extremely crazy, extremely emotional, emotional and crying before their period. So is there a gradient between PMS and PMDD?

Dr. Erin Brennand:
Absolutely. I think the majority of people who are menstruating feel true physical symptoms such as fatigue and bloating around the time of their period. They may have changes in their irritability, their affect, the way that they respond to people, but they're small and you can cope. People with PMDD are not coping. They're having significant impacts on their relationships, their ability to work. It's estimated that it affects 5% of menstruating people, and there's probably another 10% who are just below the clinical threshold but are still struggling and having problems.

Dr. Mojola Omole:
So how often is this misdiagnosed?

Dr. Blair Bigham:
Sorry, Jola, before we get into that, can you get a little bit more detailed about the difference between PMDD, like the disorder that requires care, versus what women feel at that time of the month? There's no way for a white guy to ask that question anymore respectfully. 

Dr. Mojola Omole:

It's more the fact that you're also gay. 

Dr. Blair Bigham:

That too. I  mean my husband is plenty moody at times, but I'm just curious, what are some of the really explicit differences here that people should be on the lookout for?

Dr. Erin Brennand:
Yeah, so people should be looking for, in terms of a difference between PMS and PMDD, we're really talking about the number of symptoms and the intensity of symptoms that are experienced. So you need to have five or more symptoms from a DSM-5 criteria.

Dr. Blair Bigham:
Okay. So this is a DSM-5 diagnosis?

Dr. Erin Brennand:
Yes.

Dr. Blair Bigham:
Okay.

Dr. Erin Brennand:
So PMDD is a DSM-5 diagnosis. It was added in 2013.

Dr. Blair Bigham:
Oh Ok.

Dr. Erin Brennand:
It was just quite recently. Prior to that, it was listed as an area for further study, but it got formal recognition in 2013. People need to have a cluster of five or more symptoms, and there's some really big ones. So we're talking about depressed mood. We're talking about being labile in your affect, marked anxiety, feelings of dread, persistent anger, having conflicts with people that normally you don't, being unable to concentrate. People describe having such low energy levels that they feel like they can't get out of bed. Like the simple act of getting out of bed is too much for them. They may have insomnia. They're totally unable to sleep despite being fatigued. They're overwhelmed, they're easily stressed. Things that they can usually cope with are really bringing them to their knees. There's a really high proportion of people who experience suicidal thoughts and behaviors with PMDD. So up to 70% of people report this activity, and that includes suicide attempt and self-injury. And then the real key feature is that once your period comes, this abates. You feel like you're back to yourself.

Dr. Mojola Omole:
I think what makes it sometimes challenging is that even us as clinicians, outside of maybe OB, is that we don't even know what the baseline of normal PMS is. I don't know what normal periods are supposed to feel like, for example. So therefore, not necessarily knowing what normal PMS is supposed to be like it makes it hard sometimes, even for us as clinicians and us as cisgendered females, to know what is abnormal.

Dr. Blair Bigham:

Maybe that's why it's misdiagnosed so often.

Dr. Erin Brennand:

I totally agree. We have a major issue in society where females, cisgender, non-binary people, there just isn't enough normal discourse about what is it like to menstruate? What is it like to go through perimenopause or menopause, so people suffer in silence and they don't necessarily talk to each other to figure out are other people experiencing the same thing or is it different? And then it's compounded with our medical training, which it's difficult to learn modern medicine with all of the things there are to know in a three or four year curriculum, but it's pretty undeniable that there's very minimal time on female reproductive health. For example, menopause, which is a universal female phenomenon, is estimated to get 60 minutes or less in most North American medical schools. So this is something that affects over 50% of the population, and we don't even spend an hour or more on it. And then something that's affecting 5% of the menstruating population is definitely going to get minimal time.

Dr. Mojola Omole:

So what's the impact of the misdiagnosis? Is it the more you have these cycles, the worse it becomes, or it just sucks all around?

Dr. Erin Brennand:

So the impact of misdiagnosis is massive. One of the patient advocacy groups has done some work in this space, and they've estimated that it's an average of 12 years to get a diagnosis of PMDD.  People will see an average of six healthcare providers until they get an accurate diagnosis.

Dr. Blair Bigham:

I bet most people don’t even get diagnosed.

Dr. Erin Brennand:

We don't even know the proportion that aren't diagnosed. That's a real gap that's recognized by all advocacy groups. And then during that time, people are likely to be mislabeled with other disorders, some pretty heavy labels like bipolar disorder. Those labels are hard to shake. And most importantly, it means that people aren't getting the treatment that they actually need. They're getting treatment for a disorder that they don't have.

Dr. Blair Bigham:
Tell us about the consequences of this going undetected. What have you seen in the real world? Or what does the science tell us about what happens to people?

Dr. Erin Brennand:
Yeah. This piece was written a bit like a labour of love between myself and my colleague Jennifer Gordon, who's a Canada Research Chair in women's mental health. And it came out of a conversation that we had about the consequences of this being missed. The people that she's seen as a clinical psychologist and the people that I've seen as an obstetrician-gynecologist and the years, if not decades, of lives lost to this disorder. So, quality of life. I've seen people whose marriages have broken down, who have lost custody of their children because they're deemed not fit to care for them due to their menstruation, who have been put on heavy medications for mood disorders that they didn't have. I've been consulted to the psychiatry unit a number of times for women who've attempted to end their life because of this disorder, and they weren't diagnosed. We have no idea how many actual lives are lost due to PMDD because there's no way to pick that up if people don't get their diagnosis. But it is tremendous. It is a common and treatable condition that is overlooked and misunderstood.

Dr. Mojola Omole:
So do we know what the mechanism behind—if only 5% of people who menstruate get PMDD—do we know the mechanism of why those 5% exist? And maybe it's more, but—

Dr. Erin Brennand:
The mechanism is not fully understood, but it's broadly felt to be an abnormal sensitivity to the very normal hormonal fluctuations of the menstrual cycle. And it's really important to stress that it's the fluctuations that are the problem, not the hormones themselves. This is really occurring at a cellular level, and studies suggest that hormone shifts affect the serotonin levels in our brain. In fact, people with PMDD have atypical serotonergic transmission. This is why treatments that are aimed at increasing serotonin levels have been shown to alleviate symptoms.

Dr. Blair Bigham:
It's not that the hormone levels are swinging high and bigger valleys and mountains, it's just that the sensitivity to the same swing that other people have is somehow getting wrapped up in those neurotransmitters.

Dr. Erin Brennand:
Exactly. So they don't have bigger peaks and valleys. Is that their brain?

Dr. Blair Bigham:

This is fascinating

Dr. Erin Brennand:

Yeah, it's the brain at the cellular level that is more sensitive. 

Dr. Mojola Omole:

Is it fascinating?

Dr. Erin Brennand:

It's totally fascinating.

Dr. Mojola Omole:
You know why it’s not fascinating is because I'm just like, wait, this is my life.

Dr. Blair Bigham:
I know, but people just blow this off as, oh, your hormones are up or down or this or that.

Dr. Mojola Omole:
You’re hormonal.

Dr. Blair Bigham:
Yeah, and I mean, I get that they're natural fluctuations, but we're not talking about somebody who has super high or super low hormones. We're talking about something that sounds much more like sort of a psychiatric disease. When we're talking about neurotransmitters, it's a whole different way of viewing it. I don't know. Maybe I'm just very naive to this whole topic.

Dr. Erin Brennand:
We absolutely know that this is a strongly genetic predisposition. Recent research has shown that people with PMDD have altered gene complexes that affect their responses to hormonal shifts and stressors. So there's a genetic component, and we know that it's compounded by environment or epigenetics. For example, people who experience trauma are then made more susceptible to PMDD.

Dr. Mojola Omole:
Interesting. So we know for depression and bipolar, there's tools to screen, to score, assess, all of that. Is there something like that for PMDD?

Dr. Erin Brennand:
Yes, absolutely. There's the DSM-5 criteria, which lists 11 symptoms, and people need to have five. And then there's a number of scoring rubrics or daily prospective symptom scales that people can use. In fact, the International Association for Premenstrual Disorders on their website has a printable tracker for people to access. And there's also been an iPhone app developed by researchers.

Dr. Mojola Omole:
Oh wow.

Dr. Erin Brennand:
Yeah, researchers at McMaster University. And that was in conjunction with patients who've experienced PMDD, and the goal was to improve tracking, diagnosis, and data sharing with healthcare providers.

Dr. Blair Bigham:
Okay. I'm going to sit on the fence here. And it sounds like a lot of the PMDD criteria do overlap maybe with depression and bipolar, but it would be pretty obvious if they came in and said, this only happens to me once a month, and then everything is fine. That must be the red flag, right? For people to pick this up and say, no, you're not bipolar, you're not depressed. You clearly have PMDD.

Dr. Erin Brennand:
What's really interesting to me is that studies looking at the retrospective symptoms—so basically the histories that people come and tell us when they interact with us as physicians—versus the prospective collected data in tracking forms and apps only correlates at about 60%. And I think this is really related to how difficult it is to tease out a history and how hard it is for people who are experiencing these symptoms and the distress to accurately see that cyclical pattern. It's so easy to miss. People aren't thinking about their menstrual cycle, they're thinking about their mood, they're thinking about their conflict that they're experiencing.

Dr. Blair Bigham:
So it really—

Dr. Erin Brennand:
Is actually missed a lot.

Dr. Blair Bigham:
S it’s for the clinician to draw out and say, well, is there any cycle to this?

Dr. Erin Brennand:
Absolutely.

Dr. Blair Bigham:
Got it.

Dr. Mojola Omole:
So what is the treatment for PMDD?

Dr. Erin Brennand:
There's a number of treatments, and about 60% of people will improve with a single modality. A great option is SSRIs, and they actually help with the total constellation of symptoms of PMDD, not just the mood. So it addresses irritability, mood, lability, anxiety, as well as those symptoms of fatigue and even bloating. The dosing can be continuous, so it can be every day, or it can also be luteal phase, meaning people start it right with ovulation or they start it with the onset of their symptoms, and they'll report improvement within 24 hours. Having this luteal phase approach actually helps minimize some of the side effects, like sexual dysfunction, that's associated with SSRIs.

Dr. Mojola Omole:
Interesting. But is there any role to just use the antidepressants as mood stabilizers throughout, not just in the luteal phase?

Dr. Erin Brennand:
You can absolutely use it continuously if a patient finds that that's effective, if they want to use it that way. But many patients are actually quite motivated to use it only during their periods of symptoms. Other options are reducing your variability by using the oral contraceptive pill. It has so many benefits beyond avoiding unwanted conception, and specifically the class of OCPs that have drospirenone are particularly beneficial to people with PMDD.

Dr. Blair Bigham:
Sorry, I hate to keep nailing down on details here. For antidepressants...

Dr. Mojola Omole:
You're so excited about the female reproductive system.

Dr. Blair Bigham:
I've never been as excited about the female before, but okay. So when someone prescribes an antidepressant, they normally say, you're not going to see a difference for two to four weeks, and you can't stop taking it. Once you start, you have to keep going. This sounds different, but the pathopharmacology sounds similar. Help me close that gap. You can just take it for a week, a month?

Dr. Erin Brennand:
A week to two weeks. So quite a few people with PMDD have an entire two weeks of symptoms. And it is fascinating. I was taught you don't off and on your SSRIs, but there is a good strong body of research that shows people will see improvement within 24 hours.

Dr. Blair Bigham:
Wow. Other than SSRIs, there's a couple of other treatments that you mentioned in your article. Can you tell us about those?

Dr. Erin Brennand:
Yep. So oral contraceptive pills work by taking over the hypothalamic-pituitary-ovarian axis. So you have a steady state of estrogen and progesterone every day of the month because you don't have a menstrual cycle. So OCPs will improve things for 60% of people, and particularly drospirenone-containing OCPs. And so drospirenone is a progestin that has anti-mineralocorticoid activity, so it reduces some of the bloating and the physical symptoms that many people have during menstruation, but people with PMDD report at significant levels. Other options are continuous use of OCP, so not getting a hormone-free period so that you have a withdrawal bleed or menstruation. So using your OCP every day up to 90 days—some people go 180 days.

And then for refractory cases—so these are people that are really suffering, where SSRIs and OCP in conjunction have not met their needs—you can suppress the HPO axis completely by giving a GnRH agonist like Lupron, which puts you in a state of pharmacologic menopause. This is for severe cases and has the risk of developing osteopenia and osteoporosis later in life.

Dr. Blair Bigham:
So it's progesterone—sorry, I'm trying to think back to medical school here—it's progesterone then in the luteal phase that is causing a lot of these, or assumed to be causing a lot of these neuropsychiatric symptoms?

Dr. Erin Brennand:
Progesterone is absolutely implicated. We know that progesterone metabolites interact with GABA receptors, but the entire pathophysiology of PMDD is not fully understood. So it's estrogen and progesterone sort of switch off. One is dominant in one phase of the cycle, and then the other is dominant, sort of like a roller coaster. You're going up and down. There are highs and lows, and we think both are implicated, but the progesterone is dominant in the luteal phase, causes a lot of the symptoms, the physical symptoms that we experience before menstruation.

Dr. Mojola Omole:
So I just wanted to ask a question to all the other women who are perimenopausal. What happens with PMDD during perimenopause? Is it better, or is it still hell?

Dr. Erin Brennand:
Oh, it gets worse. It gets worse.

Dr. Blair Bigham:
Oh, it gets worse. I would have thought it goes away.

Dr. Erin Brennand:
I tell medical students that the menstrual cycle is like a little roller coaster. It's the baby roller coaster that you're riding with just a lap belt. But as you get into perimenopause, that roller coaster picks up speed, and the highs and the lows are much bigger. So those shifts are wilder, and that makes the experience of PMDD worse for people who experience this disorder.

Dr. Mojola Omole:
So would HRT help with this or no?

Dr. Erin Brennand:
HRT in perimenopause would not be enough to suppress the ovarian function so that things are stable. So if somebody was experiencing PMDD exacerbations in perimenopause, they would likely benefit from an oral contraceptive pill because that does completely suppress the natural highs and lows.

Dr. Mojola Omole:
For the perimenopausal patients who might have PMDD, how does a clinician tease out PMDD versus perimenopausal hell?

Dr. Erin Brennand:
Yeah. So one of the things that clinicians are looking for when we're diagnosing PMDD is the magnitude of change that happens in the luteal phase versus people's good phase. So we are looking for a 30% exacerbation of symptoms, and there's actually rating scales that allow clinicians to say, is this 30%? It's not subjective.

Dr. Erin Brennand:
So that's actually called the Carolina Premenstrual Assessment Scoring System or CPASS. It's important to ask if these are new symptoms specific to just perimenopause or were your periods always a rollercoaster of emotions. If it's new, it can simply be that it's a perimenopausal or premenstrual exacerbation of other mood disorders. That's a whole bucket that's not well studied yet. We just sort of got a light shone on PMDD, but we absolutely know that perimenopause and premenstrual experiences exacerbate other conditions.

Dr. Mojola Omole:
So maybe there was something right about when they put every housewife in the seventies on a mood medication, a mood stabilizer. It might just be like, put Zoloft in the water, we'll all be better. Just joking. Not really. 

Dr. Erin Brennand:
Probably not.

Dr. Mojola Omole:
Well, thank you so much for shining a light on it, because I do think that women's health is definitely never funded well. I also think it's just really important to normalize for people that this is a diagnosis and this is something treatable. And that in itself, I think if there are listeners who have had PMDD or who have PMDD, that's actually comforting to know.

Dr. Blair Bigham:
And I mean, for me, it's never been on my differential. I didn't even know about it. It's just—I'm always shocked at how little I was prepared through what I always thought was formal and rigorous training to be a generalist emergency physician. And how I don't know about this just blows my mind

Dr. Erin Brennand:
I think, I would love for more emergency physicians to know about PMDD. We know that people with PMDD have seven times the odds of attempting suicide. So if you're seeing a young female person of reproductive age who's presenting with a suicide attempt, it may be something to raise with the patient or their family or the consultant psychiatrist. It may save them so many years of suffering.

Dr. Blair Bigham:
Thank you so much for speaking with us today.

Dr. Erin Brennand:
Thanks for having me.

Dr. Mojola Omole:
Dr. Erin Brennand is an associate professor in the Departments of Obstetrics and Gynecology and Community Science at the Cumming School of Medicine in Calgary. She's also the founder and director of the Sex, Gender, and Women's Health Research Unit within the O'Brien Institute for Public Health.

Blair, I found that throughout our conversation with Erin, you had a lot of questions. This was all new to you. Tell me more about—

Dr. Blair Bigham:
Well, part of it is that I just have no understanding of women's health I think Jola. Sorry, maybe I'm not giving myself enough credit, but—

Dr. Mojola Omole:
No, I think that was enough credit.

Dr. Blair Bigham:
I don't know. Yeah, no. Honestly, I don't think about these types of things when I'm working in a busy emergency department. I don't think about these things in the ICU. I guess I don't really—I don't know, I'm worried now that I don't consider sex and gender enough in my job. And this is just maybe one example, but we've had so many podcast episodes where there are unique considerations, unique physiologies, unique diagnostic criteria, and I'm like, wow, I've never even heard of this.

Dr. Mojola Omole:
Well, I think that this just—it boils down to when we talk about misogyny in medicine, which is a favorite topic of ours on the podcast, we also internalize that misogyny, right? And we are not even aware of it.

Dr. Blair Bigham:
Just to wrap this conversation up, here's my top takeaway, and I found this so interesting when Erin said it, is that although the cyclical nature of these mood—I'll call them mood swings—is common and trackable—

Dr. Mojola Omole:
I don't think—can I interrupt you? I actually don't think you should call 'em mood swings because mood swings are stigmatized, right? Oh, she's just being hysterical. Just another one of her mood swings. I do think making it medical takes away some of that stigma that's associated with women when we have changes that are occurring that we can't necessarily—

Dr. Blair Bigham:
That's a totally fair critique. It is pathophysiologically explained, it is more than a swing. You're right. But when we have these fluctuations—and it seems like a hallmark of the disorder—it might not be a hallmark for the patient. They might not come in and say, "Hey, this is clearly cyclical." And I don't think, as a physician, we necessarily elicit, "Is this cyclical?" I don't even know how to ask that question. So I think that's my top takeaway, is that you have to inquire about cyclical things in order to find out that history. Erin's right—that can be hard to elicit. And people won't necessarily give that up for free.

Dr. Mojola Omole:
And I think it's just us, as clinicians, just being aware of it. Like, wait, so this happened? And then when did it happen again? And when did that—when was that? So I think it's always just having this broader differential. When we—I'm saying that as a surgeon, when my differential is like one thing—

Dr. Blair Bigham:
I'm impressed that you know what a differential is Jola.

Dr. Mojola Omole:
It's when there's different things that can cause appendicitis. But I do think it's important that we broaden our differential, especially when we're talking in the realms of women's health.

Dr. Blair Bigham:
That's it for this episode of the CMAJ podcast. If you liked what you heard, please give us a five-star rating wherever you download your audio, share it with your networks, leave a comment, reach out to us on social media. Our handles are in the show notes. The CMAJ podcast is produced for CMAJ by PodCraft Productions.

Thanks so much for listening. I'm Blair Bigham.

Dr. Mojola Omole:
I'm Mojola Omole. Until next time, be well.