Why Doesn't My PMDD Look Like Everyone Else's?

Tried to identify with PMDD, but your worst week doesn't line up with the "classic" post-ovulation pattern? You're not alone — and you're not imagining it. In this episode, Dr Georgina Standen introduces DASH-MC, emerging research showing there isn't just one pattern of hormone sensitivity, but at least three.

In this episode:

• Why PMDD has traditionally been described as one condition — and why so many women don't recognise themselves in that description
• Type 1: the classic post-ovulation progesterone and allopregnanolone pattern
• Type 2: the lesser-known pattern driven by falling oestrogen around your period — often showing up as low mood, brain fog and fatigue rather than irritability
• Type 3: the surprising pattern linked to the oestrogen surge around ovulation — impulsivity, risk-taking and difficulty controlling urges
• Why this matters for ADHD specifically, and for choosing the right treatment

Sirona Health Podcast is hosted by Dr Georgina Standen, GP and founder of Sirona Health (sironahealth.co.uk), a specialist women's health practice covering menopause, PMS/PMDD and teen health. Book a consultation at sironahealth.co.uk.

This podcast is for general information only and doesn't replace individual medical advice — please speak to your GP or a specialist about your own symptoms. If you're struggling, please reach out for support.

Transcript

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0:05

Hormones don't just run your cycle. They run your mood, your mind, your whole sense of self. I'm Dr. Georgina Standen, GP and founder of Sirona Health, and this is the Sirona Health Podcast, where we talk about the relationship between female hormones and mental health properly without the mystique and without the dismissal. So last time, I talked about hormone sensitivity, and I went into a fair bit of detail on the traditional model, progesterone rising after ovulation, converting into allopregnanolone, and in some women, that calming effect on the GABA system flipping into something closer to anxiety or agitation. I said at the end that I wanted to come back and build on that properly, and that's what today is. There's a framework that's come out of some really interesting recent research, and I think it's genuinely one of the most exciting developments in how we understand this whole area. It's called DASH MC and stands for Dimensional Affective Sensitivity to Hormones Across the Menstrual Cycle. I know that's a mouthful, so let's just call it DASH MC, and I'll unpack exactly what it means. I think the starting point for this research is something I've touched on before, but it's worth stating plainly. For years, PMDD has been thought of as one thing, symptoms in the week before a period that resolve once menstruation starts. But clinicians like me have always seen women who don't quite fit that pattern. Some feel worse during their period itself, not before it. Some notice their ADHD symptoms spike at particular points in the month. Women with anxiety, PTSD, bipolar, eating disorders, even substance use difficulties, often describe their symptoms getting worse at certain points in their cycle in ways that don't neatly fit PMDD criteria at all. For a long time, I think we've treated these as slightly odd exceptions or misdiagnoses or just noise. But the researchers behind DASH MC took a different view, and I think it's the right one. What if this cyclical worsening isn't unusual at all? What if hormone sensitivity is what's called trans-diagnostic, meaning it's a process that can affect a whole range of different conditions, not just one specific diagnosis called PMDD? So rather than treating this as one condition, the DASH-MC framework proposes three broad distinct patterns of hormone sensitivity, each linked to a different hormonal event across the cycle. Type 1 is the pattern most of us would recognize as classic PMDD, and is exactly what I talked about last episode. After ovulation, progesterone rises, the brain converts some of that into allopregnanolone, and in most people, that has a calming effect. In hormone-sensitive women though, instead of calm, you get irritability, anger, emotional reactivity, anxiety, feeling overwhelmed, sensory sensitivity, even rage. Many women describe genuinely feeling like a different person after ovulation, and this pattern tends to improve quite rapidly once menstruation begins because that's when progesterone, and allopregnanolone with it, drops away. Type 2 is different, and I think it's genuinely under-recognized. This pattern is driven by falling estrogen around menstruation itself rather than the post-ovulation progesterone rise. So instead of symptoms starting straight after ovulation, they emerge later, right around the start of your period, and can actually continue into the early days of the next cycle. The symptoms here look different too: low mood, hopelessness, fearfulness, brain fog, poor concentration, memory difficulties, fatigue, loss of motivation, and in more severe cases, increased suicidal thoughts. This pattern seems particularly relevant for women who also have depression, ADHD, or a trauma history, and I think it makes sense once you remember that estrogen isn't just a reproductive hormone. It has real influence on dopamine, serotonin, memory, attention, and reward processing. When estrogen falls quickly, some women's brains seem particularly vulnerable to that drop, which may also explain why some women with ADHD notice their concentration and emotional regulation worsening specifically around their period, and why perimenopause, when estrogen swings become much more dramatic, can bring on depressive symptoms in some women Type three is the one I think most people find genuinely surprising, because most women actually feel their best around ovulation. But some women appear particularly sensitive to the estrogen surge that happens just before ovulation. And in this group, increased dopamine activity seems to drive impulsivity, increased alcohol use, risk-taking, gambling behaviors, excessive spending, a stronger sex drive, and real difficulty controlling urges. For women who already have some underlying vulnerability, so ADHD, bipolar, addiction, or impulsive personality traits, this hormonal surge can become genuinely clinically significant, not just a passing high-energy week I think the most important implication of this whole framework is that not all hormone-sensitive women are dealing with the same underlying biology. Two women can both tell me, "I feel awful around my period," and mean something completely different. One might have a progesterone-driven irritability pattern. Another might have an estrogen withdrawal depression pattern. And if the mechanisms are actually different, it makes complete sense that the same treatment won't work equally well for both of them. I think this genuinely explains something that's frustrated me in clinic for years, why some women respond brilliantly to an SSRI, some improve dramatically with ovulation suppression, some do best on transdermal estrogen, some need a combination of approaches, And some keep struggling even on what looks on paper like a completely standard appropriate PMDD treatment. I don't think that's treatment failure in the way it's sometimes framed. I think it's very possibly a mismatch between the treatment and that particular woman's actual sensitivity subtype. I want to spend a moment specifically on ADHD because I think this is one of the most exciting parts of this whole framework. Many women with ADHD describe real cyclical changes, concentration, organization, emotional regulation, impulsivity, motivation, all shifting across a month in a pattern they've often noticed themselves without anyone validating it. The DASH-MC model suggests that's not a coincidence. Fluctuating estrogen appears to directly influence the dopamine systems involved in executive function, which would explain why ADHD symptoms so often worsen before a period and ease around ovulation. I think understanding this can be genuinely transformative for some women. Once you know your concentration reliably dips at a predictable point in your cycle, you can actually plan around it, adjusting workload, expectations, even medication timing, rather than feeling like you're randomly failing at things you were managing fine two weeks earlier. So to bring today together, for decades, cyclical mood changes have often been dismissed as just hormones or minimized entirely. DASH-MC, I think, properly validates something many women have known about themselves for years, that hormones matter enormously, but they don't affect every brain in the same way or even at the same point in the cycle. There isn't one PMDD. There appears to be at least three distinct sensitivity patterns tied to different hormonal events with different symptoms and very possibly needing different treatment approaches. If you take one thing from today, I'd say it's this: If your symptoms consistently change at specific predictable points in your cycle, there's very likely an identifiable biological pattern underneath that, whether that's the classic post-ovulation progesterone pattern, the pre-period estrogen withdrawal pattern, or the ovulation time estrogen surge pattern. And tracking your symptoms prospectively across at least two cycles is genuinely one of the most useful things you can do to work out which of these might apply to you. Next time, I want to zoom out even further because this same underlying idea that some brains are simply more sensitive to hormonal change doesn't only show up within a single monthly cycle. It shows up across a woman's whole reproductive life in the postnatal period, in the perimenopause, and in her relationship with hormonal contraception. That's what we're calling reproductive depression, and I think it might be the single most reframe in this entire series. That's it for today. I'm Georgina. Thanks for listening. A quick note before you go. This podcast is for general information, not individual medical advice. It doesn't replace seeing your own GP or a specialist. So if anything you've heard today feels relevant to you, please do talk to someone. And if you're struggling, please reach out to your GP, to someone you trust, or to a crisis line if you need one right now. You can find Sirona Health and book your appointment at sironahealth.co.uk. See you next time