Premenstrual dysphoric disorder (PMDD) is a much more severe form of premenstrual syndrome (PMS) affecting women of childbearing age. It is a serious and enduring medical condition requiring careful attention and treatment. While the precise cause remains unclear, it may stem from an abnormal response to the routine hormone fluctuations occurring in each menstrual cycle. These hormonal shifts can potentially lead to a deficiency in serotonin, a natural substance found in the brain and intestines, which regulates blood vessel constriction, influences mood, and triggers physical symptoms.
Is it Prevalent?
The 12-month prevalence of premenstrual dysphoric disorder in the community has been estimated at 5.8% based on a large study from Germany. Another study utilizing prospective ratings to assess prevalence over two menstrual cycles discovered that 1.3% of menstruating women in the United States were identified as having the disorder. The prevalence of premenstrual dysphoric disorder symptoms in adolescent girls however may be higher than that observed in adult women.
Who is at risk?
- Environmental factors:
Stress
History of interpersonal trauma
Seasonal changes
Sociocultural aspects of female sexual behavior in general, and female gender roles in particular
-Genetic and physiological:
There haven't been studies directly assessing the heritability of premenstrual dysphoric disorder. Estimates for the heritability associated with premenstrual dysphoric disorder range from 30% to 80%. However, it's uncertain whether these symptoms are directly heritable or if they are linked with other heritable factors or traits.
What are the symptoms?
Symptoms typically emerge during the last week prior to menstruation, begin to ameliorate within a few days after menstruation begins, and diminish or disappear entirely during the week following menstruation. These symptoms significantly disrupt daily activities. PMDD symptoms are so intense that women often struggle to cope with their responsibilities at home, work, and in relationships during this period, marking a stark contrast from other times in the month. Symptoms typically cease after menopause, though cyclical hormone replacement therapy can potentially rekindle their expression.
Psychological symptoms
Marked affective liability (e.g., mood swings; feeling suddenly sad or tearful, or increased sensitivity to rejection).
Irritability or increased interpersonal conflicts.
Depressed mood, feelings of hopelessness, or self-deprecating thoughts
Anxiety, tension, and/or feelings of being keyed up or on edge.
Decreased interest in usual activities (e.g., work, school, friends, and hobbies).
Difficulty in concentration
Lethargy, easy fatigability, or marked lack of energy
Marked change in appetite; overeating; or specific food craving
Hypersomnia or insomnia
A sense of being overwhelmed or out of control.
These symptoms might be accompanied by behavioral and physical manifestations, including breast tenderness or swelling, abdominal cramps, joint or muscle pain, a sensation of bloating, constipation, nausea and vomiting, and weight gain.
Table 1: Diagnostic criteria of PMDD
As previously noted, these symptoms result in significant distress or impairment in functioning at work, school, social activities, or interpersonal relationships. This disruption isn't merely an exacerbation of symptoms from another disorder such as major depressive disorder, panic disorder, or a personality disorder (although it may coexist with any of these disorders).
The diagnosis of premenstrual dysphoric disorder is accurately confirmed through two months of prospective symptom ratings. Several scales, such as the Daily Rating of Severity of Problems and the Visual Analogue Scales for Premenstrual Mood Symptoms, have been validated and are frequently utilized in clinical trials for this disorder.
Differential Diagnosis
1.Premenstrual syndrome (PMS)- is distinguished by diagnostic criteria. Unlike PMDD, PMS does not mandate a minimum of five symptoms or specifically focus on mood-related symptoms. Additionally, PMS is generally perceived as less severe compared to PMDD.
2. Dysmenorrhea -marked by painful menstrual periods, differs from a syndrome primarily defined by mood alterations. Additionally, dysmenorrhea symptoms typically emerge with the onset of menstruation, whereas premenstrual dysphoric disorder symptoms, by definition, commence before menstruation begins, albeit they may persist into the initial days of menses.
3. Bipolar disorder, major depressive disorder, or persistent depressive disorder - Many women who have either naturally occurring or substance/medication-induced bipolar disorder, major depressive disorder, or persistent depressive disorder may mistakenly believe they have premenstrual dysphoric disorder (PMDD). However, upon tracking their symptoms, they often realize that these symptoms do not follow a consistent premenstrual pattern. While the onset of menstruation is a memorable event, they may report that symptoms only occur during the premenstrual phase or worsen during that time. This highlights the importance of requiring symptoms to be confirmed by daily prospective ratings.
4. Other medical conditions- Women who have chronic medical conditions might encounter symptoms akin to premenstrual dysphoria. As with any depressive disorder, it's crucial to eliminate medical conditions that could more adequately explain these symptoms, such as thyroid deficiency and anemia.
How is PMDD treated?
Antidepressants for PMDD
Antidepressants that inhibit the reuptake of serotonin are commonly effective for many women experiencing PMDD. Typically, the initial choice includes selective serotonin reuptake inhibitors (SSRIs) like sertraline (Zoloft), citalopram (Celexa), escitalopram (Lexapro), or fluoxetine (Prozac). Another option is venlafaxine (Effexor), a serotonin and norepinephrine reuptake inhibitor (SNRI).
Moreover, these medications tend to alleviate PMDD symptoms more rapidly than those of major depression. Consequently, women may not need to take them daily; instead, they can opt for intermittent dosing during the luteal phase, which spans roughly 14 days beginning after ovulation and ending at the onset of menstruation. Intermittent dosing may effectively address irritability or mood fluctuations, but for managing somatic symptoms like fatigue and physical discomfort, daily medication might be required.
Other classes of antidepressants that target neurotransmitters besides serotonin have not demonstrated efficacy in treating PMDD.
The side effects of serotonin reuptake inhibitors are generally mild and temporary. For instance, nausea often diminishes after the first few days of initiating medication, and it typically doesn't reoccur even with intermittent use. On the other hand, sexual side effects like decreased libido and difficulty achieving orgasm can be distressing and long-lasting, even with intermittent dosing. Nevertheless, considering that PMDD itself can diminish sexual desire, using a serotonin reuptake inhibitor intermittently may still be considered a viable approach.
Hormone therapies can be beneficial for certain women with PMDD. Rather than addressing hormonal imbalances directly, these therapies appear to function by disrupting abnormal signaling within the hypothalamic-pituitary-gonadal circuit, which connects the brain and ovaries and regulates the reproductive cycle.
PMDD lifestyle changes
Making lifestyle changes is always a worthwhile endeavor. However, for women with PMDD, the typical dietary recommendations for alleviating mild to moderate premenstrual symptoms such as reducing caffeine, sugar, or alcohol intake and opting for smaller, more frequent meals are unlikely to provide relief.
Aerobic exercise, such as walking, swimming, or cycling, although not extensively studied for PMDD, has been widely shown to enhance mood and increase energy levels.
Regarding supplements, while vitamin B6, calcium, magnesium, and herbal remedies have been explored for managing PMDD symptoms, there is currently no consistent or compelling evidence supporting their efficacy.
Conclusion
PMDD represents a notably more intense manifestation of premenstrual syndrome (PMS). While the precise cause remains elusive, what sets PMDD apart from other mood disorders or menstrual conditions is the timing and duration of its symptoms. These symptoms are so severe that they significantly impede one's ability to fulfill responsibilities at home, work, and in relationships. Throughout the span of a year, in the majority of menstrual cycles, individuals must experience 5 or more of the following symptoms: depressed mood, anger or irritability, difficulty concentrating, loss of interest in previously enjoyed activities, mood swings, increased appetite, insomnia, and feelings of being overwhelmed or out of control.
Antidepressants that slow the reuptake of serotonin provide effective treatment for premenstrual dysphoric disorder (PMDD). These drugs alleviate the symptoms of PMDD more quickly than those of major depression, which means that women don't necessarily have to take the drugs every day. Hormone therapies provide additional options but are generally considered second-line treatments. Some dietary and lifestyle changes may also help relieve symptoms.
References
American Psychiatric Association. Diagnostic and Statistical Manual Of Mental Disorders(5th edition). (pp.197-201).2022
Harvard Medical school. Treating Premenstrual dysphoric disorder. Harvard Health publishing.2022
Heather M. Jones. What You Need to Know About PMDD. Parents. 2023
Johns Hopkins Medicine. Premenstrual dysphoric disorder-PMDD. 2024
Assessed and Endorsed by the MedReport Medical Review Board
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