Approximately 75% of women experience premenstrual changes – with increased irritability, tension, depressed mood, breast tenderness and bloating – commonly referred to as premenstrual syndrome (PMS).
A small proportion (5-10%) of women experience significantly more disruptive psychological symptoms that can range from moderate to severe intensity that is recognized as Premenstrual Dysphoric Disorder (PMDD). Individuals with PMDD present with more intense psychological symptoms of substantially depressed mood and irritability, along with mood lability, anxiety, anger, difficulty concentrating, and insomnia that are of such substantial intensity that they cause significant impairment in daily functioning at work and in social and interpersonal relationships.
Physiological symptoms associated with PMDD may include fluid retention (e.g., breast fullness and pain, swelling in extremities, decreased urine output; gastrointestinal symptoms (e.g., cramps, bloating, constipation, nausea, increased appetite); skin problems (e.g., acne, itching, worsening of chronic conditions); neurological symptoms (e.g., headache, fainting, dizziness, vision changes); and other somatic symptoms.
PMDD is distinguished from other psychiatric mood disorders by their temporal cyclic nature; patients have symptoms only during the luteal phase of the menstrual cycle and report normal mood during the follicular phase. On average, symptoms last 6 days and peak 2 days before menses. Individuals experiencing this same constellation of symptoms persistently and not just exclusively in the two weeks before menses would, of course, need evaluation and treatment for other mood or psychiatric disorders, but an individual with a persisting mood disorder may also have a cyclic PMDD worsening of their symptoms.
Risk factors for PMDD include having a family history of PMS or PMDD, having a personal or family history of a mood disorder (e.g., major depressive episodes, chronic dysthymia, post-partum depression, anxiety and other mood disorders), and it is also associated with a history of trauma and abuse, cigarette smoking, and lower educational achievement.
Medical work up should include both a gynecological examination, as well as, evaluation to rule out other systemic illness such as thyroid conditions, anemia, perimenopause, menopause and other systemic illnesses. In patients who take oral contraceptive pills (OCPs), it is important to assess if symptoms are present and as severe even when they are not taking the OCPs, to eliminate the possibility that the symptoms are a side effect of the OCPs.
To help distinguish between PMDD and PMS, patients can keep a daily mood diary for a period of time to establish a pattern. The Daily Record of Severity of Problems ( https://www.aafp.org/afp/2011/1015/afp20111015p918-fig1.pdf ) is a useful tool to log daily mood symptoms.
A variety of treatment options may ameliorate the psychological symptoms of PMDD. Most particularly, antidepressants that exclusively affect serotonergic transmission (citalopram, escitalopram, fluoxetine, paroxetine, sertraline) can be effective and may be used on an on-off schedule during the luteal phase only, as they have a rapid onset of action for the condition, as compared to their typical delayed onset of action when used for treating depressive illnesses. Buspirone has been shown to be efficacious in the treatment of both premenstrual syndrome (PMS) and PMDD.
The use of combined oral contraception (estrogen and progestin) is common and more effective than either alone. Drospirenone/ethinyl estradiol is FDA-approved for PMDD. GnRH agonists have been found to be helpful but have problematic side effects, including medical menopause.
Calcium, magnesium and Vitamin B6 supplementation and judicious use of non-steroidal anti-inflammatory agents may also be of benefit.
Non-medication approaches that show some promise includes bright light therapy, exercise, and chaste berry supplements. Avoiding sugar, salt, caffeine and alcohol are also recommended.
PMDD is a serious mental health concern that can lead to significant impairment for those affected. It is important to have the tools to assess for this disorder and offer appropriate treatment when indicated.