Approximately 75% of women experience premenstrual changes – increased irritability, tension, depressed mood, breast tenderness and bloating – commonly referred to as premenstrual syndrome (PMS). About 5-10% of women experience moderate to severe premenstrual mood symptoms known as premenstrual dysphoric disorder (PMDD).
PMDD includes depressed mood, irritability, mood lability, anxiety, anger, difficulty concentrating, and insomnia that occur exclusively in the two weeks before menses and cause significant impairment in daily functioning. PMDD is distinguished from other psychiatric disorders by timing; 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.
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. There is a high co-morbidity of PMDD with other mood and anxiety disorders. It is important to screen patients with PMDD for a history of trauma and abuse, as there is a high correlation.
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.
There are a variety of treatment options for PMDD. Antidepressants that exclusively affect serotonergic transmission (citalopram, escitalopram, fluoxetine, paroxetine, sertraline) are effective and can be used on an on-off schedule during the luteal phase because they have a rapid onset of action compared to antidepressant effects for depression. 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. Non-medication approaches that show some promise includes bright light therapy, calcium supplementation and chaste berry supplements.
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.