Premenstrual Dysphoric Disorder (PMDD)

Premenstrual dysphoric disorder (PMDD) follows the same pattern as PMS, but the symptoms are more severe.

• Premenstrual dysphoric disorder (PMDD) can be considered to be a severe form of premenstrual syndrome (PMS), with symptoms that interfere with daily activities and functioning.
• PMDD occurs in 3%-8% of menstruating women.
• Fatigue, mood changes, and abdominal bloating are common symptoms, but numerous other symptoms may occur.
• PMDD is diagnosed by a symptom diary or chart in which a woman records her daily symptoms for at least two consecutive menstrual cycles.
• PMDD is effectively treated by medications including SSRIs and drugs that suppress ovulation and the production of ovarian hormones.

Symptoms of PMS include mood swings, bloating, breast tenderness, headaches, pain, food cravings, panic attack, fatigue, irritability, and trouble focusing.

Premenstrual dysphoric disorder (PMDD) can be considered a severe form of premenstrual syndrome (PMS). Both PMS and PMDD are characterized by unpleasant physical and psychological symptoms that occur in the second half of a woman's menstrual cycle, most commonly in the days preceding the menstrual period. Physical symptoms such as bloating, breast tenderness, headaches, joint pain, food cravings, mood swings or frequent crying, panic attacks, fatigue, mood changes, irritability, and trouble focusing are among the most common symptoms. Other symptoms like anxiety and trouble sleeping have been reported. PMS symptoms may be troubling and unpleasant. PMDD may cause severe, debilitating symptoms that interfere with a woman's ability to function.

The American College of Obstetricians and Gynecologists (ACOG) estimates that at least 85% of menstruating women have at least one PMS symptom as part of their monthly cycle. PMS is much more common than PMDD. You must have five or more of the symptoms listed above to be diagnosed with PMDD.

Biologic, psychological, environmental, and social factors all seem to play a part in PMDD. It is important to note that PMDD is not the fault of the woman suffering from it or the result of a "weak" or unstable personality. It is also not something that is "all in the woman's head." Rather, PMDD is a medical illness that impacts only 3%-8% of women. Fortunately, it can be treated by a health care professional with behavioral and pharmaceutical options.

PMDD has been previously medically referred to as late luteal phase dysphoric disorder.

Symptoms of PMS and PMDD can be similar but are more intense and debilitating in PMDD. The symptoms of PMDD also may vary among affected women. Some of the most commonly reported symptoms include the following:

1. Fatigue
2. Mood changes
3. Abdominal bloating
4. Breast tenderness
5. Headache
6. Irritability
7. Depression
8. Increased appetite
9. Acne
10. Oversensitivity to environmental stimuli
11. Hot flashes,
12. Heart palpitations
13. Easy crying
14. Difficulty concentrating
15. Dizziness
16. Sleeplessness
17. Forgetfulness
18. Gastrointestinal (stomach, bowel) upset

PMDD symptoms are related to the menstrual cycle, typically occurring in the second half (luteal phase) of the cycle, and resolving within the first few days after the menstrual period has begun.

Although the precise cause of PMS and PMDD is unknown, it is believed that these conditions result from the interaction of hormones produced by the ovaries at different stages in the menstrual cycle (such as estrogen and progesterone) with the neurotransmitters (chemicals that serve as messengers such as serotonin) in the brain. While the ovarian hormone levels are normal in women with PMDD, it is likely that the brain's response to these normally-fluctuating hormone levels is abnormal.

Most evidence suggests that PMS and PMDD do not result from any specific personality traits or personality types. While stress clearly is associated with PMS and PMDD, it is not considered to be a cause of PMDD. Rather, the associated stress is more likely to be a result of the PMS or PMDD symptoms. Vitamin or other nutritional deficiencies have not been shown to cause PMS or PMDD.

It is appropriate to seek medical care for troubling physical or emotional symptoms related to the menstrual cycle.

It is important to note that the depressive symptoms of PMDD may be associated with thoughts of suicide and suicidal behavior. This is a medical emergency for which medical attention should be accessed immediately.

Other treatments have been shown in some studies to be beneficial in managing PMDD symptoms. Chasteberry extract (agnus castus fruit) was effective in decreasing the symptoms of PMS in a controlled trial. Several dietary supplements, including calcium, vitamin B6, and vitamin E, have also been shown in limited studies to reduce PMS/PMDD symptoms.

PMDD must be distinguished from other physical and psychological conditions that can produce the same symptoms. The differential diagnosis (list of conditions that may produce the same symptoms) includes both mood and anxiety disorders as well as medical conditions such as thyroid disease. In addition to a thorough medical history and physical examination, blood tests may be performed to rule out whether medical conditions may be present that may account for the PMDD symptoms.

If PMDD is a concern, it is recommended that women complete a symptom chart or calendar prospectively (meaning that they record their symptoms each day for a given period) to establish the diagnosis. The symptom chart can be compared with the menstrual calendar to illustrate the relationship of symptoms to the menstrual cycle.

The American Psychiatric Association has established formal guidelines for the diagnosis of PMDD in their Diagnostic and Statistical Manual (DSM). The DSM diagnostic criteria for the diagnosis of PMDD require prospective documentation of symptoms being present for most menstrual cycles.

Five or more of the following symptoms must have been present during the week prior to the menstrual period and resolve within a few days of the start of the woman's period. The symptoms must interfere with the activities of a woman's daily living and not be a result of another condition or illness. At least one of the symptoms must be one of the first four on the list:

• Feeling sad, hopeless, or self-deprecating
• Feeling tense, anxious, or "on edge"
• Marked changes in mood, becoming sad or tearful
• Persistent irritability, anger, and increased interpersonal conflicts
• Decreased interest in usual activities, which may be associated with withdrawal from social relationships
• Difficulty concentrating
• Feeling fatigued, lethargic, or lacking in energy
• Marked changes in appetite, which may be associated with binge eating or craving certain foods
• Hypersomnia (excessive sleeping) or insomnia
• A subjective feeling of being overwhelmed or out of control

Other physical symptoms and signs of PMDD include the following:

• Breast tenderness or swelling
• Headaches
• Joint or muscle pain
• A sensation of feeling bloated
• Weight gain

A number of medical therapies have been shown to be effective in managing PMDD symptoms.

Antidepressants (SSRIs)

Several members of the selective serotonin reuptake inhibitor (SSRI) class of medications are effective in the treatment of PMDD. These medications work by regulating the levels of the neurotransmitter serotonin in the brain. SSRIs that have shown to be effective in the treatment of PMDD include the following:

• fluoxetine (Prozac, Sarafem),
• sertraline (Zoloft),
• paroxetine (Paxil), and
• citalopram (Celexa).

Up to 75% of women report relief of symptoms when treated with SSRI medications. Side effects can occur in up to 15% of women and include nausea, anxiety, and headache. SSRI medications to treat PMDD may be prescribed to be taken continuously or only during the 14-day luteal phase (second half) of the menstrual cycle. Other types of antidepressants (tricyclic antidepressants and monoamine oxidase inhibitors) and lithium (Lithobid) have not been shown to be effective in the treatment of PMDD.

Medications that interfere with ovulation and the production of ovarian hormones have also been used to treat PMDD. Oral contraceptive pills (OCPs, birth control pills) can be prescribed to suppress ovulation and regulate the menstrual cycle.

Gonadotropin-releasing hormone analogs (GnRH analogs or GnRH agonists) have also been used to treat PMDD. These drugs suppress estrogen production by the ovaries by inhibiting the secretion of regulatory hormones from the pituitary gland. As a result, menstrual periods stop, mimicking menopause. Nasal and injection forms of GnRH agonists are available.

Examples of GnRH agonists include

• leuprolide (Lupron),
• nafarelin (Synarel), and
• goserelin (Zoladex).

The side effects of GnRH agonist drugs are a result of the lack of estrogen and include the following:

• Hot flashes
• Vaginal dryness
• Irregular vaginal bleeding
• Mood changes
• Fatigue
• Osteoporosis

Adding back small amounts of estrogen and progesterone can help avoid or minimize many of the annoying side effects due to estrogen deficiency and help preserve bone density.

PMDD by definition is characterized by symptoms severe enough to interfere with daily functioning and activities. If untreated, these symptoms can significantly impact quality of life and a woman's ability to function at work, school, or home. Further, mood changes and depression that may accompany PMDD can be associated with suicidal thoughts and behavior.

Although the symptoms of PMDD can be debilitating, treatments are available that are effective in controlling symptoms for a majority of women.

Since PMDD is thought to result from interactions between ovarian hormones and neurotransmitters in the brain, there is no known way to prevent its occurrence.