Premenstrual Dysphoric Disorder

September 23, 2011

Hippocrates first documented mood and bodily symptoms related to the menstrual cycle. In 1931 the term “premenstrual tension” was introduced. This related to a set of symptoms that appeared a week before menses and resolved with the start of menses. In the 1950s, Greene and Dalton coined the term “the premenstrual syndrome” (PMS), but PMS has not been in the forefront of medical science until more recently. In contrast, popular culture has long discussed PMS. It is both a wellknown term to the layperson and now the subject of examination by the American Psychiatric Association. PMS is the diagnosis frequently given by primary care physicians and obstetrician-gynecologists. Mental health practitioners favor the term “premenstrual dysphoric disorder” (PMDD).

The continuum of PMS complaints varies with each individual. Physical symptoms include headaches, breast pain, fatigue, weight gain, appetite changes, and bloating. Emotional symptoms are irritability, depressed mood, and mood swings. Both the physical and emotional symptoms must occur in the latter half of the menstrual cycle usually ending when menstrual flow begins. Approximately 70% of menstruating American women have some type of premenstrual complaints. Only 3-5% of these women have problems severe enough to interfere with life activities, meriting a diagnosis of PMS or Premenstrual Dysphoric Disorder. For these women, the physical and emotional symptoms can significantly interfere with relationships at work and home, leading to potential economic problems and divorce.

Obtaining the correct diagnosis is crucial for the patient. Many common psychiatric disorders produce similar symptoms. Environmental factors such as the presence of active domestic violence and past sexual abuse play into the reporting of premenstrual problems. Some women may be more comfortable seeing their gynecologist as opposed to seeing a psychiatrist due to how they view psychiatric care. Ethnic and racial groups around the globe have symptoms but describe different severity levels and different manifestations of their PMS.

Risk factors include age in the late 20s to mid-30s, and for some women, a history of mental health difficulty as well as a family history of PMS. Patient evaluation for PMS/Premenstrual Dysphoric Disorder requires careful screening to rule out various disorders that may present to the physician as related to premenstrual difficulties. The key feature of both PMS and Premenstrual Dysphoric Disorder is the timing of symptoms to the latter half of the menstrual cycle (the luteal phase). After eliciting a listing of medical problems, a careful psychiatric history is crucial. Depression, anxiety/panic, eating disorders, or even substance abuse belie the true cause of their symptoms. Making the diagnosis even more challenging is the fact that the luteal phase of the menstrual cycle can exacerbate all of the above psychiatric illnesses. Asking about domestic violence or sexual abuse completes the necessary history.

In order to assess the relationship of the symptoms to the luteal phase of the menstrual cycle, a prospective recording of changes in mood, irritability, carbohydrate cravings, weight gain, and the like must be obtained. The diagnosis of Premenstrual Dysphoric Disorder requires prospective recording of two menstrual cycles. Using a graph-like system, the patient should code symptom type and severity underneath the sequential days of the cycle.

The underlying causes of PMS have not been completely elucidated. Endocrine studies show that PMS is not related to a simple excess or deficiency in hormone status. Genetic factors exist as well. Identical twins have similar scoring of their PMS symptoms in comparison to fraternal twins.

The interaction of ovarian steroid hormones with the central nervous system neurotransmitters may be the true basis for PMS. The role of the neurotransmitter compound serotonin appears to be significant. This substance is also believed to be involved in a host of psychiatric disorders. Animal data indicate that ovarian hormones influence serotonergic brain activity. Lower levels of serotonin are believed to cause symptoms of depressed mood, irritability, impulsiveness, as well as the increased desire for carbohydrates. The natural central nervous system opiate compounds along with gamma-aminobutyric acid (GABA) and adrenalinerelated neurotransmitters may also be involved.

Treatment approaches for PMS/Premenstrual Dysphoric Disorder vary widely, but only a few have undergone rigorous evaluations. Some pharmacological treatments have been studied thoroughly, whereas healthy lifestyle changes have not been evaluated under controlled studies. Antidepressants called selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac), can be administered daily or during the luteal phase of the cycle. Related compounds sertraline (Zoloft) and paroxetine (Paxil) also may be effective. These medications show efficacy both on emotional symptoms as well as some of the physical symptoms especially bloating, breast tenderness, and appetite. Adverse effects include low libido that complicates continuous dosing of these medications. The tricyclic antidepressant clomipramine showed positive results. Medication for anxiety such as alprazolam (Xanax), as well as the novel anxiolytic agent buspirone may be reasonable alternatives. Gonadotropin-releasing hormone (GnRH) analogs provide relief by stopping ovarian function. However, GnRH analogs may not relieve the severe emotional problems of PMS/Premenstrual Dysphoric Disorder and will potentially cause osteoporosis and symptoms of menopause. There have been mixed results using standard oral contraceptives, because they may improve only a few of the physical symptoms and do not always lead to improvement of the emotional symptoms. Using oral contraceptives in a continuous fashion (eliminating placebo pills, that is, the pills that do not contain hormones) may be more successful. Danazol, an androgenic synthetic hormone, may help in treating mood and physical symptoms of PMS along with relief of premenstrual migraine headache. Unfortunately, danazol and other medications also have some unwanted side effects.

Nonpharmacological approaches, though not as well researched, appear to help many women. The elimination of caffeine, alcohol, chocolate, and sugar may provide some relief. Calcium supplementation of 1,200 mg a day showed better-than-placebo (pills that do not contain any drug) rates of improvement in mood and emotional difficulties. Pyridoxine (vitamin B6) in doses under 100 mg a day may provide some efficacy, though adverse effects such as insomnia and neuropathy may complicate therapy. Aerobic exercise can be very helpful. Psychotherapy and patient education offer help to many women as well.

SEE ALSO: Anxiety disorders, Bipolar disorder, Menstrual cycle disorders, Mood disorders, Oral contraception, Psychologists, Psychotherapy

Suggested Reading

  • Group Health Cooperative. (1992). Premenstrual syndrome. Seattle, WA: Group Health Cooperative.
  • Harrison, M. (1999). Self-help for premenstrual syndrome. New York: Random House.
  • Htay, T. T., et al. (2002). Premenstrual dysphoric disorder.
  • Lark, S. (1993). Premenstrual syndrome self-help book: A woman’s guide to feeling good all month. New Providence, Bahamas: Celestial Arts.
  • Ling, F. W., et al. (Eds.). (1998). Premenstrual syndrome and premenstrual dysphoric disorder: Scope, diagnosis, and treatment. Washington, DC: Association of Professors of Gynecology and Obstetrics.
  • Yonkers, K. A., & Davis, L. L. (2000). Premenstrual dysphoric disorder. In Kaplan and Sadock’s comprehensive textbooks of psychiatry (pp. 1952-1958). Philadelphia: Lippincott, Williams & Wilkins.

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