Premenstrual Dysphoric Disorder

Premenstrual Dysphoric Disorder

Twenty to fifty percent of women between the ages of 30 to 40 with regular menstrual cycles experience premenstrual syndrome (PMS) as a regular physiological occurrence every month. In more severe cases, affecting three to five percent of menstruating women, this syndrome is labeled as premenstrual dysphoric disorder (PMDD) . Patients with severe PMDD are at risk for developing postpartum depression. Furthermore, women successfully treated with antidepressants often show breakthrough symptoms of depression in the premenstrual phase of their menstrual cycle. All that is needed is a small increase in the dosage of the antidepressant premenstrually.

PMDD Symptoms
Women with PMDD complain of irritability, anger, tension, marked depressed mood, and mood lability (crying spells for no reason, verbal outbursts, or tantrums ) to such a severity that quality of life is seriously compromised. In addition to these symptoms, some women complain of lethargy, sleep disturbance, limited concentration and a host of physical symptoms such as breast tenderness, headaches, joint and muscle pain, bloating and weight gain.
The primary symptoms that distinguish premenstrual dysphoric disorder from other mood disorders (i.e., major depression) or menstrual conditions is the onset and duration of PMDD symptoms -- with symptoms appearing during the week or so before and disappearing within a few days after the onset of menses -- and the level by which these symptoms disrupt daily living tasks. (This diminished level of functioning is generally in great contrast with the same woman's interactions and abilities at other times during the month.)The symptoms of PMDD may resemble other conditions or medical problems, such as a thyroid condition, depression, or an anxiety disorder. Consult a physician for diagnosis.

What Causes PMDD
Although the exact cause of PMDD is not known, several theories have been proposed. One theory states that women who experience PMDD may have abnormal reactions to normal hormone changes that occur with each menstrual cycle. This may include the fluctuation of estrogen and progesterone levels that normally occur with menstruation causing a serotonin deficiency, in some women (Serotonin is a substance found naturally in the brain and intestines that acts as a vessel-narrowing substance, or vasoconstrictor). Additional research is necessary.

How is Premenstrual Dysphoric Disorder Diagnosed?
Aside from a complete medical history and physical and pelvic examination, diagnostic procedures for PMDD are currently very limited. Your physician may consider recommending a psychiatric evaluation to, more or less, provide a differential diagnosis (to rule out other possible conditions). In addition, he/she may ask that you keep a journal or diary of your symptoms for several months, to better assess the timing, severity, onset, and duration of symptoms. In general, in order for a PMDD diagnosis to be made, the following symptoms must be present:
· over the course of a year, during most menstrual cycles, five or more of the following symptoms must be present:
- depressed mood
- anger or irritability
- difficulty in concentrating
- lack of interest in activities once enjoyed
- moodiness
- increased appetite
- insomnia or hypersomnia
- feeling overwhelmed or out of control
- other physical symptoms
· symptoms that disturb social, occupational, or physical functioning
· symptoms that are not related to, or exaggerated by, another medical condition

What is the Difference Between PMS and PMDD?
The physical symptom list is identical for PMS and PMDD; while the emotional symptoms are similar, they are significantly more serious with PMDD. In PMDD, the criteria focus on the mood rather than the physical symptoms. With PMS, sadness or mild depression is not uncommon. With PMDD, however, significant depression and hopelessness may occur; in extreme cases, women may feel like killing themselves or others. Attributing suicidal or homicidal feelings to “it’s just PMS” is inappropriate; these feelings must be taken as seriously as they are in anyone else and should be promptly brought to the attention of mental health professionals.
Women who have a history of depression are at increased risk for PMDD. Similarly, women who have had PMDD are at increased risk for depression after menopause. In simplest terms, the difference between PMS and PMDD can be likened to the difference between a mild headache and a migraine.

PMDD Treatment
Treatment for PMS depends on the severity of the symptoms. For mild cases, treatment recommendations include diet modifications such as high carbohydrate meals and reducing salt, caffeine and alcohol, as well as a variety of methods for stress reduction and relaxation such as exercise, counselling and stress/behaviour management strategies.
For severe PMDD, treatment is more aggressive, often requiring pharmacological intervention in addition to nonpharmacological treatments. The selective serotonin reuptake inhibitor class of antidepressants are effective in the treatment of PMDD. Fluoxetine (Prozac - Serafem) has been widely studied and found to be effective in reducing symptoms of tension, irritability and dysphoria. These results have been replicated with sertraline (Zoloft) and paroxetine (Paxil). Use of the SSRIs is positive as well in that side effects, such as nausea, diarrhea, headache, and insomnia, to name a few, are minimal and reportedly tolerable by the majority of women.
For some women, even more drastic measures must be taken to ameliorate the symptoms of PMDD. For these women, hormonal therapies are necessary that work by suppressing the menstrual cycle. Effective hormonal therapies include gonadotropin releasing hormone (GnRH) agonists, estradiol and danazol. With respect to the GnRH agonists, women may not be able to continue with this form of therapy in that side effects are similar to symptoms of menopause. This, then, can increase the occurrence or severity of osteoporosis. With estradiol treatment, women must be concurrently treated with progestogen to prevent endometrial hyperplasia. Danazol is effective, however, that has quite a severe adverse effect profile due to its androgenic and anti-estrogen properties. In addition, danazol treatment affects menstrual cycle length. Thus, the side effect profile of hormonal therapies makes them less tolerable in the treatment of PMDD.
For some women, the severity of symptoms increase over time and last until menopause (when menses ceases). For this reason, a woman may require treatment for an extended period of time, and may require several reevaluations to adjust medication dosages throughout the course of treatment.

Overcoming Stigma
In the 1999 consensus paper published in the Journal of Women's Health and Gender-Based Medicine, a 14-member panel of health care experts concluded that PMDD is a distinct clinical entity and that specifically evaluated and approved medications are needed to treat this disorder. They agreed that strong data exist to support the use of SSRIs in treating PMDD.
Women, however, do face barriers to diagnosis and treatment. There is often a stigma attached to any condition that is associated with the menstrual cycle. Many women who do not seek treatment for the mood and physical symptoms of PMDD accept their symptoms as an inevitable consequence of the menstrual cycle which cannot be addressed.
Some women view seeking treatment for PMDD as a sign of weakness. Additionally, physicians aren’t traditionally trained to recognize the signs and symptoms of PMDD—symptoms are often dismissed as just a “part of being a woman.” Therefore, help is often neither sought nor offered.If you find that your doctor is unfamiliar with PMDD, print this information and bring it with you to your visit. An alternative is to get a second opinion from another OB-GYN or psychiatrist.

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