What is premenstrual dysphoric disorder?

Premenstrual dysphoric disorder (PMDD), which can accompany menstruation, may wreak havoc on a person’s personal, social and work life.

Sadly, while PMDD often responds to effective and professional treatment, many women with PMDD do not seek treatment, and up to 90% may go undiagnosed. So says Dr Eileen Thomas, a specialist psychiatrist at Akeso Clinic Milnerton.

“PMDD is a reproductive disorder whereby women experience transient physical and emotional changes around the time of their period, PMDD is associated with a level of impairment that is similar to major depressive disorder and poorer quality of life compared with community norms, therefore it should be considered a serious health condition. PMDD can have adverse consequences on a woman’s social functioning, relationships, work productivity and healthcare use,” Thomas points out.

What are the symptoms of PMDD?

As defined in the American Psychiatric Association (APA) Diagnostic and Statistical Manual, Fifth Edition (DSM-5), one of required symptoms to make a diagnosis must come from this list of four:

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  • irritability or anger
  • anxiety and tension
  • depressed mood or feeling hopeless
  • marked affective lability (e.g., mood swings; feeling suddenly sad or tearful or increased sensitivity to rejection)

“Other symptoms include difficulty concentrating, fatigue, changes in appetite or specific food cravings, sleep disturbances, feeling overwhelmed and physical symptoms such as breast tenderness or abdominal bloating.  These symptoms occur recurrently, typically in the same constellation-set and in the majority of menstrual cycles.”

Symptoms usually emerge during a woman’s twenties and may worsen over time. For example, it has been observed that some women may experience worsening premenstrual symptoms as they enter into menopause. Less commonly, PMDD may begin during adolescence.

What’s the difference between premenstrual syndrome (PMS) and PMDD?

According to Thomas, no less than 75-90% of women experience premenstrual mood and physical changes.

“PMS is experienced by about 20% of menstruating women who have at least one physical or emotional symptom during the five days before menses. PMDD, on the other hand, occurs in about 3% to 8% of women with regular ovulatory cycles. Although PMS and PMDD criteria share mood and physical symptoms, more symptoms are required for a PMDD diagnosis and symptoms are often more severe,” she says.

Myths about PMDD

Common myths about PMDD are that it is not a real disorder or that the diagnosis was created by pharmaceutical companies to increase prescribing of medications.

“PMDD was included as a new diagnostic category in the DSM-5 in May 2013 and it is hoped that its inclusion will attract more funding for research, and a better understanding of women’s reproductive health,” says Thomas.

Who is at risk for developing PMDD?

While any woman can develop PMMD, women with a personal or family history of depression, postpartum depression, or other mood disorders are particularly at risk. Women who experience abuse (emotional, physical or sexual) in early life are at higher risk for PMS in the middle-to-late reproductive years.

What does a patient need to tell her doctor?

In order to establish the diagnosis, the clinician will request a woman to chart symptoms daily for two consecutive cycles.

“Your doctor will also ask you about your medical and psychiatric history, medication and substance use. It is important to provide accurate and thorough information to distinguish PMDD from mimics, for example dysmenorrhea,” Thomas stresses.

“A woman must experience at least five of 11 possible symptoms in the week before menstruation starts (the luteal phase). Symptoms must improve once menstruation has begun and the symptoms must be absent the week after menstruation has ended.  Women with PMDD report a normal mood and functioning during the follicular phase of the menstrual cycle (i.e. the first day of the menstrual cycle until ovulation).”

Treatment options for PMDD

Treatment comprises both pharmacological and non-pharmacological therapies. Treatment is tiered and individualised, dependent on factors such as the woman’s choice, contra-indications to certain medications, cost and contraception-needs, says Thomas.

1. Lifestyle changes

“In general, lifestyle changes can help to ameliorate symptoms. Although solid evidence is lacking, clinicians generally recommend that patients with PMS or PMDD decrease or eliminate the intake of caffeine, sugar and sodium,” says Thomas, “Other helpful lifestyle modifications include decreasing alcohol and nicotine use, ensuring adequate sleep and regular aerobic exercise. Herbal remedies include calcium carbonate and chaste berry.”

2. Pharmacological treatment

“The first line pharmacological treatment to reduce both the physical and emotional symptoms is serotonergic antidepressant drugs, particularly selective serotonin reuptake inhibitors (SSRIs). In general, women respond to low doses of SSRIs, and this treatment response usually occurs rapidly, often within several days.

“Different dosing-regimens exist, whereby women may choose to take the antidepressant treatment continuously throughout the whole month, or only in the luteal phase (the week leading up to period).  Other pharmacological options include hormonal treatment such as oral contraceptives that contain drosperinone – an antidiuretic or short term anxiolytic use.

“Treatment generally continues for the duration of a women’s reproductive life.  If one considers that a female typically menstruates 300-500 times during her lifetime, timely identification and initiation of appropriate treatment may prevent impairment. This, together with support and TLC from loved ones or spouses, can go a long way towards improving the quality of life of PMDD sufferers,” concludes Thomas.

While All4Women endeavours to ensure health articles are based on scientific research, health articles should not be considered as a replacement for professional medical advice. Should you have concerns related to this content, it is advised that you discuss them with your personal healthcare provider.