What is Premenstrual Dysphoric Disorder (PMDD)?

Premenstrual Dysphoric Disorder (PMDD)

Premenstrual Dysphoric Disorder (PMDD) is a severe form of premenstrual syndrome affecting approximately 5-7% of reproductive-age women, characterized by significant mood, physical, and cognitive symptoms that begin during the luteal phase of the menstrual cycle and resolve shortly after menstruation begins.

Definition and Diagnostic Criteria

PMDD is officially recognized in diagnostic manuals as a distinct disorder with the following characteristics:

• Symptoms occur during the luteal phase (1-2 weeks before menses) and improve within a few days after the onset of menstruation
• Symptoms become minimal or absent within 1 week following the onset of menses 1
• The condition significantly interferes with work, school, social activities, and relationships

Key Symptoms Include:

• Mood symptoms:

  • Marked depressed mood
  • Anxiety or tension
  • Affective lability (mood swings)
  • Persistent anger or irritability

• Physical symptoms:

  • Breast tenderness
  • Headaches
  • Joint and muscle pain
  • Bloating and weight gain

• Cognitive/behavioral symptoms:

  • Decreased interest in activities
  • Difficulty concentrating
  • Lack of energy
  • Changes in appetite or sleep
  • Feeling out of control 2

Prevalence and Impact

• Affects approximately 5-7% of women of reproductive age 3, 4
• Significantly impacts quality of life and daily functioning
• Can adversely affect work performance, social relationships, and overall wellbeing

Pathophysiology

The exact cause of PMDD remains unclear, but several mechanisms have been proposed:

1. Hormonal sensitivity: Women with PMDD appear to have an abnormal response to normal hormonal fluctuations, particularly to progesterone and its metabolite allopregnanolone 3

2. Serotonergic dysfunction: Abnormalities in serotonergic activity during the luteal phase 3, 5

3. GABA receptor alterations: Changes in GABA-A receptor configuration triggered by exposure to progesterone metabolites 3, 4

4. Reproductive subtype: PMDD is considered part of a "reproductive subtype" of mood disorders related to hormonal fluctuations throughout a woman's reproductive life (menstrual cycle, pregnancy, postpartum, menopause) 1

Differential Diagnosis

Important to distinguish PMDD from:

• Major depressive disorder
• Generalized anxiety disorder
• Bipolar disorder
• Other cyclical mood disorders that may worsen premenstrually 2

Treatment Options

First-Line Treatments:

1. Selective Serotonin Reuptake Inhibitors (SSRIs):

   • Most effective pharmacological treatment with strong evidence 6, 7
   • Can be administered continuously or during the luteal phase only
   • Continuous administration appears more effective than luteal phase dosing 6
   • Sertraline, fluoxetine, paroxetine, escitalopram, and citalopram have all shown efficacy 6
   • Unique feature: SSRIs work more rapidly for PMDD than for depression or anxiety disorders 5

2. Combined Hormonal Contraceptives (CHCs):

   • Particularly effective: 20mcg ethinyl estradiol/3mg drospirenone in a 24/4 extended cycle regimen 3
   • Other monophasic extended cycle pills with less androgenic progestins may also help 3, 7

Second-Line Treatments:

1. GnRH Agonists:

   • For refractory cases 7
   • Create a temporary menopausal state
   • Limited by side effects and long-term risks

2. Non-Pharmacological Approaches:

   • Cognitive Behavioral Therapy (CBT) 4
   • Regular exercise
   • Dietary modifications
   • Stress reduction techniques
   • Certain supplements (though evidence is limited) 4, 7

Contraceptive Considerations for Women with PMDD

• Recommended options:

  • Combined hormonal contraceptives (particularly with drospirenone)
  • Copper IUDs (non-hormonal option) 3

• Use with caution:

  • Progestin-only methods (pills, implants, DMPA, LNG-IUD) may worsen mood symptoms in women with PMDD 3

Treatment Algorithm

1. Diagnosis: Confirm PMDD through prospective daily symptom tracking over at least two menstrual cycles

2. Initial treatment:

   • For women needing contraception: Trial of combined hormonal contraceptive with drospirenone
   • For women not needing contraception: SSRI (either continuous or luteal phase dosing)

3. If inadequate response:

   • Switch to a different SSRI or try continuous instead of luteal phase dosing
   • Add CBT if not already implemented

4. For refractory cases:

   • Consider GnRH agonists
   • Surgical options (oophorectomy with hysterectomy) as last resort for severe cases 7

Common Pitfalls in PMDD Management

• Failing to distinguish PMDD from other mood disorders
• Inadequate dosing or premature discontinuation of treatment 1
• Overlooking comorbidities that may impact treatment effectiveness 1
• Using progestin-only contraceptives which may worsen symptoms 3
• Not providing adequate follow-up, especially during initial treatment

PMDD is a distinct disorder requiring specific treatment approaches. With proper diagnosis and management, most women can experience significant symptom relief and improved quality of life.