Can a patient with a Mirena (levonorgestrel-releasing intrauterine device) IUD, who has amenorrhea (absence of menstruation), still experience premenstrual dysphoric disorder (PMDD)-like symptoms?

PMDD Can Occur in Women with Amenorrhea Due to Hormonal IUDs

Yes, it is entirely possible for a patient to experience premenstrual dysphoric disorder (PMDD) symptoms despite having amenorrhea from a Mirena IUD. The cyclical mood symptoms your patient is experiencing are consistent with PMDD even in the absence of visible menstruation.

Understanding PMDD with Levonorgestrel IUDs

Levonorgestrel-releasing IUDs like Mirena work primarily through local effects on the endometrium, causing endometrial thinning that often leads to amenorrhea in many users 1. However, these important points explain why PMDD symptoms can persist:

• The Mirena IUD does not completely suppress ovulation in all women
• Hormonal fluctuations can still occur despite the absence of visible bleeding
• PMDD is triggered by sensitivity to normal hormonal changes, not necessarily by the bleeding itself

Hormonal Mechanisms Behind PMDD with IUDs

PMDD develops in predisposed individuals after exposure to progesterone at the time of ovulation 2. Research suggests PMDD is attributable to:

• Luteal phase abnormalities in serotonergic activity
• Altered configuration of GABA-A receptors in the brain
• Sensitivity to allopregnanolone (a progesterone metabolite) 2

Even with a Mirena IUD, these hormonal fluctuations may continue to occur cyclically despite the absence of visible menstruation.

Clinical Presentation and Diagnosis

Your patient's presentation is classic for PMDD despite amenorrhea:

• Cyclical pattern of symptoms (2-3 days monthly)
• Depressed mood that resolves suddenly
• Symptoms significantly interfering with functioning

The DSM criteria for PMDD focus on the cyclical nature of symptoms rather than requiring visible menstruation. The most common and clinically significant symptom is irritability, though depressed mood is also frequently reported 3.

Treatment Considerations

For women with PMDD using a Mirena IUD who continue to experience symptoms:

1. First-line treatment: Selective serotonin reuptake inhibitors (SSRIs)

   • SSRIs have moderate-certainty evidence for reducing premenstrual symptoms 4
   • Can be used continuously or during the luteal phase only
   • Common side effects include nausea, insomnia, and sexual dysfunction

2. Contraceptive adjustments:

   • If symptoms are severe, consider switching to a copper IUD (non-hormonal option) 1
   • Combined hormonal contraceptives with less androgenic progestins may be helpful for some women 2
   • The 20mcg ethinyl estradiol/3mg drospirenone in a 24/4 extended cycle regimen has shown significant improvement in PMDD symptoms 2

3. Lifestyle modifications:

   • Regular exercise
   • Stress reduction techniques
   • Dietary modifications (reducing caffeine, salt, alcohol)

Important Clinical Considerations

• PMDD is distinct from both depression and anxiety disorders, with irritability and affect lability as the most characteristic features 5
• Tracking symptoms over at least two menstrual cycles can help confirm the diagnosis
• Consider screening for comorbid mood disorders, as past episodes of mood disorder and family history of mood disorder are common in women with PMDD 6

Remember that PMDD symptoms can significantly impact quality of life, and treatment should be offered even when traditional menstruation is absent. The cyclical nature of symptoms is the key diagnostic feature, not the presence of bleeding.