What is the prevalence of premenstrual dysphoric disorder (PMDD) in women with bipolar disorder?

Prevalence of Premenstrual Dysphoric Disorder in Bipolar Disorder

Premenstrual dysphoric disorder (PMDD) is significantly more common in women with bipolar disorder, with prevalence rates ranging from 27% to 76%, compared to the general population rate of 3-8%. 1

Epidemiology of PMDD in Bipolar Disorder

• The comorbidity between PMDD and bipolar disorder is substantial, with studies showing that 27-76% of women with bipolar disorder meet criteria for PMDD 1
• Conversely, approximately 10-15% of women with PMDD receive a diagnosis of bipolar disorder 1
• This rate is significantly higher than the general population prevalence of PMDD, which is estimated at 3-8% of women of reproductive age 2
• Some studies suggest that up to 13-18% of reproductive-age women may experience premenstrual dysphoric symptoms severe enough to cause impairment, even if they don't meet the full diagnostic criteria of 5 symptoms 2

Clinical Implications of Comorbid PMDD and Bipolar Disorder

• Women with comorbid bipolar disorder and PMDD experience an earlier onset of bipolar illness 3
• These women show higher rates of rapid cycling (p=0.039) and increased number of past-year hypomanic/manic episodes (p=0.003) 3
• They also experience more lifetime and past-year depressive episodes (p<0.05) 3
• The gap between bipolar disorder onset and age of menarche is closer in women with comorbid PMDD (p=0.003), suggesting hormonal influences on disease onset 3

Associated Comorbidities

• Women with both bipolar disorder and PMDD have higher rates of:
  • Panic disorder 3
  • Post-traumatic stress disorder 3
  • Generalized anxiety disorder 3
  • Bulimia nervosa 3
  • Substance abuse 3
  • Adult attention deficit disorder 3

Hormonal Sensitivity and Clinical Course

• Women with comorbid PMDD and bipolar disorder report more severe mood symptoms during the perinatal period 3
• They also experience worsening symptoms while taking oral contraceptives (p<0.001) 3
• These findings suggest that sensitivity to endogenous hormones may impact both the onset and clinical course of bipolar disorder 3

Diagnostic Challenges

• A key challenge in accurately determining prevalence is the failure of many studies to employ prospective monitoring of symptoms, which is essential for confirming PMDD and differentiating it from premenstrual exacerbation of bipolar disorder 1
• Approximately 60% of women with mood disorders report premenstrual exacerbations (PME) of their symptoms, which must be distinguished from true PMDD 4
• Some women with bipolar disorder also show symptom exacerbations around ovulation, not just premenstrually 4

Clinical Impact and Disease Burden

• The impairment and reduced quality of life associated with PMDD is similar to that of dysthymic disorder and approaches that of major depressive disorder 2
• The disability-adjusted life years (DALY) lost due to PMDD is comparable to other major recognized disorders 2
• Despite this significant impact, PMDD remains under-recognized in large epidemiological studies and assessments of disease burden 2

Treatment Considerations

• Treatment approaches that work for PMDD alone may show less or no efficacy in premenstrual exacerbations of bipolar disorder 4
• For women with bipolar disorder experiencing premenstrual exacerbations, adjustable augmentation of treatment dosages during the luteal phase may be beneficial 4
• Lamotrigine augmentation has been reported as potentially effective in treatment-resistant PMDD cases 5

The high comorbidity between bipolar disorder and PMDD highlights the need for clinicians to screen for both conditions when either is present. Given the significant impact on illness course and burden, proper recognition and treatment of this comorbidity is essential for improving outcomes in affected women.