Symptoms of Premenstrual Dysphoric Disorder (PMDD)
Core Diagnostic Features
PMDD is characterized by a specific pattern of mood, somatic, and cognitive symptoms that occur during the luteal phase of the menstrual cycle (several days before menses), improve within a few days after menses onset, and become minimal or absent within one week following menses. 1
Symptom Categories
Mood and Affective Symptoms
- Markedly depressed mood 2
- Anxiety or tension 2
- Affective lability (mood swings) 1, 2
- Persistent anger or irritability 1, 2, 3
- Dysphoria (general dissatisfaction or unease) 4
- Internal tension 4
Cognitive Symptoms
- Difficulty concentrating 2
- Forgetfulness 1
- Decreased interest in usual activities 2
- Feeling out of control 2
Somatic/Physical Symptoms
- Breast tenderness 2, 3
- Headache 2
- Joint and muscle pain 2
- Bloating and weight gain 2, 3
- Abdominal bloating 3
- Acne 3
Neurovegetative Symptoms
- Change in appetite or food cravings 2, 3
- Change in sleep patterns 2
- Lack of energy or fatigue 2, 3
- Overeating 1
Critical Diagnostic Requirements
The symptoms must substantially interfere with work, school, usual social activities, or relationships with others to meet diagnostic criteria. 2 This functional impairment distinguishes PMDD from milder premenstrual syndrome (PMS), which affects 20-40% of menstruating women but causes less severe symptoms. 3
PMDD affects only 3-8% of menstruating women and represents the severe, disabling end of the premenstrual disorder spectrum. 5
Temporal Pattern (Essential for Diagnosis)
The symptoms must follow a specific temporal pattern:
- Begin several days before menses onset 1
- Start to improve within a few days after menses begins 1
- Become minimal or absent within one week following menses onset 1
- Occur regularly during the luteal phase 2
Differential Diagnosis Considerations
Care must be taken to rule out other cyclical mood disorders that may be exacerbated during the premenstrual period rather than representing true PMDD. 2 This includes distinguishing PMDD from premenstrual magnification of underlying major depressive disorder, anxiety disorders, or other psychiatric conditions. 4
Treatment Overview
First-Line Pharmacological Treatment
Selective serotonin reuptake inhibitors (SSRIs) are the first-line pharmacological treatment for PMDD, with FDA-approved options including fluoxetine, sertraline, and controlled-release paroxetine. 2, 6 SSRIs can be administered either continuously throughout the menstrual cycle or only during the luteal phase (intermittent dosing). 5, 4
For sertraline specifically, treatment should be initiated at 50 mg daily, either throughout the menstrual cycle or limited to the luteal phase, with dose increases up to 150 mg/day for continuous dosing or 100 mg/day for luteal phase dosing if needed. 2
SSRIs probably reduce overall premenstrual symptoms with moderate-certainty evidence (SMD -0.57), and continuous administration appears more effective than luteal-phase-only dosing. 7
Non-Pharmacological Treatment
Cognitive Behavioral Therapy (CBT) shows positive results in reducing functional impairment, depressed mood, and anxiety in PMDD patients. 8 Lifestyle modifications including diet and exercise are recommended as first-line approaches for all women with PMS/PMDD and may be sufficient for mild-to-moderate symptoms. 6
Common Adverse Effects of SSRIs
The most common adverse effects include:
- Nausea (OR 3.30) 7
- Asthenia/decreased energy (OR 3.28) 7
- Somnolence and decreased concentration (OR 3.26) 7
- Sexual dysfunction or decreased libido (OR 2.32) 7
- Insomnia (OR 1.99) 7
Alternative Pharmacological Options
Hormonal interventions aimed at suppressing ovulation can eliminate premenstrual symptoms, but the benefit-risk ratio must be carefully evaluated as oral contraceptives do not restore spontaneous menses and may have other metabolic effects. 1, 4 Anxiolytics, spironolactone, and NSAIDs can provide supportive symptom relief. 6