What is Premenstrual Dysphoric Disorder (PMDD) in females of reproductive age?

What is Premenstrual Dysphoric Disorder (PMDD)?

PMDD is a severe psychiatric disorder affecting 3-8% of menstruating women, characterized by disabling mood, cognitive, and physical symptoms that occur exclusively during the luteal phase of the menstrual cycle (the two weeks before menstruation), improve within days after menses begins, and become minimal or absent within one week following menses. 1, 2

Core Diagnostic Features

PMDD is distinguished from general premenstrual syndrome (PMS) by its severity and functional impairment. The essential diagnostic criteria include: 3

Mood and Behavioral Symptoms (Most Distressing)

• Markedly depressed mood 3
• Anxiety or tension 3
• Affective lability (sudden mood swings, tearfulness) 3, 4
• Persistent anger or irritability 3
• Decreased interest in usual activities 3
• Difficulty concentrating 3
• Feeling out of control 3

Cognitive Symptoms

• Forgetfulness 1
• Impaired concentration 3

Physical/Somatic Symptoms

• Breast tenderness 3
• Headache 3
• Joint and muscle pain 3
• Bloating and weight gain 3
• Overeating (neurovegetative symptom) 1
• Lack of energy 3
• Changes in appetite or sleep 3

Critical Temporal Pattern (Required for Diagnosis)

The timing is pathognomonic and distinguishes PMDD from other mood disorders: 1

• Symptoms must begin several days before menses onset (during the luteal phase) 1
• Symptoms start to improve within a few days after menses begins 1
• Symptoms become minimal or absent within one week following menses onset 1
• The disturbance markedly interferes with work, school, or usual social activities and relationships 3

Differential Diagnosis: Key Distinction

PMDD must be differentiated from Bipolar Disorder, which shows mood episodes lasting days to weeks independent of menstrual cycle timing, not strictly confined to the luteal phase. 1 This is a critical pitfall—other cyclical mood disorders may be exacerbated by the menstrual cycle but do not follow the strict luteal-phase-only pattern required for PMDD diagnosis. 3

Underlying Pathophysiology

The mechanism involves differential hormonal sensitivity rather than abnormal hormone levels: 1

• Women with PMDD demonstrate differential sensitivity to normal gonadal steroid fluctuations (estrogen and progesterone), not abnormal absolute hormone levels 1
• The luteal phase features progressive increases in estrogen and progesterone until mid-luteal phase, followed by a decline before menstruation 1
• The withdrawal of estrogen and progesterone during the luteal phase triggers system dysregulation in vulnerable women 1
• This involves abnormalities in serotonergic activity and altered GABA-A receptor configuration triggered by the progesterone metabolite allopregnanolone 5

Prevalence and Impact

• Affects 3-8% of menstruating women 2, 6
• Represents the severe, disabling end of the premenstrual disorder spectrum 6
• Can adversely affect personal relationships and occupational functioning 7
• Mean duration of symptoms before diagnosis is approximately 10.5 years 3