Premenstrual dysphoric disorder (PMDD)

Premenstrual Syndrome (PMS)

• PMS: Clinically significant somatic and psychological symptoms during the luteal phase causing distress and functional impairment, resolving after menstruation begins.
• Prevalence: Affects 47.8% of reproductive-age women worldwide; 20% have symptoms disrupting daily activities.
• Symptoms: Appetite changes, weight gain, abdominal pain, back pain, breast tenderness, nausea, constipation, anxiety, irritability, anger, fatigue, mood swings, crying.

Premenstrual dysphoric disorder (PMDD)

• Severe Form: PMDD is a more severe form of PMS, classified as a psychiatric disorder in DSM-5.
• Treatment: Nonpharmacological therapies for mild symptoms; SSRIs for severe symptoms.

Historical Nomenclature

• 18th Century: “Menses moodiness”
• Early 19th Century: “Premenstrual tension”
• 1950s: “Premenstrual syndrome (PMS)”

DSM-5 Criteria for PMDD

• Criterion A: At least 5 of 11 symptoms, including at least 1 of the first 4:
  1. Depressed mood, hopelessness
  2. Anxiety, tension
  3. Affective lability
  4. Anger or irritability
  5. Decreased interest in activities
  6. Difficulty concentrating
  7. Lethargy or lack of energy
  8. Change in appetite
  9. Sleep disturbances
  10. Overwhelmed or out of control
  11. Physical symptoms (e.g., breast tenderness, bloating)
• Criterion B: Symptoms significantly interfere with daily functioning.
• Criterion C: Symptoms linked to menstrual cycle, not due to another disorder.
• Criterion D: Confirmed by daily ratings over 2 consecutive symptomatic cycles.

Etiology and Risk Factors

• Unknown exact cause.
• Proven Risk Factors:
  • Traumatic events, preexisting anxiety disorders.
  • Cigarette smoking.
  • Obesity.
• Speculative Risk Factors:
  • Genetics, including serotonergic and estrogen receptor gene variants.

Epidemiology

• Affects all women of reproductive age.
• US Prevalence:
  • 70-90% experience some discomfort.
  • 3-8% have PMDD.

Pathophysiology

• Heightened sensitivity to hormonal variations.
• Key Hypotheses:
  • Progesterone and its metabolite allopregnanolone.
  • Estrogen fluctuations.
  • Central neurotransmitters like serotonin, GABA, glutamate.

Uncertain: Linked to hormonal fluctuations (estrogen surplus, progesterone deficiency) and serotonin regulation.

Mechanisms:

• Estrogen fluctuations impact mood.
• Serotonin levels increase during specific menstrual cycle phases.
• Decreased estrogen triggers norepinephrine release, affecting neurotransmitters and causing symptoms.

Lifestyle Factors:

• Diet: High intake of sweets, junk food, and coffee.
• Lifestyle: Poor sleep quality, less exercise.

Genetics: Potential role in PMS/PMDD development.

Symptoms

• Mood: Depression, mood swings, irritability, anxiety.
• Behavioral: Fatigue, decreased interest, concentration problems, appetite changes, sleep disturbances, feeling overwhelmed.
• Somatic: Breast tenderness, bloating, headaches, weight gain.

Evaluation

• Diagnostic Criteria:
  • Symptoms consistent with PMS.
  • Symptoms occur only during luteal phase.
  • Negative impact on function and lifestyle.
• Exclusion of Other Disorders: Rule out thyroid disorders, Cushing syndrome, hyperprolactinemia.
• Symptom Diary: Recommended for assessing cycle-to-cycle variability.

Treatment and Management

• Non-Pharmacological:
  • Lifestyle Modifications: Exercise, stress avoidance, healthy sleep habits.
  • Cognitive-Behavioral Therapy (CBT): Corrects disruptive thoughts and behaviors.
• Pharmacological:
  • Psychotropic agents:
    • Serotonin Reuptake Inhibitors (SRIs): Effective for severe symptoms.
    • Benzodiazepines: For severe anxiety and insomnia.
  • Hormonal therapies:
    • GnRH agonists, Danazol, Oral contraceptive pills (OCPs).

Differential Diagnosis

• Major depressive disorder, thyroid disease, generalized anxiety disorder, mastalgia.

Interprofessional Management

• Coordination between primary physician, gynecologist, psychiatrist.
• Patient education and symptom tracking.
• Therapy for coping skills.