Better Understanding of PMDD

Approximately 75% of women experience a premenstrual change in emotional or physical symptoms commonly referred to as premenstrual syndrome (PMS). These symptoms include increased irritability, tension, depressed mood, and somatic complaints such as breast tenderness, bloating, and headaches. It is estimated that 5-9% of women experience moderate to severe premenstrual mood symptoms that meet criteria for premenstrual dysphoric disorder (PMDD).  PMDD includes depressed or labile mood, anxiety, irritability, anger, insomnia, difficulty concentrating, and other symptoms that occur exclusively during the 2 weeks before menses and cause significant deterioration in daily functioning. Women with PMDD use general and mental health services more often than women without the condition. They may experience impairment in marital and parental relationships as severe as that experienced by women with recurrent or chronic major depression.

A distinguishing characteristic of PMDD is the timing of symptom onset. In women with PMDD, mood symptoms occur only during the time from ovulation until onset of menses and resolve after menstruation onset. Women with PMDD report normal mood and function during the time between first day of the menstrual cycle and ovulation. Although PMS and PMDD criteria share mood and physical symptoms, more symptoms are required for a PMDD diagnosis, and symptoms often are more severe.

A PMDD diagnosis requires prospective daily monitoring of symptoms for at least two consecutive months. To distinguish the disorder from PMS, the Daily Record of Severity of Problems (DRSPP) used to quantify the severity of physical, emotional, and behavioral symptoms.

Many women respond to treatment with birth control, however it is very difficult to predict who will respond, and there are side effect concerns. Attempts to strategically balance estrogen and progesterone levels can be effective. A combination oral contraceptive drospirenone/ethinyl estradiol, is FDA approved for treating PMDD in women seeking hormonal contraception. With antidepressant medication treatment there may also be improvements in perceived productivity, social activities, and interpersonal relationships.

Antidepressants have been show to effectively ameliorate affective and physical symptoms and improve quality of life and psychosocial function in patients with PMS and PMDD. The response rates for selective serotonin reuptake inhibitors (SSRIs) in PMDD treatment vary but are approximately 60%.

The antidepressants that target serotonin are effective in PMDD. They include: the tricyclic antidepressant clomipramine, the SSRIs citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft), and the serotonin-noradrenergic reuptake inhibitor venlafaxine (Effexor).

The antidepressant agent’s rapid onset in PMDD allows for several dosing options. Some women prefer continuous dosing throughout the month because they do not have to keep track of when ovulation occurs. Alternatively, dosing antidepressants only in the luteal phase (taking the antidepressant from ovulation onset to the start of menses) is an effective treatment strategy. Many women prefer to take medication for only 2 weeks per month, which can decrease side effects and lower treatment costs. Another treatment approach is symptom-onset dosing – initiating the antidepressant when PMDD symptoms begin and stopping at menses onset or within 3 days thereafter – has shown promising results.

Ultimately, increasing awareness of PMDD symptoms and associated impairment can lead to seeking treatment with a medical doctor. With effective treatment, patients can experience a significant improvement in mood, anxiety, sense of self and quality of life.