Premenstrual Dysphoric Disorder (PMDD) Virtually

Premenstrual Dysphoric Disorder (PMDD)

Virtually all women of childbearing age know that the female menstrual cycle can bring mood swings. Called "Pre-menstrual Syndrome" (PMS), it is accepted as a fact of life by most women and is frequently the punch line for jokes about women's behavior. PMS is a nuisance and an inconvenience, but a significant number of women have symptoms that are so extreme and so incapacitating that it interferes with social, work and/or sexual activities (Bhatia, 2002). While 20-40% of women may have some degree of PMS, for 2-8%, the difficulties they experience during the second half (luteal, or post-ovulation) cycle constitutes Premenstrual Dysphoric Disorder (PMDD), a severe variant of PMS (!).

CAUSE

Although a lot has been learned about both PMS and PMDD, researchers have not been able to identify a clear cause for PMDD, which has both physical and psychological symptoms. The studies done so far tend to conflict with each other, denying both those who have PMDD and the doctors trying to help them a clear explanation for what is going on (Bosarge, 2003). However, recent research suggests that PMDD may result from an interaction between hormones released by the ovaries at ovulation and certain neurotransmitters in the brain (Bosarge, 2003). This would at least explain why the severe symptoms of PMDD appear during the second half of the reproductive cycle. Most researchers and doctors now believe that ovarian function rather than a hormonal imbalance causes PMDD, and that the condition is an interaction between the ovaries, the central nervous system and other organs (Steiner, 2000).

DIAGNOSIS

For women suspected of having PMDD, an accurate diagnosis is crucial. The condition is diagnosed by the pattern of symptoms (Bhatia, 2002) along with ruling out any other possible causes for the person's symptoms (Bosarge, 2003) as required by the Diagnostic and Statistical manual (DSM), the diagnostic manual for conditions with a psychological or psychiatric component.

For women suffering from premenstrual syndrome or premenstrual dysphoric disorder, an accurate diagnosis is the first step toward relief (Bosarge, 2003). Documenting an individuals' symptoms can be complicated and requires taking a careful medical history, because over 150 symptoms have been tied to either PMS or PMDD. They fall into two categories - physical and behavioral/psychological. Physical symptoms including weight gain, fluid retention, craving for specific foods, changes in appetite, and certain bodily pains. Behavioral/psychological changes can include difficulty concentrating, mood swings, forgetfulness, and depression, which can range from mild to severe (Bosarge, 2003). Medical practitioners note that the physical symptoms can be bothersome, but women are more likely to seek a diagnosis because of the psychological symptoms (Bosarge, 2003).

One crucial step in the diagnosis is to distinguish between PMS and PMDD. The difference is largely one of degree. PMS symptoms are viewed as milder and less disruptive. In PMDD, the symptoms are so severe that they interfere with normal life functioning in significant ways (Steiner, 2000). In DSM-IV, PMDD is classified as a depressive disorder and concentrates on the emotional and behavioral symptoms. It lists eleven specific symptoms, and the patient must display at least five to a degree significant enough to interfere with life. In addition, symptoms must be present during the luteal stage, and not throughout the cycle. In addition, they shouldn't be just an increase in severity of symptoms otherwise always present in the individual. During the first half of the menstrual cycle (follicular stage), the patient should be symptom-free. This goes to differential diagnosis, or confirming that PMDD is the best explanation for the person's symptoms (Bhatia, 2002). A person with another kind of depression or anxiety disorder would have symptoms throughout the entire cycle without regard to menstrual status.

Because symptoms follow a distinct time pattern, a symptom diary can be a valuable diagnostic tool (Bosarge, 2003). The patient records when symptoms occur, which can then be compared to the individual's personal menstrual cycle. Each day for two to three months, the woman uses her symptom diary to record any symptom, and rates them for severity on a scale of 0-4. Zero means the symptom is not present, and 4 would mean that the symptom was incapacitating (Bosarge, 2003). This diary is also useful once treatment has been started, because it can help the medical practitioner and the patient decide how effective treatment has been (Bosarge, 2003).

Along with a detailed patient history and the personal diary, some lab tests should be used to rule out other possible physical causes, including a complete blood cell count, basic blood chemistry, and thyroid function. Since PMDD is not a truly-hormone-based disorder (Bhatia, 2002), hormone profiles are often not useful. Psychological testing may be warranted as well (Bosarge, 2003), but the person's menstrual cycle should be taken into consideration. If the purpose is to clarify how the person functions during the follicular phase, then the testing must be done during that phase of her cycle. The final distinction made between PMS and PMDD is one of degree: PMS is a nuisance and unpleasant, but PMDD interferes with functioning in significant ways.

TREATMENT

Fortunately for those with PMDD, research has provided treatments demonstrated to help the troubling psychological effects of the disorder (Bhatia, 2002). While PMS typically does not require any kind of medication, patients with PMDD can often be greatly helped by medication. Of the medications available, selective serotonin reuptake inhibitors, or SSRI's, are a first line of treatment (Bhatia, 2002). Fluoxetine (trade name Prozac) was approved by the FDA in 2000 for the treatment of PMDD (Steiner, 2000). Research has shown that fluoxetine brought significant improvement for patients with PMDD, particularly in the area of social functioning (Steiner, 2000).

While fluoxetine is the only medication specifically approved for the treatment of PMDD, other medications have been successfully been used "off-label" for women who did not respond well to fluoxitine in some way (Sherman, 2001). As a group, SSRI's appear to diminish the difficulties in psychosocial, cognitive behavioral and even physical symptoms from PMDD (Bhatia, 2002). Sertraline, another SSRI, has been shown in research to help PMDD. In addition, venlafaxine, which is not an SSRI, has also been shown to be beneficial (Sherman, 2001). In research, sertlaine was found to provide significant improvement within the completion of three menstrual cycles. This occurred whether the patient took it continuously or only during the luteal phase. Interestingly, patients reported fewer problems with the medication when it was taken continuously (Sherman, 2001). The response to venlafaxine was rapid, with 80% of patients who responded to it reporting improvement after only one menstrual cycle. In addition, women tended to respond positively to low doses. The side effect profile was favorable. 8% of the group dropped out because of adverse reactions, but so did 6% in the control (placebo) group (Sherman, 2001).

In othe research, fluoxetine, citalopram, sertaline and clomipramine were all helpful when taken only during the luteal phase (Bhatia, 2002). This is significant because use during only the luteal phase will reduce cost, reduce side effects, and make it easier for the patient if the medication must be discontinued (Bhatia, 2002).

Other medications shown to be effective for some patients include alprazolam, again used during the luteal phase only, and this medication can be considered a second choice if SSRI's are not suitable for the patient (Bhatia, 2002).

CRITICS of the DIAGNOSIS