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Premenstrual dysphoric disorder

Alternative Names

PMDD; Severe PMS

Definition

Premenstrual dysphoric disorder (PMDD) is a condition in which a woman has severe depression symptoms, irritability, and tension before menstruation. The symptoms of PMDD are more severe than those seen with premenstrual syndrome (PMS).

PMS refers to a wide range of physical or emotional symptoms that typically occur about 5 to 11 days before a woman starts her monthly menstrual cycle. The symptoms usually stop when or shortly after her period begins.

Causes, incidence, and risk factors

The causes of PMS and PMDD have not been found.

Hormone changes that occur during a woman's menstrual cycle appear to play a role.

PMDD affects between 3% and 8% of women during the years when they are having menstrual periods.

Many women with this condition have:

• Anxiety
• Major depression
• Seasonal affective disorder (SAD)

Other factors that may play a role include:

• Alcohol abuse
• Being overweight
• Drinking large amounts of caffeine
• Having a mother with a history of the disorder
• Lack of exercise

Symptoms

The symptoms of PMDD are similar to those of PMS. However, they are generally more severe and debilitating and include a least one mood-related symptom. Symptoms occur during the week just before menstrual bleeding and usually improve within a few days after the period starts.

Five or more of the following symptoms must be present to diagnose PMDD, including one mood-related symptom:

• Disinterest in daily activities and relationships
• Fatigue or low energy
• Feeling of sadness or hopelessness, possible suicidal thoughts
• Feelings of tension or anxiety
• Feeling out of control
• Food cravings or binge eating
• Mood swings marked by periods of teariness
• Panic attack
• Persistent irritability or anger that affects other people
• Physical symptoms, such as bloating, breast tenderness, headaches, and joint or muscle pain
• Problems sleeping
• Trouble concentrating

Signs and tests

No physical examination or lab tests can diagnose PMDD. A complete history, physical examination (including a pelvic exam), and psychiatric evaluation should be done to rule out other conditions.

Keeping a calendar or diary of symptoms can help women identify the most troublesome symptoms and the times when they are likely to occur. This information may help the health care provider diagnose PMDD and determine the best treatment.

Treatment

A healthy lifestyle is the first step to managing PMDD.

• Eat a balanced diet (with more whole grains, vegetables, fruit, and little or no salt, sugar, alcohol, and caffeine)
• Get regular aerobic exercise throughout the month to redue the severity of PMS symptoms
• Try changing your sleep habits before taking drugs for insomnia (See also: Sleeping difficulty)

Keep a diary or calendar to record:

• The type of symptoms you are having
• How severe they are
• How long they last

Antidepressants may be helpful.

The first option is usually an antidepressant known as a selective serotonin-reuptake inhibitor (SSRI). You can take SSRIs in the second part of your cycle up until your period starts, or for the whole month. Ask your doctor.

Cognitive behavioral therapy (CBT) may be used either with or instead of antidepressants. During CBT, you have about 10 visits with a mental health professional over several weeks.

Other treatments that may help include:

• Birth control pills may decrease or increase PMS symptoms, including depression
• Diuretics may be useful for women who gain a lot of weight from fluid retention
• Nutritional supplements -- such as vitamin B6, calcium, and magnesium -- may be recommended
• Other medicines (such as Depo-Lupron) suppress the ovaries and ovulation
• Pain relievers such as aspirin or ibuprofen may be prescribed for headache, backache, menstrual cramping and breast tenderness

Support Groups

Expectations (prognosis)

After proper diagnosis and treatment, most women with PMDD find that their symptoms go away or drop to tolerable levels.

Complications

PMDD symptoms may be severe enough to interfere with a woman's daily life. Women with depression may have worse symptoms during the second half of their cycle and may need changes in their medication.

As many as 10% of women who report PMS symptoms, especially those with PMDD, have had suicidal thoughts. Suicide in women with depression is much more likely to occur during the second half of the menstrual cycle.

PMDD may be associated with eating disorders and smoking.

Calling your health care provider

Call 911 or a local crisis line immediately if you are having suicidal thoughts.

Call for an appointment with your health care provider if:

• Symptoms do not improve with self-treatment
• Symptoms interfere with your daily life

Prevention

References

Vigod SN. Understanding and treating premenstrual dysphoric disorder: an update for the women's health practitioner. Obstet Gynecol Clin North Am. 2009;36:907-924, xii.

Lentz GM. Primary and secondary dysmenorrhea, premenstrual syndrome, and premenstrual dysphoric disorder: etiology, diagnosis, management. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, eds. Comprehensive Gynecology. 5th ed. Philadelphia, Pa: Mosby Elsevier; 2007:chap 36.