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April 29, 2019

Premenstrual Dysphoric Disorder

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Premenstrual dysphoric disorder (PMDD) is a severe and disabling form of premenstrual syndrome affecting 1.8 to 5.8% of menstruating people.[1] Originally called "late luteal phase dysphoric disorder," this disorder consists of a variety of affective, behavioral and somatic symptoms that recur monthly during the luteal phase of the menstrual cycle.[2][3] It is a disorder that affects those who menstruate from their early teens up until menopause, excluding those suffering from hypothalamic amenorrhea or during pregnancy and breastfeeding.[4] PMDD was added to the list of depressive disorders in the Diagnostic and Statistical Manual of Mental Disorders in 2013.[1] It has 11 possible symptoms, and a person has to exhibit a minimum of 5 symptoms in order to qualify for PMDD.[5] It has been found that roughly 20% of menstruating people show signs pre-menstrual distress similar to PMDD, but they do not qualify for diagnosis for reasons of not meeting the 5 symptom minimum or failing to meet the functional impairment requirement.[6]

Treatment of PMDD relies largely on antidepressants that modulate serotonin levels in the brain via selective serotonin reuptake inhibitors (SSRIs) as well as ovulation suppression using contraception and GnRH analogues.[3] SSRIs are the most common treatment, as they tend to improve both the physical and emotional symptoms as well as general behavior and functionality of the patient.[3] GnRH agonists are the more extreme treatment in comparison, as they suppress ovulation through inhibition of the gonadotropic hormones, LH and FSH. The emotional effects of premenstrual dysphoric disorder are theorized to be the result of severe gonadal steroid fluctuations, as they cause dysregulation of serotonin uptake and transmission, and potentially calcium regulation, circadian rhythm, BDNF, the HPA-axis, and immune function as well.[5] Some studies have suggested that those who suffer from PMDD are more at risk of developing Postpartum Depression after pregnancy, but other evidence has been found to suggest against that notion.[7]

Signs and Symptoms

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Premenstrual dysphoric disorder (PMDD) is a severe form of premenstrual syndrome (PMS). Like PMS, premenstrual dysphoric disorder follows a predictable, cyclic pattern. Symptoms begin in the late luteal phase of the menstrual cycle (after ovulation) and end shortly after menstruation begins.[8] On average, the symptoms last six days but can start up to two weeks before menses. Severe symptoms begin about 6 days before the start of menstruation, with the most intense symptoms occurring two days before the start through to the first day of menstrual blood flow.[2] The symptoms usually cease shortly after the start of the menstrual period.[3][9] The onset of symptoms only during or around the luteal phase is key for diagnosing a patient with PMDD rather than any other mood disorders.[4]

The symptoms in PMDD can be both physical and emotional, but mood symptoms must be present for the diagnosis.[8] Individuals experiencing PMDD may note suicidal ideation and temptation to self-harm.[10] Many doctors recommend patients keep a mood log to record their mood patterns over the course of the high point of the symptoms in order to prescribe the proper treatment for the individual.[4]

The International Society for the Study of Premenstrual Disorders (ISPMD) defines two clinical categories for premenstrual disorders[4]:

  1. Core PMD
  2. Variant PMD

Core PMD has six characteristics, all mainly focusing on the cyclical nature of PMDD and its typical onset pre-menses tracked over the course of more than two menstrual cycles. The four classified Variant PMDs involve more unexpected variables that cause the onset of premenstrual distress; such as, PMD with absent menstruation or premenstrual exacerbation, wherein the symptoms of another preexisting psychological disorder may be heightened as a result of PMDD onset.[4]

A large majority of menstruating people claim feeling premenstrual symptoms to some degree, with 20-30% feeling enough symptoms to qualify for diagnosis of PMS and only 3-8% of that group qualifying for diagnosis of PMDD.[2] The most agreed-upon possibilities for what causes PMDD currently are heightened sensitivity to fluctuating levels of certain hormones (i.e. the reproductive hormones), environmental stress, and genetic predisposition.[4] The sex steroids—estrogen and progesterone—are neuroactive; they have been noted in rat models to be involved in serotonin pathways.[4][11] Serotonin is involved in mood regulation alongside estrogen, whose receptors are found in the prefrontal cortex and hippocampus—the regions most known for their involvement in regulating one's mood and cognition overall.[2][4]

Etiology

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The etiology of PMDD is still an active area of research. While the timing of symptoms suggests hormonal fluctuations as the cause of PMDD, a demonstrable hormonal imbalance in individuals with PMDD has not been identified. In fact, levels of reproductive hormones and their metabolites in those with and without PMDD are indistinguishable.[12][13][14] It is instead hypothesized that people with PMDD are more sensitive to normal levels of hormone fluctuations, predominantly estrogen and progesterone, which produces biochemical events in the nervous system that cause the premenstrual symptoms.[14] These symptoms are more prominent in people who have a predisposition to the disorder.[8]

It is apparent that the premenstrual disorders are biologically driven and are not only psychological or cultural phenomena. PMDD has been reported by women and other menstruating individuals worldwide, indicating a biological basis that is not geographically selective.[2] Most psychologists infer that this disorder is caused by both a reaction to hormone flux and also genetic components. There is evidence of heritability of (retrospectively-reported) premenstrual symptoms from several twin and family studies done in the 1990s, with the heritability of PMDD proving to be about 56%.[15][16][17][18] The investigation into which genes are involved is ongoing; one study has tested the gene-based haplotypes of alpha and beta estrogen receptors (ESR1 and ESR2) in women with PMDD by comparing their structures to 25 SNPs from two government databases.[15] The researchers uncovered a number of loci responsible for indirectly facilitating serotonin receptor function through the concurrent functioning of the estrogen receptors. They also checked a specific polymorphism in the COMT gene, which is known to be involved in estrogen metabolism, contains estrogen response elements, is often cited as a cause of sex steroid associated cancers, and regulates dopamine levels in the prefrontal cortex (a region whose cerebral function and blood flow is regulated by estradiol); that polymorphism has been linked to risk for schizophrenia and OCD, and can moderate the effects of environmental factors on expression of the disorders.[15]

Disorders of this nature are often caused by a mix of both environmental and biological factors. Environmental stressors have also been found to prospectively increase risk for PMDD symptoms.[19][20] Genetics do not operate in a vacuum: environmental components such as stress, hormonal fluctuation, and epigenetics play a key role in the pathology and onset of the disorder.[21][15] Some studies have noted evidence of interpersonal trauma (domestic violence, physical or emotional trauma, or substance abuse) or seasonal changes (making PMDD potentially comorbid with Seasonal Affective Disorder) having an impact on PMDD risk.[3][22] But the most common pre-existing disorder found in those diagnosed with PMDD is major depression, wherein they either actually had it or were misdiagnosed when they should have only been diagnosed with PMDD.[22] The last environmental factor is primarily sociological: the sociocultural aspects of being female, performing female gender roles, and stress from engaging in female sexual activity.[1]

Diagnosis

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Currently, authoritative diagnostic criteria for PMDD are provided by a number of expert medical guides, most notably the DSM-5 which established seven criteria (A through G) for the diagnosis of PMDD.[1] There is heavy overlap between the criteria for PMDD in the DSM-5 and the criteria found in the Daily Record of Severity of Problems (DRSP).[23][24] 

♦ The symptoms of Criteria A-C must have been met for most menstrual cycles that occurred in the preceding year, and have to have affected normal functioning to some degree (Criterion D).[1]

Criterion A: During most menstrual cycles throughout the past year, at least 5 of the following 11 symptoms (especially including at least 1 of the first 4 listed) must be present in the final week before the onset of menses, must start to improve within a few days after the onset of menses, and become minimal or absent in the week post-menses:[1]

  1. Marked lability (e.g., mood swings)
  2. Marked irritability or anger
  3. Markedly depressed mood
  4. Marked anxiety and tension
  5. Decreased interest in usual activities
  6. Difficulty in concentration
  7. Lethargy and marked lack of energy
  8. Marked change in appetite (e.g., overeating or specific food cravings)
  9. Hypersomnia or insomnia
  10. Feeling overwhelmed or out of control
  11. Physical symptoms (e.g., breast tenderness or swelling, joint or muscle pain, a sensation of bloating and weight gain)[1][3]

Criterion B: One (or more) of the following symptoms must be present:[1]

  1. Marked affective lability (e.g., mood swings; feeling suddenly sad or tearful, or increased sensitivity to rejection).
  2. Marked irritability or anger or increased interpersonal conflicts.
  3. Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts.
  4. Marked anxiety, tension, and/or feelings of being keyed up or on edge.

Criterion C: One (or more) of the following symptoms must be present additionally, to reach a total of 5 symptoms when combined with present symptoms from Criterion B above:[1]

  1. Decreased interest in usual activities (e.g., work, school, friends, hobbies).
  2. Subjective difficulty in concentration.
  3. Lethargy, easy fatiguability, or marked lack of energy.
  4. Marked change in appetite; overeating; or specific food cravings.
  5. Hypersomnia or insomnia.
  6. A sense of being overwhelmed or out of control.
  7. Physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of bloating, or weight gain.

Criterion D: The symptoms observed in Criteria A-C are associated with clinically significant distress or interference with work, school, usual social activities, or relationships with others (e.g., avoidance of social activities; decreased productivity and efficiency at work, school, or home).[1]

  • Clinically significant distress is not defined explicitly by the DSM-IV, where it has been critiqued by multiple scholars as being too vague, and potentially detrimental for those who have symptoms of depression, anxiety, or other mood disorders because they do not meet the clinical significance requirement.[25][26]

Criterion E: The disturbance is not merely an exacerbation of the symptoms of another disorder, such as major depressive disorder, panic disorder, persistent depressive disorder (Dysthymia), or a personality disorder—although it may co-occur with any of these disorders.[1]

Criterion F: Criterion A should be confirmed by prospective daily ratings during at least two symptomatic cycles. The diagnosis may be made provisionally prior to this confirmation.[1]

Criterion G The symptoms are not attributable to the physiological effects of a substance (e.g., drug abuse, a medication, other treatments) or another medical condition (e.g., hyperthyroidism).[1]

Summary

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According to the DSM-5, a diagnosis of PMDD requires the presence of at least five of these symptoms with one of the symptoms being numbers 1-4.[1] These symptoms should occur during the week before menses and remit after initiation of menses. In order to meet criteria for the diagnosis, the symptoms should be charted prospectively for two consecutive ovulation cycles in order to confirm a temporal and cyclical nature of the symptoms. The symptoms should also be severe enough to affect normal work, school, social activities, and/or relationships with others.[1]

Other organizations that have published diagnostic criteria for PMDD include the Royal College of Obstetricians and Gynecologists and the International Society for the Study of Premenstrual Disorders (ISPMD).[27][28] The ISPMD was a consensus group established by an international multidisciplinary group of experts. The group's diagnostic criteria for PMDD focuses on the cyclic nature of the symptoms occurring during the luteal phase of the menstrual cycle, as well as the symptoms being absent after menstruation and before ovulation and causing significant impairment. The ISPMD diagnostic criteria for PMDD do not specify symptom characteristics or number of symptoms.[27]

Diagnostic criteria for PMDD are also provided by the 2016 World Health Organization's International Classification of Diseases (ICD-11-CM):[29]

GA34.41 Premenstrual dysphoric disorder

Description

During a majority of menstrual cycles within the past year, an individual experiences a pattern of mood symptoms (depressed mood, irritability), somatic symptoms (lethargy, joint pain, overeating), or cognitive symptoms (difficulty concentrating, forgetfulness) that begin several days before the onset of menses, start to improve within a few days after the onset of menses, and then become minimal or absent within approximately 1 week following the onset of menses. The temporal relationship of the symptoms and luteal and menstrual phases of the cycle may be confirmed by a prospective symptom diary. The symptoms are severe enough to cause significant distress or significant impairment in personal, family, social, educational, occupational or other important areas of functioning and do not directly represent the exacerbation of a mental disorder.[29]

Thus today many well-recognized health organizations in many parts of the world provide guides for the diagnosis of PMDD. As a historical footnote, early drafts of the ICD failed to recognize PMDD as a separate condition.[30] In 2003, before the current ICD 10 guidelines, the Committee for Proprietary Medicinal Products required the manufacturer of Prozac (fluoxetine) to remove PMDD from the list of indications for fluoxetine sold in Europe.[31] In Australia, PMDD is recognized by the Therapeutic Goods Administration. However, antidepressants are not reimbursed for PMDD under the Pharmaceutical Benefits Scheme.[32]

Treatment

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Medication

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Several medications have received empirical support for the treatment of PMDD. Selective serotonin reuptake inhibitors (SSRIs) are the first-line medication, as 60-70% of patients respond well to them.[8][33][34] The U.S. Food and Drug Administration (FDA) has approved four SSRIs for the treatment of PMDD: Fluoxetine (available as generic or as Prozac or Sarafem), sertraline (Zoloft), paroxetine (Paxil), and escitalopram oxalate (Lexapro).[32] Unlike treatments for depressive disorders, SSRIs do not need to be taken daily but instead can be taken only in the luteal phase or during PMDD symptoms.[3] This is because those who respond to SSRIs usually experience symptoms relief within 1–2 days.[35] Studies in rats suggest this rapid response to SSRIs is due to the elevation of the neuroactive progesterone metabolite allopregnanolone in the brain, rather than serotonin.[36][37] Luteal phase dosing can be started 14 days before menses and subsequently discontinued after start of menstrual flow.[32] Women taking SSRIs to ease PMDD generally report >50% alleviation in symptoms, which was significant improvement compared to placebo.[35]

Although less studied, SNRIs have also shown benefits for those with PMDD. In a randomized, controlled clinical trial of women with PMDD, 60% of the subjects taking venlafaxine (Effexor) improved, versus 35% on placebo. Improvement was noticed during the first treatment cycle with 80% symptom reduction.[37]

Another FDA approved treatment for PMDD is the oral contraceptive with ethinylestradiol and drospirenone (a novel progestin) taken on a 24-4 schedule (24 active pills, 4 inactive pills).[32] It has been shown that hormonal birth control containing drospirenone and low levels of estrogen helps relieve severe PMDD symptoms, for at least the first three months that it is used.[38] The idea behind using oral contraceptives is to suppress ovulation, therefore suppressing sex hormone fluctuations.

Another treatment, typically used when other options have failed, is injection of a gonadotropin-releasing hormone agonist.[39] These drugs create a temporary, drug-induced menopause-likecondition. Addback of estradiol is recommended to prevent bone loss in the long-term; this generally necessitates the concurrent addback of progesterone to prevent estradiol-induced endometrial hyperplasia. Two landmark studies have demonstrated that the addback of estradiol or progesterone on top of GnRH agonists can cause a resurgence of PMDD symptoms but that this resurgence of symptoms remits after one month of stable addback.[40][41][42]

Psychotherapy

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Cognitive behavioral therapy (CBT) has been shown to be effective in reducing premenstrual symptoms in women with (retrospectively-reported) PMS.[43] CBT is an evidence-based approach for treating depression and focuses on the link between mood, thoughts, and actions to help patients address their current issues and symptoms. When CBT was compared to SSRI alone or in combination with SSRI, groups receiving CBT had significant improvement of PMS symptoms.[43] Through the practice of CBT, patients are better able to recognize and modify recurrent issues as well as thoughts and behavioral patterns that interfere with functioning well or that make depressive symptoms worse. However, a recent meta-analysis suggests that existing psychotherapies may primarily be useful for reducing impairment (rather than symptom severity) in PMDD.[43]

Surgery

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When drug-based treatments are ineffective or produce significant side effects, then removing the ovaries through oophorectomy can produce an immediate and permanent cure.[44] Typically, the uterus is removed during the same surgery, and the woman is prescribed a low-dose estrogen patch to reduce the symptoms produced by surgically induced menopause.[44]

Alternative medicine

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There have been a handful of nutritional supplements that have been shown to help alleviate the symptoms of PMDD. In 1998, a placebo-controlled, randomized trial of 720 women with PMDD found that calcium carbonate demonstrated up to a 50% reduction in symptoms, compared with a 30% reduction in the control group.[45][46] Herbal treatments that have shown promise in PMDD include chasteberry (Vitex agnus castus), St. John's wort (Hypericum perforatum), and ginkgo (Ginkgo biloba). Studies have been conducted on the efficacy of chasteberry and gingko, but as of this writing, no randomized controlled trial has been conducted on the efficacy of St. John's wort in alleviating PMDD symptoms.[45]

Epidemiology

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20-30% of women who menstruate experience symptoms severe enough to meet PMS criteria and 3-8% of women who are of reproductive age meet the PMDD criteria.[3] With only a small fraction feeling such intense distress linked to the onset of menstruation, any fear of social pathologizing of normal emotional and physical symptoms as a result of menstruation is unnecessary; PMDD is distinct, and having it included in the DSM-5 works to affirm that.[22]

Bipolar depression, anxiety disorders, and other Axis I disorders are more common in women with PMDD than in the general population.[47] In women with PMDD, there is a 50-78% higher chance of various psychiatric disorders such as generalized anxiety disorder, seasonal affective disorder, and major depressive disorder.[3]

The symptoms which coincide with mood disorders, i.e. major depressive disorder or bipolar disorder, may worsen during the premenstrual period and thus may mimic PMDD. This phenomenon is known as premenstrual exacerbation (PME) and refers to the worsening of mood disorder symptoms during the premenstrual phase. An estimated 40% of those who seek treatment for PMDD are found to not have PMDD, but rather a PME of an underlying mood disorder.[48]

Medical personnel can avoid misdiagnosis by having women who are seeking treatment for PMDD use a daily charting method to record their symptoms.[4] Daily charting helps to distinguish when mood disturbances are experienced and allows PMDD to be more easily distinguished from other mood disorders. With PMDD, mood symptoms are present only during the luteal phase, or last two weeks, of the menstrual cycle.[8] While PMDD mood symptoms are of a cyclical nature, other mood disorders are variable or constant over time. Although the medical community lacks a consensus on the most efficient instrument by which to confirm a PMDD diagnosis, several well-validated scales for recording premenstrual symptoms include the Calendar of Premenstrual Experiences (COPE), Daily Record of Severity of Problems (DRSP), and Prospective Record of the Severity of Menstruation (PRISM).[23][24] In the context of research, standardized numerical cutoffs are often applied to verify the diagnosis.[23]

PMDD mood symptoms are only present in individuals who are capable of menstruating. Thus, symptoms do not occur during pregnancy and after menopause. Other mood disorders typically persist across all reproductive life events and are independent of a person's menstrual cycle or lack thereof.[49]

In addition to Axis I disorders, several other medical illnesses such as chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome and migraine disorder may present symptoms similar or identical to those of PMDD.

Relationship to Pregnancy

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Women with PMDD usually see their symptoms disappear while they are pregnant. Premenstrual dysphoric disorder is primarily a mood disorder that is associated with onset of menstruation; pregnancy, menopause, and hysterectomies all cause menstruation to cease, thereby stopping the proposed sex steroid-/serotonin-caused symptoms from occurring.[11][44][50] Although one might expect a higher rate of postpartum depression among those with PMDD, a large study of women with prospectively-confirmed PMDD did not find a higher prevalence of postpartum depression than in controls.[50][7] If a person had experienced PPD beforehand, there was found to be a less-than 12% chance of PMDD pathology emerging—hardly any differentiation from the regular population of those who have never experienced postpartum depression.[50] However, PMDD symptoms can get worse following pregnancy, or other associated events such as birth and miscarriage.[10]

Menopause launches an individual into an associated mood disorder called climacteric depression.[7] The permanent stopping of the menstrual cycle causes a myriad of physiological and psychological symptoms and issues, all associated with the natural estrogen deficiency post-menopause.[7]

History

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The diagnostic category was discussed in the DSM-IIIR (1987), in which the proposed condition was named "Late Luteal Phase Dysphoric Disorder" and was included in the appendix as a proposed diagnostic category needing further study.[51] Preparations for the DSM-IV led to debate about whether to keep the category at all, only keep it in the appendix, or remove it entirely; the reviewers determined that the condition was still too poorly studied and defined, so it was kept in the appendix but elaborated with diagnostic criteria to aid further study.[50][52]

As preparations were underway in 1998 for the DSM-IV-TR, the conversation changed, as Eli Lilly and Company paid for a large clinical trial of fluoxetine as a potential treatment for the condition that was then conducted by Canadian academics and published in the New England Journal of Medicine in 1995.[53] Other studies have been conducted as well, wherein all found that approximately 60% of women with PMDD in the trials improved with the drug; representatives from Lilly & Co. and the FDA participated in the discussion.[50][52]

Various strong stances were taken in said discussion. Sally Severino, a psychiatrist, argued that because symptoms were more prevalent in the United States, PMDD was a culture-bound syndrome and not a biological condition; she also claimed it unnecessarily pathologized the hormonal changes of the menstrual cycle.[50] Jean Endicott, another psychiatrist and chair of the committee, has argued that it was a valid condition from which people suffer and should be diagnosed and treated, and has claimed that if the symptoms were felt by males, far more effort and research would have been done by that moment. In the end the committee kept PMDD in the appendix.[50]

The decision has been criticized as being driven by Lilly's financial interests, and possibly by financial interests of members of the committee who had received funding from Lilly.[50] Paula Caplan, a psychologist who had served on the committee for the DSM-IV, noted at the time of the DSM-IV-TR decision that there was evidence that calcium supplements could treat PMDD but the committee gave it no attention. She had also claimed that the diagnostic category is harmful to women with PMDD, leading them to believe they are mentally ill, and potentially leading others to mistrust them in situations as important as job promotions or child custody cases.[50] She has called PMDD a fake disorder.[54] Nada Stotland has expressed concern that women with PMDD may actually have a more serious condition like major depressive disorder or may be facing difficult circumstances—such as suffering domestic abuse—and therefore may have their true issues remain undiagnosed and mismanaged if their gynecologist diagnoses them with PMDD and gives them drugs to treat it.[50]

The validity of PMDD was once more heavily debated when it came time to create the DSM-5 in 2008.[55][56] In the end it was moved out of the appendix and into the main text as a formal category. A review in the Journal of Clinical Psychiatry published in 2014 examined the arguments against inclusion, which it summarized as: (1) the PMDD label will harm women economically, politically, legally, and domestically; (2) there is no equivalent hormone-based medical label for males; (3) the research on PMDD is faulty; (4) PMDD is a culture-bound condition; (5) PMDD is due to situational, rather than biological, factors; and (6) PMDD was fabricated by pharmaceutical companies for financial gain.[57] Each argument was addressed and researchers found: (1) No evidence of harm; (2) no equivalent hormone-driven disorder has been discovered in men despite research seeking it; (3) the research base has matured and many more reputable studies have been performed; (4) several cases of PMDD have been reported or identified; (5) a small minority of people do suffer from the condition; and (6) while there has been financial conflict of interest, it has not made the available research unusable.[2][57] It concluded by noting that women have historically been under-treated and told that they were making their symptoms up, and that the formal diagnostic criteria would spur more funding, research, diagnosis and treatment for people who suffer from PMDD.[57]

References

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