What is Premenstrual Dysphoric Disorder?
Premenstrual symptoms are changes in mood, behavior, and physical sensations that occur in a repeating pattern just before a woman’s menstrual period. These tend to disappear after the period. While most women experience minor discomfort that does not interfere with daily activities, around 5% to 8% of women face more severe symptoms, causing significant distress and affecting their daily tasks.
Although these symptoms have been acknowledged for a long period, only recently have guidelines been set for their diagnosis. The term for these disorders has changed significantly over time, evolving from “menses moodiness” in the 18th century to “premenstrual tension” in the 19th century, and then to “premenstrual syndrome” in the 1950s. While some discomfort before menstruation is standard, premenstrual syndrome (PMS) refers to severe symptoms that significantly affect daily activities and functioning. Additionally, the most severe form of PMS, known as premenstrual dysphoric disorder (PMDD), greatly affects the quality of life in women, often leading them to seek medical treatment. Anyone with ovaries, including transgender individuals, may experience PMDD.
Currently, PMDD is classified as a depressive disorder in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). The diagnosis requires meeting certain criteria. They must have at least 5 out of 11 specific symptoms, including one of the first 4, which include significant depression, anxiety, mood swings, and persistent anger or irritation. Other symptoms could include lack of interest in usual activities, difficulty focusing, fatigue, changes in appetite, sleep issues, or feeling overwhelmed. Physical symptoms, like breast tenderness or swelling, headaches, joint or muscle pain, bloating, and weight gain can also be experienced. These symptoms need to be severe enough to interfere significantly with social, work, sexual, or academic functioning. Also, they should have a clear relation to the menstrual cycle and should not be simply an increase in symptoms of another disorder. Lastly, this diagnosis requires tracking these symptoms over at least two menstrual cycles.
It’s worth noting that women with moderate to severe PMS or PMDD often have a decreased quality of life, reduced work productivity, and they may have more substantial healthcare costs compared to women with no or mild symptoms.
What Causes Premenstrual Dysphoric Disorder?
The exact cause of PMS/PMDD, which are conditions that cause emotional and physical issues before a woman’s period, is presently unknown. However, there are some factors that might make you more likely to have these conditions. Some are proven, while others are just guesses.
Proven Risks:
* Past traumatic experiences: If you’ve had traumatic events in your past or if you have an anxiety disorder, you might be more likely to get PMDD. Scientists aren’t sure why this could be, so more research is needed.
* Smoking: If you smoke, you are far more likely to have severe forms of PMS compared to someone who doesn’t smoke. Even if you used to smoke but quit, you still have a higher risk. Plus, the more you smoke, the higher your risk is. And if you started smoking as a teenager, your risk of having PMDD is significantly higher.
Being overweight: There’s a strong relationship between your body mass index (BMI) when you have your baseline, or regular, period and your risk of getting PMS. For example, for each 1 kg/m2 increase, the associated risk increases by 3%. The risk of PMS also significantly increases in women with a BMI at or greater than 27.5 compared with women with a BMI of less than 20.0 kg/m2. If your BMI is 35.0 kg/m2, your risk is 66% higher.
Possible Risks:
* Genetics: Some studies on twins have suggested that PMS/PMDD might be passed down through families. Recent research has also suggested that certain genes, specifically the one that makes the 5HT1A receptor, a part of the nervous system that uses serotonin, and different versions of the gene that makes the estrogen receptor alpha might be involved in the development of PMS/PMDD.
Risk Factors and Frequency for Premenstrual Dysphoric Disorder
Premenstrual symptoms can affect all women of reproductive age, starting from when their periods first begin (menarche) until they stop (menopause). These symptoms are a common issue among women of reproductive age in the United States. Nearly 70-90% of them experience some degree of premenstrual discomfort. Among these, about a third report symptoms serious enough to be diagnosed as Premenstrual Syndrome (PMS). The most severe form of premenstrual symptoms, called Premenstrual Dysphoric Disorder (PMDD), affects 3-8% of these women. It’s important to note that transgender individuals and anyone with ovaries can also experience these symptoms.
According to a study, women in the U.S. have around 481 menstrual cycles in their lifetime. If we consider around 22 months for two pregnancies and their postpartum periods, women usually have approximately 459 cycles during their childbearing years. Women with PMDD experience severe symptoms for an average of 6.4 days per menstrual cycle. Over a lifetime, this roughly computes to eight whole years of intense symptoms. From this, it’s clear that PMS or PMDD can significantly impact a person’s quality of life, making it a crucial health concern.
Signs and Symptoms of Premenstrual Dysphoric Disorder
Premenstrual dysphoric disorder (PMDD) is a condition associated with severe emotional and physical problems that occur in the week or two before your period. It can be categorized under three main heads:
- Mood symptoms:
- Feelings of sadness, depression, hopelessness, worthlessness
- Strong mood swings; sudden sadness or tearfulness
- Increased irritability and anger; frequent conflicts with family or at work
- Increased anxiety or feeling on edge all the time
- Behavioral symptoms:
- Lack of energy, fast fatigue
- Diminished interest in everyday activities
- Difficulty concentrating
- Changes in appetite like overeating or specific food cravings
- Alterations in sleep patterns, either oversleeping or insomnia
- Feelings of being overwhelmed or out of control
- Physical symptoms (also called somatic symptoms):
- Breast swelling or tenderness
- Joint or muscle aches
- Feeling bloated or weight gain
- Headaches
The duration for which women experience these PMDD symptoms varies from a few days to 2 weeks. Typically, symptoms get worse six days before the menstrual cycle and are the strongest two days before menstruation. It’s important to note that these should not merely be an escalation of symptoms of another disorder such as major depressive disorder, panic disorder, or a personality disorder. The signs should be confirmed through daily ratings across at least 2 consecutive menstrual cycles for certain diagnosis. Despite this, a provisional diagnosis can be made before confirmation.
Testing for Premenstrual Dysphoric Disorder
Doctors and researchers use different scales or tools to understand and assess Premenstrual Dysphoric Disorder (PMDD), which is a severe form of premenstrual syndrome that causes physical and mood changes before periods. Here are some examples of these tools:
1. Premenstrual Symptom Screening Tool (PSST): This is a questionnaire of 19 questions. The patient answers these questions to explain how severe their symptoms are. This information is then used to diagnose PMDD.
2. Calendar of Premenstrual Experiences (COPE): This tool lists 22 symptoms and groups them into four categories: mood changes, physiological/cognitive changes (like memory problems or feeling dizzy), changes in appetite, and symptoms related to fluid retention (like bloating or weight gain).
3. Visual Analogue Scale (VAS): This scale was created by Steiner and others in 1999. It’s used to rate the four main symptoms of PMDD, which are mood swings, irritability, tension, and depression. The scale is a 100mm vertical line. On one end is 0 or “no symptom.” On the other end is 100 or “severe.”
4. Daily Record of Severity of Problems (DRSP): DRSP is a scale that includes 24 items. Out of these, 21 items are grouped into 11 different symptoms, and three items measure how much these symptoms affect daily life. The items are rated from 1 (not at all) to 6 (extreme).
5. Patient Reported Outcomes Measurement Information System (PROMIS): Deorte et al. used the PROMIS computerized tool to detect premenstrual symptoms of depression, anxiety, and fatigue. Their results showed that the PROMIS instruments could be useful for measuring effective premenstrual symptoms.
Treatment Options for Premenstrual Dysphoric Disorder
There are two main categories of treatment for PMDD or premenstrual dysphoric disorder — ones that you can do yourself, and ones that require medication.
Non-drug treatments include:
– Exercise: Even though we don’t have much scientific evidence yet, working out seems to help improve symptoms by raising levels of beta-endorphins, which are chemicals in your body that help you feel better.
– Dietary modifications: If you eat more complex carbohydrates or proteins (foods that give you long-lasting energy), it could help produce more serotonin, a hormone that helps regulate mood. Calcium has also been found to help lessen emotional and physical symptoms. Some studies also show benefits from vitamin B6 and Chaster-berry/vitex agnus-castus, which affects certain chemicals in the brain.
– Stress management: Relaxation techniques like meditation, yoga, or controlled breathing can help manage stress, which might help with PMDD symptoms.
Drug treatments might include:
– Psychotropic agents: These are medicines for your brain. Selective serotonin reuptake inhibitors (SRIs) — such as clomipramine, citalopram, escitalopram, fluoxetine, paroxetine, sertraline, and venlafaxine — have all been found to help severe mood and physical symptoms of PMDD. SRIs work quickly and can be used just during the time when PMDD symptoms are present.
– Benzodiazepines (BZDs): These are medicines that help with anxiety and sleep, such as alprazolam. These can be beneficial for people with severe anxiety and sleep problems related to PMDD, but they can be habit-forming, so it’s important for the doctor to monitor their use.
– Hormonal therapies and Danazol: In severe cases, drugs that affect hormones and stop the menstrual cycle can be used. These include gonadotropin-releasing hormone (GnRH) agonists (drugs that stop the menstrual cycle), tibolone (a synthetic steroid), and danazol (a drug that inhibits ovulation). However, these may cause other symptoms like hot flashes and increase the risk of osteoporosis, so they are generally only used when other treatments haven’t worked.
– Oral contraceptive pills (OCPs): While birth control pills are often used to manage PMDD, their effectiveness hasn’t been strongly proven by scientific evidence. These pills can cause more hormone-related symptoms on days when they aren’t taken, so different types of birth control pills with fewer hormone-free days might be more beneficial for women with PMDD.
What else can Premenstrual Dysphoric Disorder be?
If you have premenstrual dysphoric disorder (PMDD), your symptoms can look very similar to a few other mental health conditions, especially major depression. It’s absolutely crucial to make sure you are dealing with PMDD and not some other issue before starting any kind of treatment. One major clue that it’s PMDD and not something else is if your symptoms follow your menstrual cycle.
Here are some of the most common conditions that can appear very similar to PMDD:
- Major depressive disorder: Symptoms can include feeling sad or having a lack of energy, not enjoying things the way you used to, changes in eating habits, trouble sleeping, difficulty focusing, and thoughts of suicide. It’s also worth noting that about half of those with PMDD also have depression. People can develop depression before they start experiencing PMDD, or the two conditions can start at the same time.
- Thyroid disease (either an overactive or underactive thyroid):
- Underactive thyroid: This might lead to gaining weight, constipation, sensitivity to cold, feelings of depression, dry skin, and slow reactions.
- Overactive thyroid: This can cause weight loss, trouble sleeping, sensitivity to heat, heart rhythm problems such as atrial fibrillation, and fast reactions.
- Anxiety disorders: symptoms can include a racing heart and feelings of fear. People with anxiety often can point to specific things that trigger their anxiety and avoid these triggers. Unlike PMDD, anxiety stays constant instead of changing with the menstrual cycle. Like depression, anxiety can co-exist with PMDD.
- Breast pain: This may show up only as tenderness and swelling in the breasts that gets worse during certain times in the menstrual cycle.
All these conditions have their own diagnostic criteria, which must be considered separately in each case.
