Premenstrual Dysphoric Disorder (PMDD)

What is premenstrual dysphoric disorder (PMDD)?

Premenstrual dysphoric disorder (PMDD) can be considered to be a severe form of premenstrual syndrome (PMS). Both PMS and PMDD are characterized by unpleasant physical and psychological symptoms that occur in the second half of a woman’s menstrual cycle, most commonly in the days preceding the menstrual period. Fatigue, mood changes, irritability, and abdominal bloating are among the most common symptoms of PMS and PMDD, but numerous other symptoms have been reported. Whereas the symptoms of PMS may be troubling and unpleasant, PMDD may cause severe, debilitating symptoms that interfere with a woman’s ability to function.

PMS is much more common than PMDD. PMS may affect to 30% of women with regular menstrual cycles, while only 3% to 8% of these women have true PMDD.

PMDD has been previously medically referred to as late luteal phase dysphoric disorder.

What causes PMDD?

Although the precise cause of PMS and PMDD is unknown, it is believed that these conditions result from the interaction of hormones produced by the ovaries at different stages in the menstrual cycle (such as estrogen and progesterone) with the neurotransmitters (chemicals that serve as messengers) in the brain. While the ovarian hormone levels are normal in women with PMDD, it is likely that the brain’s response to these normally-fluctuating hormone levels is abnormal.

Most evidence suggests that PMS and PMDD do not result from any specific personality traits or personality types. While stress clearly is associated with PMS and PMDD, it is not considered to be a cause of PMDD. Rather, the associated stress is more likely to be a result of the symptoms of PMS or PMDD. Vitamin or other nutritional deficiencies have not been shown to cause PMS or PMDD.

What are the symptoms of PMDD?

Symptoms of PMS and PMDD can be similar but are more intense and debilitating in PMDD. The symptoms of PMDD also may vary among affected women. Some of the most commonly reported symptoms include:

  • fatigue,
  • mood changes,
  • abdominal bloating,
  • breast tenderness,
  • headache,
  • irritability,
  • depression,
  • increased appetite,
  • acne,
  • oversensitivity to environmental stimuli,
  • hot flashes,
  • heart palpitations,
  • easy crying,
  • difficulty concentrating,
  • dizziness,
  • forgetfulness, and
  • gastrointestinal (stomach, bowel) upset.

The symptoms of PMDD are related to the menstrual cycle, typically occurring in the second half (luteal phase) of the cycle, and resolving within the first few days after the menstrual period has begun.

When should I call a doctor about PMDD?

It is appropriate to seek medical care for troubling physical or emotional symptoms related to the menstrual cycle.

It is important to note that the depressive symptoms of PMDD may be associated with thoughts of suicide and suicidal behavior. This is a medical emergency for which health care should be accessed immediately.

How is PMDD diagnosed?

PMDD must be distinguished from other physical and psychological conditions that can produce the same symptoms. The differential diagnosis (list of conditions that may produce the same symptoms) includes both mood and anxiety disorders as well as medical conditions such as thyroid disease. In addition to a thorough medical history and physical examination, blood tests may be performed to rule out whether medical conditions may be present that may account for the symptoms of PMDD.

If PMDD is a concern, it is recommended that women complete a symptom chart or calendar prospectively (meaning that they record their symptoms each day for a given period) to establish the diagnosis. The symptom chart can be compared with the menstrual calendar to illustrate the relationship of symptoms to the menstrual cycle.

The American Psychiatric Association has established formal guidelines for the diagnosis of PMDD in their Diagnostic and Statistical Manual (DSM-IV). The DSM-IV diagnostic criteria for the diagnosis of PMDD require prospective documentation of symptoms being present for at least two consecutive menstrual cycles.

Five or more of the following symptoms must have been present during the week prior to the menstrual period and resolve within a few days of the start of the woman’s period. The symptoms must interfere with the activities of a woman’s daily living and not be a result of another condition or illness. At least one of the symptoms must be one of the first four on the list:

  • feeling sad, hopeless, or self-deprecating;
  • feeling tense, anxious, or “on edge;”
  • marked changes in mood, becoming sad or tearful;
  • persistent irritability, anger, and increased interpersonal conflicts;
  • decreased interest in usual activities, which may be associated with withdrawal from social relationships;
  • difficulty concentrating;
  • feeling fatigued, lethargic, or lacking in energy;
  • marked changes in appetite, which may be associated with binge eating or craving certain foods;
  • hypersomnia (excessive sleeping) or insomnia;
  • a subjective feeling of being overwhelmed or out of control; and
  • other physical symptoms, such as breast tenderness or swelling, headaches, joint or muscle pain, a sensation of bloating, weight gain.

What is the treatment for PMDD?

A number of medical therapies have been shown to be effective in managing the symptoms of PMDD.

Antidepressants (SSRIs)

Several members of the selective serotonin reuptake inhibitor (SSRI) class of medications are effective in the treatment of PMDD. These medications work by regulating the levels of the neurotransmitter serotonin in the brain. SSRIs that have shown to be effective in the treatment of PMDD include:

  • fluoxetine (Prozac, Sarafem),
  • sertraline (Zoloft),
  • paroxetine (Paxil), and
  • citalopram (Celexa).

Up to 75% of women report relief of symptoms when treated with SSRI medications. Side effects can occur in up to 15% of women and include nausea, anxiety, and headache. SSRI medications to treat PMDD may be prescribed to be taken continuously or only during the 14-day luteal phase (second half) of the menstrual cycle. Other types of antidepressants (tricyclic antidepressants and monoamine oxidase inhibitors) and lithium (Lithobid) have not been shown to be effective in the treatment of PMDD.

Oral contraceptives and GnRH agonists

Medications that interfere with ovulation and the production of ovarian hormones have also been used to treat PMDD. Oral contraceptive pills (OCPs, birth control pills) can be prescribed to suppress ovulation and regulate the menstrual cycle.

Gonadotropin-releasing hormone analogs (GnRH analogs or GnRH agonists) have also been used to treat PMDD. These drugs suppress estrogen production by the ovaries by inhibiting the secretion of regulatory hormones from the pituitary gland. As a result, menstrual periods stop, mimicking menopause. Nasal and injection forms of GnRH agonists are available.

Examples of GnRH agonists include:

  • leuprolide (Lupron),
  • nafarelin (Synarel), and
  • goserelin (Zoladex).

The side effects of GnRH agonist drugs are a result of the lack of estrogen, and include hot flashes, vaginal dryness, irregular vaginal bleeding, mood changes, fatigue, and loss of bone density (osteoporosis). Adding back small amounts of estrogen and progesterone can help avoid or minimize many of the annoying side effects due to estrogen deficiency and help preserve bone density.

Danazol (Danocrine)

Danazol (Danocrine) is a synthetic drug that creates a high androgen (male type hormone) and low estrogen hormonal environment by interfering with ovulation and ovarian production of estrogen. It has been successfully used to treat PMDD, but up to 75% of women develop side effects from the drug including:

  • weight gain,
  • edema,
  • decreased breast size,
  • acne,
  • oily skin,
  • hirsutism (male pattern hair growth),
  • deepening of the voice,
  • headache,
  • hot flashes,
  • changes in libido, and
  • mood changes.

All of these changes are reversible, except for voice changes, but the return to normal may take many months. Because of these side effects, this medication is typically used only when other therapies have failed. Danazol (Danocrine) should not be taken by women with certain types of liver, kidney, and heart conditions.

Other treatments

Other treatments have also been shown in some studies to be beneficial in managing the symptoms of PMDD. Chasteberry extract (agnus castus fruit) was effective in decreasing the symptoms of PMS in a controlled trial. Several dietary supplements, including calcium, vitamin B6, and vitamin E, have also been shown in limited studies to reduce PMS/PMDD symptoms.

What are the complications of PMDD?

PMDD by definition is characterized by symptoms severe enough to interfere with daily functioning and activities. If untreated, these symptoms can significantly impact quality of life and a woman’s ability to function at work, school, or home. Further, mood changes and depression that may accompany PMDD can be associated with suicidal thoughts and behavior.

Can PMDD be prevented?

Since PMDD is thought to result from interactions between ovarian hormones and neurotransmitters in the brain, there is no known way to prevent its occurrence.

What is the outlook for PMDD?

Although the symptoms of PMDD can be debilitating, treatments are available that are effective in controlling symptoms for a majority of women as described above.

Premenstrual Dysphoric Disorder (PMDD) At A Glance

  • Premenstrual dysphoric disorder (PMDD) can be considered to be a severe form of premenstrual syndrome (PMS), with symptoms that interfere with daily activities and functioning.
  • PMDD occurs in 3% to 8% of menstruating women.
  • Fatigue, mood changes, and abdominal bloating are common symptoms, but numerous other symptoms may occur.
  • PMDD is diagnosed by a symptom diary or chart in which a woman records her daily symptoms for at least two consecutive menstrual cycles.
  • PMDD is effectively treated by medications including SSRIs and drugs that suppress ovulation and the production of ovarian hormones.

This information is provided by MedicineNet.