Premenstrual Dysphoric Disorder (PMDD)
Premenstrual Dysphoric Disorder (PMDD) falls under theWomen’s Healthcategory.
Premenstrual dysphoric disorder (PMDD) is the most severe form of premenstrual syndrome (PMS). It is characterized by physical and behavioral symptoms that occur repeatedly in the late luteal phase of the menstrual cycle, usually beginning the week before menstruation and resolving a few days after menstruation. These symptoms cause significant distress or interference with daily activities and are not caused by an underlying psychiatric condition. Anger, irritability, depression, and internal tension are especially prominent symptoms. PMDD is a chronic condition, typically beginning in the adolescent years and continuing until the menopause transition, and requires an individualized approach to treatment.
People with PMDD report a wide variety of physical, behavioral, emotional, and cognitive symptoms; usually, the behavioral and emotional symptoms are the most prominent. Some common symptoms include irritability, mood swings, depression, anxiety, fatigue, body aches, and bloating. These symptoms are severe enough to cause serious distress or interference with daily activities and only occur during the late luteal and very early follicular phases of the menstrual cycle. Symptoms tend to be at their worst 3 to 4 days before through 3 days after menstruation.
Additional symptoms include:
- Difficulty concentrating and decreased interest in usual activities
- Excessive sleepiness or difficulty sleeping
- Changes in appetite, including food cravings and binge eating
- Feelings of being overwhelmed or out of control
- Breast tenderness
- Joint or muscle pain
- Hot flashes
- Cramps, constipation, nausea, or vomiting
- Fluid retention, including swelling and periodic weight gain
PMDD is diagnosed based on a history of severe, cyclic PMDD symptoms that are not caused by an underlying condition. To meet the PMDD criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), there must be at least 5 specific PMDD symptoms present, one of which must be a key major mood symptom, and these symptoms must both cause significant distress or interference with daily activities and occur during the late luteal phase of most menstrual cycles over the previous year. Prospective documentation using a validated questionnaire for at least two symptomatic cycles is also required.
Additional tests, like laboratory tests, a pelvic exam, and imaging, are not necessary for a PMDD diagnosis, but they are used to rule out other conditions that cause similar symptoms.
Medical treatments for PMDD focus on relieving symptoms, usually by increasing the availability of serotonin in the brain or by suppressing cyclic changes in sex hormones. Selective serotonin reuptake inhibitors (SSRIs) have the best evidence for efficacy and are the main medication used to treat PMDD. They can be taken continuously, only during the luteal phase, or at the time of symptom onset through the first few days of menstruation. Symptoms should improve by the first menstrual cycle following SSRI treatment. Serotonin-norepinephrine reuptake inhibitors (SNRIs) may also be used. For people who desire contraception, a combined estrogen-progestin oral contraceptive can be prescribed, although oral contraceptives may not decrease depressive symptoms.
Gonadotropin-releasing hormone (GnRH) agonists in combination with low doses of estrogen and progesterone are reserved for people who do not respond to the aforementioned treatments. When all other therapies have failed and symptoms are debilitating, surgical removal of the ovaries may be considered.
A number of supplements, such as myo-inositol, calcium, vitamin E, vitamin D, St. John's Wort, saffron, magnesium, fish oil, curcumin, vitamin B6, vitex agnus-castus (chaste tree), and evening primrose oil, have been studied for premenstrual symptoms. Most are only effective for mild to moderate symptoms, when used in combination with other therapies, or to correct nutritional deficiencies. In fact, compared to PMS, there are few trials specific to supplements for PMDD. Chaste tree is perhaps the most well-studied, and although some trials find that it reduces PMDD symptoms, the quality of available evidence is low, and it may not be as effective for psychological symptoms as antidepressants.
There is little data to support a strong relationship between diet and PMDD. However, dietary patterns that emphasize eating a variety of whole foods (e.g., fruits, vegetables, nuts), while reducing the intake of ultraprocessed foods, salt, caffeine, and alcohol, are associated with a lower risk of premenstrual symptoms. Diets rich in calcium, zinc, magnesium, and B vitamins may also reduce the risk of PMS. Whether this data applies to PMDD is unclear, but adopting a healthful diet is unlikely to worsen the condition and could provide benefits.
Because PMDD strongly affects psychosocial health, certain therapeutic interventions can improve quality of life, promote positive coping skills, and decrease feelings of depression, anxiety, and distress. Cognitive behavioral therapy, couple-based cognitive behavioral therapy, and mindfulness-based therapies can all benefit people with PMDD. Additionally, acupuncture and acupressure may improve the symptoms of PMDD when compared to sham treatment, but more research specific to PMDD is needed. This is also true of exercise, which can reduce the severity of PMS and is thus encouraged for PMDD management as well.
The exact cause of PMDD is unknown, but it is believed to be an abnormal response to the natural hormonal fluctuations that occur throughout the menstrual cycle. It is important to note that PMDD is not caused by irregular blood levels of estrogen, progesterone, or progesterone metabolites (like allopregnanolone). The cyclic changes in sex hormones between people with and without PMDD are similar.
Rather, in people with PMDD, the brain is highly sensitive to the hormonal shifts in the luteal phase, especially the rise in allopregnanolone, provoking an aberrant neurotransmitter response that negatively affects emotional regulation. The opioid, GABA, and serotonin systems have all been implicated in the pathology of PMDD, but the serotonin system appears to be the most important (likely underlying the effectiveness of SSRIs for many people with PMDD).
- ^Hofmeister S, Bodden SPremenstrual Syndrome and Premenstrual Dysphoric Disorder.Am Fam Physician.(2016-Aug-01)
- ^Rapkin AJ, Winer SAPremenstrual syndrome and premenstrual dysphoric disorder: quality of life and burden of illness.Expert Rev Pharmacoecon Outcomes Res.(2009-Apr)
- ^Hantsoo L, Epperson CNPremenstrual Dysphoric Disorder: Epidemiology and Treatment.Curr Psychiatry Rep.(2015-Nov)
- ^Hartlage SA, Freels S, Gotman N, Yonkers KCriteria for premenstrual dysphoric disorder: secondary analyses of relevant data sets.Arch Gen Psychiatry.(2012-Mar)
- ^Yan H, Ding Y, Guo WSuicidality in patients with premenstrual dysphoric disorder-A systematic review and meta-analysis.J Affect Disord.(2021-Dec-01)
- ^O'Brien PM, Bäckström T, Brown C, Dennerstein L, Endicott J, Epperson CN, Eriksson E, Freeman E, Halbreich U, Ismail KM, Panay N, Pearlstein T, Rapkin A, Reid R, Schmidt P, Steiner M, Studd J, Yonkers KTowards a consensus on diagnostic criteria, measurement and trial design of the premenstrual disorders: the ISPMD Montreal consensus.Arch Womens Ment Health.(2011-Feb)
- ^Marjoribanks J, Brown J, O'Brien PM, Wyatt KSelective serotonin reuptake inhibitors for premenstrual syndrome.Cochrane Database Syst Rev.(2013-Jun-07)
- ^Cohen LS, Soares CN, Lyster A, Cassano P, Brandes M, Leblanc GAEfficacy and tolerability of premenstrual use of venlafaxine (flexible dose) in the treatment of premenstrual dysphoric disorder.J Clin Psychopharmacol.(2004-Oct)
- ^de Wit AE, de Vries YA, de Boer MK, Scheper C, Fokkema A, Janssen CAH, Giltay EJ, Schoevers RAEfficacy of combined oral contraceptives for depressive symptoms and overall symptomatology in premenstrual syndrome: pairwise and network meta-analysis of randomized trials.Am J Obstet Gynecol.(2021-Dec)
- ^Johnson SRPremenstrual syndrome, premenstrual dysphoric disorder, and beyond: a clinical primer for practitioners.Obstet Gynecol.(2004-Oct)
- ^Maharaj S, Trevino KA Comprehensive Review of Treatment Options for Premenstrual Syndrome and Premenstrual Dysphoric Disorder.J Psychiatr Pract.(2015-Sep)
- ^Carlini SV, Lanza di Scalea T, McNally ST, Lester J, Deligiannidis KMManagement of Premenstrual Dysphoric Disorder: A Scoping Review.Int J Womens Health.(2022)
- ^Verkaik S, Kamperman AM, van Westrhenen R, Schulte PFJThe treatment of premenstrual syndrome with preparations of Vitex agnus castus: a systematic review and meta-analysisAm J Obstet Gynecol.(2017 Aug)
- ^Atmaca M, Kumru S, Tezcan EFluoxetine versus Vitex agnus castus extract in the treatment of premenstrual dysphoric disorderHum Psychopharmacol.(2003 Apr)
- ^Hashim MS, Obaideen AA, Jahrami HA, Radwan H, Hamad HJ, Owais AA, Alardah LG, Qiblawi S, Al-Yateem N, Faris MAEPremenstrual Syndrome Is Associated with Dietary and Lifestyle Behaviors among University Students: A Cross-Sectional Study from Sharjah, UAE.Nutrients.(2019-Aug-17)
- ^Siminiuc R, Ţurcanu DImpact of nutritional diet therapy on premenstrual syndrome.Front Nutr.(2023)
- ^B M KirbyOral flaps. Principles, problems, and complications of flaps for reconstruction of the oral cavityProbl Vet Med.(1990 Sep)
- ^Weise C, Kaiser G, Janda C, Kues JN, Andersson G, Strahler J, Kleinstäuber MInternet-Based Cognitive-Behavioural Intervention for Women with Premenstrual Dysphoric Disorder: A Randomized Controlled Trial.Psychother Psychosom.(2019)
- ^Ussher JM, Perz JEvaluation of the relative efficacy of a couple cognitive-behaviour therapy (CBT) for Premenstrual Disorders (PMDs), in comparison to one-to-one CBT and a wait list control: A randomized controlled trial.PLoS One.(2017)
- ^Bluth K, Gaylord S, Nguyen K, Bunevicius A, Girdler SMindfulness-based Stress Reduction as a Promising Intervention for Amelioration of Premenstrual Dysphoric Disorder Symptoms.Mindfulness (N Y).(2015-Dec)
- ^Mike Armour, Carolyn C Ee, Jie Hao, Tanya Marie Wilson, Sofia S Yao, Caroline A SmithAcupuncture and acupressure for premenstrual syndromeCochrane Database Syst Rev.(2018 Aug 14)
- ^Yonkers KA, Simoni MKPremenstrual disorders.Am J Obstet Gynecol.(2018-Jan)
- ^Nguyen TV, Reuter JM, Gaikwad NW, Rotroff DM, Kucera HR, Motsinger-Reif A, Smith CP, Nieman LK, Rubinow DR, Kaddurah-Daouk R, Schmidt PJThe steroid metabolome in women with premenstrual dysphoric disorder during GnRH agonist-induced ovarian suppression: effects of estradiol and progesterone addback.Transl Psychiatry.(2017-Aug-08)
- ^Andersch B, Abrahamsson L, Wendestam C, Ohman R, Hahn LHormone profile in premenstrual tension: effects of bromocriptine and diuretics.Clin Endocrinol (Oxf).(1979-Dec)
- ^Bixo M, Johansson M, Timby E, Michalski L, Bäckström TEffects of GABA active steroids in the female brain with a focus on the premenstrual dysphoric disorder.J Neuroendocrinol.(2018-Feb)
- ^Stiernman L, Dubol M, Comasco E, Sundström-Poromaa I, Boraxbekk CJ, Johansson M, Bixo MEmotion-induced brain activation across the menstrual cycle in individuals with premenstrual dysphoric disorder and associations to serum levels of progesterone-derived neurosteroids.Transl Psychiatry.(2023-Apr-14)
- ^Gehlert S, Song IH, Chang CH, Hartlage SAThe prevalence of premenstrual dysphoric disorder in a randomly selected group of urban and rural women.Psychol Med.(2009-Jan)
- ^Tiranini L, Nappi RERecent advances in understanding/management of premenstrual dysphoric disorder/premenstrual syndrome.Fac Rev.(2022)
- ^Hardy C, Hardie JExploring premenstrual dysphoric disorder (PMDD) in the work context: a qualitative study.J Psychosom Obstet Gynaecol.(2017-Dec)
- ^Elizabeth Osborn, Anja Wittkowski, Joanna Brooks, Paula E Briggs, P M Shaughn O'BrienWomen's experiences of receiving a diagnosis of premenstrual dysphoric disorder: a qualitative investigationBMC Womens Health.(2020 Oct 28)
- ^Kuehner C, Nayman SPremenstrual Exacerbations of Mood Disorders: Findings and Knowledge Gaps.Curr Psychiatry Rep.(2021-Oct-09)
- ^Yen JY, Liu TL, Chen IJ, Chen SY, Ko CHPremenstrual appetite and emotional responses to foods among women with premenstrual dysphoric disorder.Appetite.(2018-Jun-01)
- ^Yen JY, Lin HC, Lin PC, Liu TL, Long CY, Ko CHLeptin and ghrelin concentrations and eating behaviors during the early and late luteal phase in women with premenstrual dysphoric disorder.Psychoneuroendocrinology.(2020-Aug)
- ^Ko CH, Yen CF, Long CY, Kuo YT, Chen CS, Yen JYThe late-luteal leptin level, caloric intake and eating behaviors among women with premenstrual dysphoric disorder.Psychoneuroendocrinology.(2015-Jun)
- ^Joyce KM, Good KP, Tibbo P, Brown J, Stewart SHAddictive behaviors across the menstrual cycle: a systematic review.Arch Womens Ment Health.(2021-Aug)
- ^Wei SM, Baller EB, Martinez PE, Goff AC, Li HJ, Kohn PD, Kippenhan JS, Soldin SJ, Rubinow DR, Goldman D, Schmidt PJ, Berman KFSubgenual cingulate resting regional cerebral blood flow in premenstrual dysphoric disorder: differential regulation by ovarian steroids and preliminary evidence for an association with expression of ESC/E(Z) complex genes.Transl Psychiatry.(2021-Apr-08)
- ^Hantsoo L, Payne JLTowards understanding the biology of premenstrual dysphoric disorder: From genes to GABA.Neurosci Biobehav Rev.(2023-Jun)
- ^Perkonigg A, Yonkers KA, Pfister H, Lieb R, Wittchen HURisk factors for premenstrual dysphoric disorder in a community sample of young women: the role of traumatic events and posttraumatic stress disorder.J Clin Psychiatry.(2004-Oct)
- ^Cohen LS, Soares CN, Otto MW, Sweeney BH, Liberman RF, Harlow BLPrevalence and predictors of premenstrual dysphoric disorder (PMDD) in older premenopausal women. The Harvard Study of Moods and Cycles.J Affect Disord.(2002-Jul)
- PMS Symptoms - Brownley KA, Girdler SS, Stout AL, McLeod MNChromium supplementation for menstrual cycle-related mood symptomsJ Diet Suppl.(2013 Dec)
- PMS Symptoms - Atmaca M, Kumru S, Tezcan EFluoxetine versus Vitex agnus castus extract in the treatment of premenstrual dysphoric disorderHum Psychopharmacol.(2003 Apr)
- PMS Symptoms - Nemets B, Talesnick B, Belmaker RH, Levine JMyo-inositol has no beneficial effect on premenstrual dysphoric disorderWorld J Biol Psychiatry.(2002 Jul)
- PMS Symptoms - Gianfranco C, Vittorio U, Silvia B, Francesco DMyo-inositol in the treatment of premenstrual dysphoric disorderHum Psychopharmacol.(2011 Oct)