Many people are familiar with premenstrual syndrome in which a woman who has it experiences a variety of unpleasant physical symptoms such as breast tenderness, pelvic cramping and fluid retention during the week preceding the onset of menses. The symptoms clear after menses begins.
While this is a relatively common condition there is a syndrome that shares some characteristics but is much more serious: Premenstrual Dysphoric Disorder (PMDD). It is now classified as a disorder or illness since it causes marked distress and often interferes with normal functioning. Like PMS, it begins during the week prior to menses (luteal phase of the cycle) and resolves over a few days once menses begins.
Premenstrual Dysphoric Disorder (PMDD) is characterized by at least five of these symptoms: mood swings, sadness, tearfulness, increased emotional sensitivity, irritability, hopelessness, anxiety, poor concentration, decreased interest in things, fatigue or low energy, sleep disturbance, change in appetite, craving certain foods, feeling overwhelmed or out of control. In addition to these symptoms it is common to have physical symptoms such as breast tenderness or swelling, joint or muscle pain, bloating, and/or weight gain.
The main difference between PMS and PMDD is the greater number of symptoms, marked distress and/or interference with normal functioning in school/work or interpersonal relations in the latter condition. Also, the emotional-type of symptoms are much more apparent with PMDD.
The diagnosis of PMDD cannot be made unless the symptoms are found during most cycles in the past year. To be confident that the symptoms are clearly menstrual cycle-related, it is important to keep a diary of daily symptoms in relation to phases of the menstrual cycle. This should be done for a minimum of two cycles in a row.
PMDD is found in about 1.5 to 6% of menstruating women. It can begin anytime after a girl first begins to menstruate. It has a significant hereditary component and may run in families. It is often worse when a woman is stressed, during certain seasons of the year, or when dealing with gender role issues. For some women it gets worse as they become pre-menopausal.
This syndrome is thought to be primarily due to hormonal changes during the menstrual cycle. Some investigators have thought it may be due to inadequate levels of the hormone progesterone that typically increases after ovulation. However, treatment with progesterone has not been shown to help. There is good evidence that inadequate serotonin plays a significant role, and it has been shown that medications that increase serotonin can be very helpful. Certain medications used to treat depression increase serotonin levels. The most potent ones are called, Selective Serotonin Reuptake Inhibitors (SSRI) such as fluoxetine (Prozac) or sertraline (Zoloft). There are several others that can be used including dual acting medications that raise norepinephrine as well as serotonin.
Although these antidepressants are beneficial for PMDD, this disorder is not a form of depression. In fact, the SSRIs can just be given during the last half of the cycle; this type of intermittent treatment is ineffective with depressive disorders. Some women do find that they get better results if they take the medication every day, especially if they have irregular cycles and have trouble knowing when they ovulate.
Birth control pills help some women but aggravate PMDD in others. Only a trial of such medications will show whether it works for any particular woman. Also, there is a transdermal patch containing an estrogen called estradiol that may help.
For those women with significant fluid retention a diuretic may be beneficial. The type that seems to be best is called spironolactone. Many of the other physical symptoms may respond to a non-steroidal anti inflammatory medicine such as naproxen.
Any woman with symptoms of PMDD should seriously consider seeing their doctor to discuss treatment options.
Peter M. Hartmann, MD
Family Medicine & Psychiatry
