What You Need to Know About Premenstrual Dysphoric Disorder
Most women would say they have PMS. Inevitably, once a month you get cranky, weep at funny movies, have mood swings, get cramps or feel bloated. In fact, about 85 percent of women experience one or two premenstrual symptoms.
But this isn’t PMS, also known as premenstrual syndrome. According to Andrea Rapkin, M.D., a professor of obstetrics and gynecology at the David Geffen School of Medicine at UCLA, there’s confusion over the true definition of premenstrual syndrome – and it seems to get applied to everyone who has a period.
In actuality, only about 8 to 18 percent of women struggle with PMS, she said. The American Congress of Obstetricians and Gynecologists (ACOG) defines PMS as severe enough to significantly disrupt a woman’s day-to-day life.
About 5 to 10 percent of women struggle with an even more debilitating form of premenstrual syndrome called premenstrual dysphoric disorder (PMDD), which impairs social and occupational functioning, according to Samantha Meltzer-Brody, MD, MPH, director of the Perinatal Psychiatry Program at the UNC Center for Women’s Mood Disorders. PMDD begins one to two weeks before menstruation and stops within four days after the onset of menstruation (called the luteal phase).
Women struggle with a variety of symptoms, such as irritability, anxiety, anger, sadness or loss of interest. Some may be argumentative, lash out at loved ones (and feel guilty afterward) and even feel paranoid.
According to the DSM-IV, in order to be diagnosed with PMDD, a woman must have five of the following symptoms for at least a year (* with at least one of these symptoms).
- Mood swings*
- Loss of interest in activities
- Difficulty concentrating
- Lack of energy
- Depressed mood or hopelessness*
- Tension or anxiety*
- Sleep changes
- Appetite changes
- Feeling out of control or overwhelmed
- Physical symptoms, such as bloating
PMDD often gets confused with major depression (MDD) because of their similar symptoms. “At least 50 percent of women who self refer for PMDD actually have MDD,” according to Dr. Meltzer-Brody. For this reason, a diagnosis is only made after a woman keeps daily ratings of her symptoms for at least two months, she said. Retroactive recall, she said, is not accurate.
But it can still get tricky, because women with major depression may notice that their mood sinks even more during the luteal phase, Meltzer-Brody said. “However, women with MDD will not return to normal mood in the follicular phase [the first half of the menstrual cycle] – they will continue to exhibit mood symptoms all month to some degree,” she said.
Also, women with PMDD tend to respond faster to medication – usually within days – in the luteal phase than women with MDD, Meltzer-Brody said.
The Role of Serotonin & GABA in PMDD
The precise cause of PMDD is not known. But research has pointed to both serotonin and gamma–aminobutyric acid (GABA) in contributing to the disorder, according to Dr. Rapkin.
Serotonin controls mood, eating and sleep. In one study, Rapkin (1992) found an association between decreased serotonin transmission and premenstrual symptoms, such as mood swings, irritability, anxiety and difficulty concentrating. Women who struggle with premenstrual symptoms exhibit changes in serotonin function during the luteal phase. Also, estrogen and progesterone impact the availability of serotonin in the brain.
GABA is a neurotransmitter that inhibits the activity of nerve cells in the brain and regulates anxiety and stress. A progesterone derivative called allopregnanolone (ALLO) regulates GABA. Research has suggested that GABA activity differs between women without PMDD and women with the disorder.
Effective Medication for PMDD
Fortunately, PMDD is highly treatable. SSRIs (selective serotonin reuptake inhibitors) are typically the first-line treatment. Numerous studies have demonstrated their efficacy. (SSRIs also are FDA-approved to treat PMDD.) For instance, one meta-analysis looking at 15 randomized placebo-controlled studies found that SSRIs effectively reduced symptoms of PMDD.
According to Rapkin, research has specifically shown that fluoxetine and sertraline reduced both physical and affective symptoms and improved quality of life and psychosocial functioning.
Women may take medication during the luteal phase only, or some take medication all month and increase the dose during the luteal phase, Meltzer-Brody said. Studies have found that both intermittent and continuous use is effective.
“Some women need more aggressive treatment with adjunctive agents for mood or anxiety during the worst of their cycles,” Meltzer-Brody added.
The oral contraceptive YAZ (drospirenone 3 mg and ethinyl estradiol 20 mcg in a regimen of 24 active pills followed by four inactive pills) is effective for treating PMDD, Rapkin said. YAZ is especially helpful for women who also have painful or irregular periods, she said. Contrary to media reports, Rapkin noted that YAZ doesn’t increase blood clots any more than other newer oral contraceptives.
Struggling with PMDD Symptoms?
If you think you have PMDD, Rapkin suggested recording your five worst symptoms, and rating each as none (0) mild (1), moderate (2) or severe (3) throughout the month. (Or download a copy of the Daily Record of Severity of Problems.) Then take this information to your gynecologist or primary care physician. Another options is to see a mental health professional or a psychiatrist for an accurate diagnosis. Importantly, if your practitioner seems to minimize or dismiss your concerns, see someone else, Rapkin said.
Cunningham, J., Yonkers, K.A., O’Brien, S., Eriksson, E. (2009). Update on research and treatment of premenstrual dysphoric disorder. Harvard Review of Psychiatry, 17, 120-137.
Eriksson, O., Wall, A., Marteinsdottir, I., Agren, H., Hartvig, P., Blomqvist, G., Långström B, Naessén T. (2006). Mood changes correlate to changes in brain serotonin precursor trapping in women with premenstrual dysphoria. Psychiatry Research, 146, 107-16.
Rapkin AJ. (1992). The role of serotonin in premenstrual syndrome. Clinical Obstetrics And Gynecology, 35, 629-36.
Rapkin AJ, Winer SA. (2008). The pharmacologic management of premenstrual dysphoric disorder. Expert Opinion on Pharmacotherapy, 9, 429-45.
Sundström-Poromaa, I., Smith, S., Gulinello, M. (2002). GABA receptors, progesterone and premenstrual dysphoric disorder. Archives of Women’s Mental Health, 6, 23-41.
Tartakovsky, M. (2018). What You Need to Know About Premenstrual Dysphoric Disorder. Psych Central. Retrieved on April 2, 2020, from https://psychcentral.com/lib/what-you-need-to-know-about-premenstrual-dysphoric-disorder/