How can premenstrual dysphoric disorder (PMDD) be treated?

PMS, or premenstrual syndrome, is a common problem that affects many women (30-40% of women of reproductive age). However, most of the time, it is unreported and untreated as most women think that this is just part of the normal menstrual cycle and have learned to "live with it". Most are unaware that effective treatments are available.

Premenstrual dysphoric disorder (PMDD) is a more serious form of PMS and in which irritability, anxiety and even depression occur 1-2 weeks before the period begins. It tends to disappear within 2-3 days after the period starts. It can affect up to 5% of women of reproductive age. This can severely affect one's lifestyle and daily functioning. The good news is that PMDD can be treated successfully if women were to seek the appropriate medical help.

The most convenient and acceptable treatment for most women is to start on Yaz (oral contraceptive pill, OCP) which is the only OCP to be FDA-approved to treat PMDD. Other benefits of Yaz are:

• contraception
• regulation of irregular prolong menses
• treatment of painful and heavy menses.

Yaz also reduces acne, improves skin complexion and is not associated with weight gain (unlike some other OCPs). This can be taken long term, especially if the other gynaecological disorders (mentioned above) warrant treatment at the same time.

Alternatively, there are also antidepressants called selective serotonin reuptake inhibitors (SSRIs), but women usually are not keen to take this long-term. Other treatments which do not involve medication include relaxation techniques and meditation but the effectiveness varies between patients.

Thank you for asking a question on a scenario that is commonly encountered by gynaecologists and mental health professionals.

Premenstrual dysphoric syndrome (PMDD) is a condition similar to premenstrual syndrome (PMS) that also happens in the week or two before a woman’s period starts as hormone levels begin to fall after ovulation.

The difference is that PMDD causes more severe symptoms than PMS, including severe depression, irritability and tension. PMDD causes emotional and physical symptoms like PMS, but women with PMDD find their symptoms debilitating, and they often interfere with their daily lives, including work, school, social life, and relationships

PMDD affects up to 5% of women of childbearing age. Many women with PMDD may also have anxiety or depression. To date, researchers do not know for sure what causes PMDD or PMS. Hormonal changes throughout the menstrual cycle may play a role. Studies have shown a connection between PMDD and low levels of serotonin, a chemical in the brain that helps transmit nerve signals. Certain brain cells that use serotonin also control mood, attention, sleep, and pain. Hormonal changes may cause a decrease in serotonin, leading to PMDD symptoms. Serotonin levels have been found to change throughout the menstrual cycle. Some women may be more sensitive to these changes.

The symptoms of PMDD usually show up the week before the start of a woman’s period and last until a few days after it begins. Symptoms of PMDD include:

• Mood swings

• Depression or feelings of hopelessness

• Intense anger and conflict with other people

• Tension, anxiety, and irritability

• Decreased interest in usual activities

• Difficulty concentrating

• Fatigue

• Change in appetite

• Feeling out of control

• Sleep problems

• Cramps and bloating

• Breast tenderness

• Headaches

• Joint or muscle pain

• Hot flashes

Aside from a complete medical history and physical and pelvic exam, there are very few diagnostic tests. Because there are mental health symptoms, the doctor may want the person to be evaluated for mental health concerns. In addition, the doctor may ask that the individual keep a journal or diary of her symptoms for several months. In general, to diagnose PMDD the following symptoms must be present:

• Over the course of a year, during most menstrual cycles, 5 or more of the following symptoms must be present:

o Depressed mood

o Anger or irritability

o Trouble concentrating

o Lack of interest in activities once enjoyed

o Moodiness

o Increased appetite

o Insomnia or the need for more sleep

o Feeling overwhelmed or out of control

o Other physical symptoms, the most common being belly bloating, breast tenderness, and headache

• Symptoms that disturb her ability to function in social, work, or other situations

• Symptoms that are not related to, or exaggerated by, another medical condition

Before making a diagnosis of PMDD, the doctor will make certain that emotional problems, such as depression or panic disorder, are not what is causing the symptoms. Other medical or gynaecological conditions, such as endometriosis, fibroids, menopause, and hormone problems also have to be ruled out.

PMDD is a serious, chronic condition that does need treatment. Several of the following treatment approaches may help relieve or decrease the severity of PMDD symptoms:

1. Antidepressants called selective serotonin reuptake inhibitors (SSRIs). SSRIs change serotonin levels in the brain. The Food and Drug Administration (FDA) approved three SSRIs to treat PMDD: Sertraline, Fluoxetine, Paroxetine HCl.
2. Birth control pills. The FDA has approved a birth control pill containing drospirenone and ethinyl estradiol, to treat PMDD.
3. Some over-the-counter pain relievers such as aspirin, ibuprofen, and nonsteroidal anti-inflammatory drugs (NSAIDs) may help some symptoms such as headache, breast tenderness, backache, and cramping. Diuretics, also called “water pills,” can help with fluid retention and bloating.
4. Stress management, such as relaxation techniques and spending time on activities that the individual enjoys. Talking to a therapist may also help a person deal with coping strategies.
5. Making healthy changes, such as eating a healthy combination of foods across the food groups, cutting back on salty and sugary foods, and getting more physical activity, may also help relieve some PMDD symptoms. Changes in diet to increase protein and carbohydrates and decrease sugar, salt, caffeine, and alcohol are all useful interventions.

For some women, the severity of symptoms increases over time and lasts until menopause. For this reason, a woman may need treatment for an extended time. Medicine dosage may change throughout the course of treatment.