Premenstrual Dysphoric Disorder (PMDD)

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Great Pearls of Exxcellence article about this from Society for Academic Specialists in General Ob/Gyn (SASGOG).If you haven’t heard of the Pearls of Exxcellence, go and check it out! Great review for CREOGs and boards.

Background

  • What is PMDD? 

    • You have probably heard of premenstrual syndrome (PMS) 

      • PMS: wide variety of signs and symptoms that occur in a predictable pattern usually before or during menses 

        • Symptoms/signs: mood swings, tender breasts, food cravings, fatigue, irritability, depression 

        • Can affect up to 3 out of 4 menstruating people 

        • Estimated that 15-20% of patients who have PMS will have PMS that significantly impairs functioning 

    • PMDD is a more severe form of premenstrual syndrome, according to the DSM-V 

      • Usually appears the week before menstruation and end within a few days of menses starting 

      • Will involve at least one severe affective symptom such as depression, hopelessness, anxiety, affective lability, or persistent anger that resolves around time of menses onset 

      • But not just mood, it can involve multiple systems (don’t have to list all of them, just some) 

        • Psychological symptoms 

          • Irritability, nervousness, feeling of lack of control, anger, insomnia, difficulty concentrating, severe fatigue, depression, anxiety, confusion, forgetfulness, paranoia, emotional sensitivity

        • Respiratory problems 

          • Allergies, infections 

        • Eye problems 

          • Vision changes 

        • GI symptoms 

          • Abdominal cramping, bloating, constipation, nausea/vomiting, pelvic heaviness or pressure, backache 

        • Skin symptoms 

          • Acne, itching, aggravation of other skin disorders (ie. coldsores) 

        • Neurologic/vascular symptoms 

          • Headache, dizziness, fainting, numbness, tingling, heart palpitations, muscle spasms 

        • Other 

          • Painful menstruation, diminished sex drive, appetite changes, food cravings, hot flashes, weight gain/swelling, breast tenderness/pain 

      • Approximately 3-8% of patients who menstruate will have PMDD 

  • Differential diagnosis 

    • Diagnosis of PMDD 

      • As discussed above, can be any of those symptoms + one severe affective symptom 

      • Be coordinated with timing of menses (onset prior to menses and resolves within a few days of menses) 

      • Demonstrates a history of two consecutive menstrual cycles in exclusion of other medical conditions 

    • Should rule out primary mood or anxiety disorders, thyroid function, substance abuse, and menopausal transition

      • This means that we need to take an extensive history and do a physical exam to rule out these other possibilities 

      • Other tests that you may want to order depend on patient symptoms 

        • Ie. excessive fatigue/insomnia/temperature dysregulation, weight gain, etc: rule out thyroid disorders 

        • If concerns for premenopausal transition, can order FSH/estrogen

        • If concerns for heavy bleeding, irregular bleeding, depending on situation may need to do endometrial biopsy, etc

        • We won’t go into everything here, as we have other episodes that discuss how to manage AUB 

        • If you think the patient has a mood disorder that is not due to menstrual cycle, can be a reason to start treatment, refer to psychiatry/psychology 

What are some conservative ways to manage PMDD? 

  • A word on management 

    • As with many chronic conditions in medicine, the goal of treatment is to improve patient function and symptoms, with the understanding that we may not be able to make symptoms go away 100% 

    • Often, it may not be a single management method that helps but a combination 

  • Lifestyle modifications 

    • Diet 

      • Some evidence that diet can affect severity of PMS and PMDD - doesn’t mean that eating certain foods will cause PMDD, but there is a possibility that certain dietary modifications can reduce severity 

      • Reduction of sugar, salt, red meat, caffeine, and alcohol may reduce PMDD symptoms 

      • Some evidence that calcium and vitamin B6 supplementation can benefit 

    • Exercise 

      • Aerobic exercise can improve PMDD symptoms 

      • One study showed that women that did 60 minute aerobic exercise 3x/week for 8 weeks felt much improved physically, mentally, and emotionally 

      • A systematic review and meta-analysis shows that there is likely some improvement in symptoms, but some uncertainty remains: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7465566/

    • Adjunct/alternative treatments 

      • Some studies, but no enough evidence at this time to recommend routinely the following: 

        • Massage, biofeedback, yoga, chiropractic manipulation, evening primrose oil and Chinese herbal medicines 

        • If patients find these work for them, they can continue 

      • Things that have some limited evidence that they may work: bright light therapy, stress reduction, and adequate sleep 

      • Low quality evidence suggests that acupuncture may reduce symptoms of PMDD 

  • Cognitive behavioral therapy

    • Can be effective 

    • Group psychoeducation and relaxation therapy may benefit patients with significant stress or anxiety component 

  • Pharmacologic Therapy/Medication 

    • Psychoactive therapy 

      • Selective serotonin reuptake inhibitors (SSRIs) have been shown to be very effective and are first line treatment for PMDD 

      • Results in response in 60-70% of patients 

      • You can try both continuous or just luteal phase SSRIs 

      • No single agent has been shown to be better than the other 

      • First line therapy include sertraline, paroxetine, citalopram, escitalopram, and fluoxetine 

      • Second line: venlafaxine, alprazolam 

    • Hormonal therapies 

      • Combined oral contraceptives have shown mixed effects in RCTs 

        • Both cyclic and extended regimens inhibit ovulation and may reduce physical symptoms 

      • For patients who desire contraception, COC is reasonable first line therapy with addition of SSRI if needed 

      • Drospirenone-containing COC formulations are specifically FDA approved for treating PMDD, with 48-60% of patients reporting significant improvement 

    • NSAIDs 

      • May be useful to manage physical symptoms 

More advanced therapies 

  • GnRH agonists 

    • Example: leuprolide 

    • Has been shown to be effective for ovulation suppression and physical symptoms of PMDD 

    • Long term use should be approached with caution, and only after informed consent 

    • Reasoning: side effects (ie. hot flashes), and irreversible bone loss 

  • Surgery 

    • If patient has disabling symptoms refractory to other medical therapies, oophorectomy can be considered 

    • A 3-6 month trial of GnRH agonist demonstrating efficacy is a prerequisite to surgical treatment 

    • Must discuss risks and benefits, given oophorectomy in younger women can be associated with multiple morbidities such as cardiovascular events and osteoporosis