Pre-menstrual Dysphoric Disorder: A Review

Introduction

Premenstrual dysphoric disorder (PMDD) is a very distressing disorder among child-bearing females. It is generally neglected and undifferentiated from premenstrual syndrome (PMS).^1,2 It is commonly named as premenstrual tension/premenstrual syndrome/late luteal phase dysphoric disorder/premenstrual tension syndrome (International Classification of Diseases, Tenth Revision) or PMDD (Diagnostic and Statistical Manual of Mental Disorders, fifth edition).^3,4 In ICD-11, it is now out of the appendix. ⁵ The American College of Obstetricians and Gynecologists also defines PMDD similarly. ⁶ The prevalence of PMDD is 3% to 9%. ⁷ Similar numbers have been reported from India across various states.^8–13

Etiology

Currently, there is no consensus on the cause of PMDD. Biologic, genetic, psychological, environmental and social factors all seem to play a very important role.

Classification of PMS

Royal College of Obstetricians and Gynaecologists classifies PMS into four variants ⁶⁰ :

‘Premenstrual exacerbation of an underlying disorder’, such as diabetes, depression, epilepsy, asthma, and migraine.

National Association for Premenstrual Syndrome subdivide PMS into mild, moderate, and severe. ⁶²

Clinical Features

Symptoms in PMDD include anxiety, depression, irritability, anger, bloating, muscle pain, poor concentration, etc., causing severe distress that is persistent in several cycles, characteristically appearing one week before periods and disappearing within first two days of bleeding. ⁶³ Women with PMDD usually have comorbid physical and psychiatric disorders, and one must always keep these comorbidities as dual diagnosis whenever in doubt.^64–72

Management

Thorough investigations for comorbidities must always be done. Among psychological tools, the premenstrual symptoms screening tool was developed at McMaster University in 2003 and a new Japanese scale was made in 2009.^73,74 There is a scale currently validated for the Indian population as well.

In psychopharmacological treatment, the British Journal of Obstetricians and Gynecologists protocol emphasizes the use of fluoxetine and sertraline in the treatment of PMDD.^60,75 The hormonal therapies recommended by the British Journal of Obstetricians and Gynecologists include leuprolide depot, leuprolide depot with ovarian hormone supplements, goserelin with estrogen supplementation, danazol, oral contraceptive pills, progesterone-only drugs, estradiol patches, spironolactone, bromocriptine, Ibuprofen, etc.^14,60

In non-pharmacological treatment, lifestyle changes including regular, frequent, small balanced meals rich in complex carbohydrates and low in salt, fat, and caffeine, regular exercise, smoking cessation, alcohol restriction, regular sleep, and maintaining PMDD charts have been found to be helpful. Nutritional supplements including vitamin B6, up to 100 mg per day, vitamin E, up to 600 IU per day, calcium carbonate, 1200 to 1600 mg per day, magnesium, up to 500 mg per day, tryptophan, up to 6 g per day have been suggested.

Others therapies with some benefit include stress reduction and management, anger management, self-help support group, individual and couples therapy, cognitive behavioral therapy, music therapy, light therapy with 10,000 lux cool white fluorescent light, etc.^14,20,60

Conclusion

PMDD is prevalent mental health condition affecting mental and physical well-being of women and yet is underdiagnosed. Careful history and examination regarding PMDD should be a norm in every woman patient presenting to a psychiatrist. Management consists of pharmacological and non-pharmacological intervention with variable prognosis.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.