Download Premenstrual Syndrome and Premenstrual Dysphoric Disorder

Premenstrual Syndrome and
Premenstrual Dysphoric Disorder
Deb Rink
Surveys have suggested that 75-80% of women in reproductive ages
experience symptoms of premenstrual syndrome (PMS) with more than 100
physical and psychological symptoms reported.1 It is estimated that 20% of
women experience PMS to a degree that warrants clinical treatment. 2 PMS has
been defined as; having mild to severe physical and/or emotional symptoms that
typically occur about 5-11 days before a woman starts her monthly menstrual
cycle, and these symptoms stop shortly after mences begins. Premenstrual
dysphoric disorder (PMDD) is defined as a condition in which a woman has
severe depression symptoms not otherwise specified and emotional and
cognitive behavioral symptoms before menstruation that interfere with daily
function.3–6 The symptoms of PMDD are more severe than those seen with PMS
and approximately 2-10% of women report these more severe symptoms.1,3,7
These disorders can impair a woman’s function in daily living by impeding work
productivity and quality of life.2,5,6 In athletes, it is important to track female
menstrual cycles for many reasons that are obvious, but of the less obvious is
that PMS may affect athletic performance.
The symptoms of PMDD and PMS are similar, however PMDD symptoms
are usually more severe and include at least one psychological symptom. Signs
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and symptoms of PMS and PMDD include physical, cognitive and psychological
categories and will occur, most commonly during the week before mences begins
and will subside shortly after mences begins.1–7 There are 11 typical symptoms
listed in the literature including, but not limited to; depressed moods, anxiety,
lability, irritability, decreased interest in usual activities, concentration difficulties,
lack of energy, change in appetite, sleep changes, feeling overwhelmed, and
physical symptoms such as bloating, breast tenderness, headaches, joint pain,
weight gain, and cramps.1–7 Other suggested symptoms found commonly are;
mood swings, feeling out of control, feeling hopeless, possible suicidal thoughts,
and panic attacks.2–4,6 A woman must display 1 of 4 core symptoms (irritability,
anxiety, dysphoria, or lability), have at least 5 of the 11 typical symptoms listed
above, and have had the symptoms in most of her cycles for the last 12 months
in order to be diagnosed with PMDD. These symptoms must have interfered with
social or occupational function.1 PMS has very similar symptoms, however, a
diagnosis of PMS does not require an emotional symptom, nor is there a need to
confirm daily functional impairment.1
It is frequently thought in society that irritability is the predictor of the onset
of PMS, however irritability has been shown to have no discrimination between
normal and PMS participants in research and is reported by most women,
therefore it cannot be used as a sole predictor that PMS has begun.2 Possibly,
irritability is the most visible and most offensive symptom seen by others,
therefore others need to attach a reason to the offenses that they experience
with the individual displaying irritability. However, there are strong predictors of
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PMS that have been reported in research, such as; mood swings, anxiety,
decreased interest in activity, appetite changes, aches and cramps.2,6 Lifestyle
factors that may affect the severity and presence of these symptoms are obesity,
alcohol abuse, smoking, lack of exercise, and drinking excess caffeine, eating
disorders, and increased stress.3,5,7 It is always recommended to decrease any
of the lifestyle factors possible in order to limit the symptoms a woman will
experience. Symptoms are reported to come on several years after the start of
mences and begin at an average age of 26 years. Younger women who have
started mences are not reported to have symptoms severe enough for
treatment.5
There are no objective measurements that will diagnose PMS or PMDD.
All diagnostic tools are subjective in nature and their inclusion in so many other
diagnostic assessments produces noise that reduces diagnostic accuracy and
causes difficulties in a true diagnosis of PMS/PMDD. A thorough history,
physical exam, and a symptom log are important in diagnosing the disorders. A
symptoms log should be kept every day for 2 full cycles with symptoms repeating
in both cycles in order to make the diagnosis.1–3,6 This log is one of the most
important tools in the diagnosis and might include information about type,
severity and duration of symptoms, daily food log, sleep patterns, and exercise
habits.1,6,7 The etiology of PMS/PMDD is unknown, but normal ovarian function
is known to trigger the biochemical events that lead to the starting of symptoms
every month. Hormone changes during the menstrual cycle may play a role and
there is increasing evidence that suggests serotonin may be important with
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PMDD. Biochemical factors, however, cannot fully account for the appearance of
symptoms.1,4,6,7 PMS/PMDD also have a genetic component and are more likely
in women whose mother’s have a history of PMS or PMDD.3,5,7 There is still
much to learn about the etiology of PMS and PMDD.
PMS and PMDD are stated in the literature as a biological phenomena
rather than psychological or psychosocial condition, although the symptoms
overlap with many psychological and social disorders.1,3 Since there are no
objective measures to diagnose PMS/PMDD, it is important to rule out any other
medical conditions. Family history is also important in ruling out other differential
diagnosis that display similar symptoms such as anemia, thyroid disease, mental
disorders, and personality disorders.1 Many of these medical conditions do have
objective testing in order to rule them out as clinical diagnosis which will help in
narrowing the possible differential diagnosis. Another complication in diagnosing
PMS/PMDD includes the fact that it has coexisted with such psychological
disorders as anxiety disorders, phobias, obsessive-compulsive and panic
disorders.4 To differentiate PMDD from many psychiatric disorders, there will be
a symptom free time period recorded in the patient’s log within the monthly
cycle.3 After medical screening and symptom logging for 2 months, there are still
a range of possible diagnosis which include; PMS or PMDD, another psychiatric
or medical illness only, PMS or PMDD coexisting with another illness,
premenstrual exacerbation of an underlying psychiatric or medical illness, or no
diagnosis.1 Therefore, it can be difficult and take a long time to diagnose
PMS/PMDD and follow up with the correct treatment.
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Treatments for PMS and PMDD begin with a healthy lifestyle that prevents
severe symptoms from occurring and improves social and occupational
functioning. Proper diet, regular exercise, good sleep, and daily vitamins are
suggested habits that may help prevent or decrease PMS/PMDD symptoms. A
proper diet would include more whole grains, fruits, vegetables and would limit or
not include tobacco, salt, sugar, alcohol, and caffeine.1,3,7 Supplemental vitamins
and minerals have been recommended to decrease symptoms such as, vitamin
B6, calcium, magnesium, and vitamin E.1,3 Women should also review their
monthly logs and identify triggers that exacerbate symptoms. It is important for
the patient to be very aware of herself during the diagnosis time trial. Awareness
of all symptoms and lifestyle factors will decrease questions and be helpful in the
diagnosis. Regular aerobic exercise is important to reduce any symptoms and
has the added benefit of reducing stress, which is another major lifestyle factor
that increases symptoms.1,3,7 Cognitive behavior therapy has been suggested,
with individual sessions showing the most success in improving symptoms and
functional impairment.1,3 However, group and individual sessions were both
helpful. Stress management, support groups and education of PMS/PMDD have
also been suggested as non-pharmacologic treatments of PMS and PMDD and
have shown some success in research.3
Nonprescription and prescription medicines are treatment options for PMS
and PMDD and have been proven to help with improving symptom relief of PMS
and PMDD. Over the counter pain reducers and NSAID’s may be useful with any
symptoms of pain. Diuretics may help with bloating and weight gain from fluid
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retention.7 The main prescription approaches to PMS and PMDD are
psychotrophic and hormonal interventions. There is good evidence supporting
serotonergic dysregulation in PMS.4 Selective serotonin reuptake inhibitors
(SSRI) have excellent efficacy and minimal side effects when conservative
treatments have failed. SSRIs are the first line of pharmaceutical treatment for
severe PMS and PMDD and common prescriptions used are Citalopram,
Fluoxetine, and Sertaline.1,3,7 SSRIs may be prescribed in the second half of the
monthly cycle or for the whole month.1,7 Anxiolytics have shown good results
also (Alprazolam), but not quite as good as the SSRIs.1,3 Hormonal agents have
been used as a second line of treatment for PMS and PMDD if all other
treatments have failed. Common hormone prescriptions used are Leuprolide
depot and Danazol.1,3 Gonadotropin releasing hormones can temporarily
suppress the menstrual cycle and are known as causing “medical menopause”.
Long term use is not recommended as side effects mimic menopause and
include the potential for osteoporosis. Symptoms typically return upon cessation
of the medication.1,3 Oral contraceptives show mixed results with increasing and
decreasing symptoms of PMS and PMDD and are not recommended for
treatment.1,3 Herbal therapies that have shown efficacy in treatment of PMS are
evening primrose oil and chaste tree berry, however they have not been
approved by the FDA for use, and safety has not been established.3 To date,
there is no single intervention that has proven effective in treating all women with
PMS or PMDD symptoms. Another complication of this disorder is the difficulty
in finding the best individual treatment option for each patient.
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Therapeutic goals for each patient should be to decrease the symptoms
as much as possible with the hope of a cessation of symptoms. After proper
diagnosis and treatment, most women with severe symptoms do report a
cessation or a drop in symptom intensity to tolerable levels.1,7 However, there
are concerns with the prognosis in severe PMS and PMDD which includes
evidence that symptoms gradually increase over time and symptoms will recur
when treatment is haulted.1
One 20 year story or case study of a female runner explains PMDD well in
an athlete. A 16 year old high school middle distance runner on the track team
had a history of difficult monthly cycles. She would complain of heavy flows and
intense cramps that caused nausea and vomiting. Headaches would sometimes
incapacitate her for a day or two. Other symptoms she reported were being
irritable, having mood swings, depression, and crying easily. She remembers
having depression then and not relating it to her menstrual cycle. I am talking to
her now, 20 years later at the age of 36 years. As an adult, she has become an
endurance runner and triathlete, however, she could not train regularly in order to
participate in running events and triathlons like she would want to. Over the
years, she reports some of her symptoms have gotten worse around her monthly
cycle. It has been the psychological symptoms of depression and moods that
have gotten worse and affected her family and work life. She has not been able
to perform as a mother and a wife as usual over the years and has also been
know to call in sick to work often. She states that her two children get upset that
she does not participate in everything that they do. They don’t understand why
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she can participate sometimes and sometimes she cannot. This is a common
misunderstanding with her husband and friends also. Three months ago, she
obtained her first diagnosis of PMDD in life. The symptoms reported in her
recent investigation were menorrhagia, painful cramping, headaches, losing
interest in the activities she likes, feeling hopeless, depression, lack of energy,
crying easy, irritability, bloating and weight gain. She kept a log of her symptoms
for 2-3 months and these symptoms all followed her cycle for the two months that
she logged daily menstrual events. Her emotional symptoms were more severe
during luteal phase of menstruation, but didn’t fully subside through the follicular
phase. The physical symptoms of cramping and bloating were only present
during the luteal phase. Other testing that she performed in order to make this
diagnosis included several blood tests for thyroid and hormone levels. She had a
full psychiatric evaluation done. She was found to have low thyroid levels a few
years ago and has been taking thyroid replacements for a few years and her
levels are stable now. This complicated and prolonged a PMDD diagnosis as
more testing was needed in order to prove that the thyroid was not the cause of
some of her symptoms. After several months of psychiatric and medical testing,
a diagnosis of PMDD was given. The series of testing took about 6 months to
complete before she was given a treatment plan and prognosis. She has
accepted taking SSRIs for treatment and reports all of her psychiatric symptoms
are significantly subsided or nonexistent now. Her physical symptoms have
subsided some but still remain. This past summer, she completed training and
performing in her first half Ironman triathlon and also finished an Xterra triathlon.
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She performed in several running events as well. After the diagnosis, she was
able to train for these events, be more social and more consistent in her social
activities that she enjoys.
After living with many symptoms of PMDD, this case study found an
acceptable prognosis. This case took 4-6 months to investigate and diagnose
which shows the difficulty in ruling out other possibilities. There are many
differential diagnosis to consider, including physiological, psychological, and
social disorders before the conclusion can be made of PMDD. There are many
symptoms investigated that appear to be difficult to investigate. Psychological
symptoms take a lot of time and effort on the part of the clinician and the patient
in order to have good information. Daily logs or diaries seem to be the most
helpful tool to determine the psychological role in PMDD. There also seems to
be a cultural denial of the effect that PMS/PMDD has on women, in the United
States, that is difficult to overcome. The effect that this disorder can have on
women is real and significant to their lives, and the effect on athletes includes the
aspect of performance as well. A woman with PMDD can seem inconsistent with
all aspects of her life, and is not able to explain her inconsistencies well. PMDD
needs to be a possible differential diagnosis in the mind of an athletic trainer, for
any athlete who exhibits the symptoms and performs inconsistently. With more
research, PMS and PMDD can be more widely known and accepted in our
culture, and we can make strides towards finding easier and quicker diagnosing
tools and treatments.
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References
1. Steiner M. Premenstrual syndrome and premenstrual dysphoric disorder:
guidelines for management. J Psychiatry Neurosci. 2000;25(5):459.
2. Freeman EW, Halberstadt SM, Rickels K, Legler JM, Lin H, Sammel MD.
Core Symptoms That Discriminate Premenstrual Syndrome. J Womens Heal
15409996. 2011;20(1):29–35.
3. Bhatia SC, Bhatia SK. Diagnosis and treatment of premenstrual dysphoric
disorder. Am Fam Physician. 2002;66(7):1239–1249.
4. Firoozi R, Kafi M, Salehi I, Shirmohammadi M. The Relationship between
Severity of Premenstrual Syndrome and Psychiatric Symptoms. Iran J
Psychiatry. 2012;7(1):36–40.
5. Orsal O, Tozun M, Unsal A. Relationship between Premenstrual syndrome
and depressive symptoms among nursing students. HealthMed.
2013;7(2):508–515.
6. Wang Y, Lin S, Chen R, Benita W-M. Pattern of moderate-to-severe
symptoms of premenstrual syndrome in a selected hospital in China. J Obstet
Gynaecol Res. 2012;38(1):302–309.
7. Board ADAME. Premenstrual dysphoric disorder. 2012. Available at:
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0004461/. Accessed October
28, 2013.
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