Monthly anguish: Premenstrual dysphoric disorder comes out of the shadows

Monthly anguish: Premenstrual dysphoric disorder comes out of the shadows

A pre-menstrual disorder, PMDD causes extreme distress but new recognition should help us to identify and treat it early, writes Dr Brendan Kelly.

IN May 2019, the World Health Organisation added premenstrual dysphoric disorder (PMDD), a severe, disabling form of premenstrual syndrome, to the 11th revision of its International Classification of Diseases. 

This welcome move validates PMDD as a legitimate medical diagnosis, recognising both the extreme distress it can cause and the need for increased awareness, treatment, and research.

PMDD affects up to 6% of menstruating women who have a greater sensitivity to the regular hormonal changes that occur during the menstrual cycle. 

Symptoms include mood swings, crying episodes, anxiety, depression, and suicidal ideation. 

There can also be irritability, reduced interest, problems concentrating, lethargy, sleep problems, changes in appetite, a feeling of being overwhelmed, and a variety of physical problems such as joint pain and breast tenderness.

The key feature of PMDD is that these symptoms occur during the luteal phase of the cycle (ie, after ovulation and prior to the period). 

Although the duration of this phase can vary widely between women and cycles, it lasts on average for around two weeks. 

During this time, PMDD symptoms often result in severe deterioration in the person’s mood and general wellbeing. 

Once menses commence, the symptoms resolve quite rapidly, until the next ovulation occurs.

There is often a delay in diagnosing PMDD, for a wide variety of reasons. The greatest problem is limited awareness, which will hopefully be addressed by the WHO’s recent recognition.

Monthly anguish: Premenstrual dysphoric disorder comes out of the shadows

For some women, PMDD may involve symptoms similar to those of depression and can lead to further delay in diagnosis. But the woman with PMDD, unlike the person with depression, experiences improvement within days of the onset of menses.

Women with PMDD can also be misdiagnosed with bipolar disorder (manic depression) because both conditions involve fluctuating moods, but mood swings in bipolar disorder typically have a longer duration than those in PMDD and are not alleviated by menses.

In terms of treatment, reaching a diagnosis of PMDD is critical. 

Acknowledging and naming the condition not only validates the patient’s concerns but also supports her as she deals with the fluctuating and often highly distressing symptoms of the condition. 

Relaxation, exercise, and other lifestyle measures can also help with symptom management.

In terms of medication, certain anti-depressant medications are used internationally. 

In the US, the Food and Drug Administration has approved a number of selective serotonin reuptake inhibitors (SSRIs) for PMDD, including fluoxetine, sertraline, and paroxetine. 

As usual, the benefits of medication need to be weighed against any adverse effects for each individual. 

Specific side-effects vary between medications and are detailed on information sheets provided with the medications themselves. Overall, many women with PMDD report significant benefit from SSRIs.

From a psychological perspective, cognitive-behaviour therapy can also assist with PMDD, and various alternative therapies have been proposed but are not yet studied in a systematic way. .

Monthly anguish: Premenstrual dysphoric disorder comes out of the shadows

Even so, a range of lifestyle measures can prove very helpful in individual cases. And, with increased recognition of the condition, it is hoped that the evidence-base for treatment will improve over the coming years.

In the meantime, if one knows what to look out for, PMDD is a highly predictable condition. If, however, awareness is low, it can seem that there is no real consistency in symptoms which simply appear to fluctuate at random.

Missing the diagnosis is very regrettable because PMDD is often very amenable to treatment, and proper management can greatly reduce the suffering of those affected.

Brendan Kelly is professor of psychiatry at Trinity College Dublin and author of The Doctor Who Sat For A Year (Gill, 2019).

Additional research by Deirdre O’Flaherty, incoming MSc candidate for global mental health at the University of Glasgow.

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