Premenstrual Dysphoric Disorder (PMDD)

Premenstrual dysphoric disorder (PMDD) has similar symptoms (fatigue, tiredness, mood changes, and bloating) as premenstrual syndrome (PMS), however, the symptoms are more severe with PMDD.

• Premenstrual dysphoric disorder (PMDD) is a particularly severe form of premenstrual syndrome (PMS).
• Both PMS and PMDD cause disturbing symptoms during the second half, known as the luteal phase, of a woman's menstrual cycle.
• The symptoms tend to worsen over the week prior to the onset of the menstrual period and then improve within a few days after the period starts.
• PMDD can cause a number of different symptoms, but fatigue, tiredness, mood changes, and bloating are common. A low percentage of menstruating women are estimated to suffer from PMDD.
• In contrast to PMS, the symptoms of PMDD are severe enough to have a significant impact upon the woman's daily activities and functioning.

• PMS and PMDD are believed to be caused by a complex interaction of the hormones produced by the ovaries during a normal menstrual cycle (estrogen and progesterone) with neurotransmitters (chemical messengers) in the brain.
• Serotonin is a neurotransmitter that is believed to be important in the development of PMDD, and PMDD may be the result of alterations in brain serotonin levels. The exact mechanism by which neurotransmitters and hormones interact to cause PMDD is not yet understood.

Symptoms of PMDD can vary significantly among women. Symptoms that have been reported by women suffering from PMDD include

• fatigue,
• mood changes,
• abdominal bloating,
• breast tenderness,
• appetite changes,
• hot flashes,
• palpitations,
• crying spells,
• headache,
• difficulty concentrating or forgetfulness,
• feeling irritable, tense, or overly sensitive to stimuli,
• depression,
• acne, and
• gastrointestinal (stomach and intestine) upset.

While these symptoms can all occur to some extent in PMS, in true PMDD they are pronounced enough to cause a significant impact upon a woman's daily functioning.

• If a woman has disturbing symptoms that occur in relationship to her menstrual period, it is appropriate to contact a health care practitioner for an evaluation.
• If PMDD is causing significant depression, suicidal thoughts may occur. Ideas of suicide are considered a medical emergency, and emergency care should be accessed immediately.

• Taking a medical history and performing a physical examination are the first steps in the diagnosis of PMDD. While there are no specific tests or physical findings that can establish the diagnosis, it is important to rule out other conditions that may be responsible for the symptoms.
• Since many of the symptoms of PMDD are fairly nonspecific, a number of other conditions, including pregnancy, may be responsible for a woman's symptoms. Blood tests may be ordered to help rule out other conditions that may mimic PMDD.
• In order to diagnose PMDD, it must be shown that the symptoms are directly related to the menstrual cycle. To do this, women are usually asked to complete a symptom chart or calendar and record their symptoms each day for a given length of time. The symptoms can then be correlated with the menstrual cycle and onset of the menstrual period.

• PMDD is a treatable condition, and a number of different therapies have been shown to be successful in helping reduce or resolve the symptoms.
• Medications remain the mainstay of therapy for PMDD. Medications from a number of different classes have been effective in treating PMDD.

Several dietary supplements have been shown in limited clinical studies to help alleviate the symptoms of PMDD in some women, but none of these remedies has been proved with absolute certainty to be effective.

The following have all been shown in some studies to reduce PMS/PMDD symptoms:

• Chasteberry extract (agnus castus fruit)
• calcium,
• vitamin B6, and
• vitamin E supplements.

Antidepressants

The selective serotonin reuptake inhibitor (SSRI) (antidepressant medications) commonly used to treat depression are the most common medical treatment for PMDD. Up to 75% of women will have reduction in symptoms when treated with SSRI medications.

Side effects can include nausea, anxiety, and headache, although more serious side effects are possible. SSRI medications to treat PMDD may be prescribed to be taken continuously or only during the 14-day luteal phase (second half) of the menstrual cycle.

Examples are

• fluoxetine (Prozac, Sarafem),
• sertraline (Zoloft),
• paroxetine (Paxil), and
• citalopram (Celexa).

Other Medication

Other medical treatments that have been used in PMDD are drugs that interrupt ovulation. These can include oral contraceptive pills (OCPs, birth control pills) as well as Gonadotropin-releasing hormone analogs (GnRH analogs or GnRH agonists), which stop menstrual periods by inhibiting the secretion of ovarian regulatory hormones from the pituitary gland.

Examples of GnRH agonists include

• leuprolide (Lupron),
• nafarelin (Synarel), and
• goserelin (Zoladex).

The side effects of GnRH agonist drugs can be unpleasant and mimic menopausal symptoms (hot flashes, vaginal dryness, irregular vaginal bleeding, mood changes, fatigue, and loss of bone density).

Treatment with small amounts of estrogen and progesterone along with the GnRH analog medications can help reduce the side effects and preserve bone density.

Danazol (Danocrine)

Danazol (Danocrine) is a drug that has sometimes been used to treat PMDD when other treatments have failed. Danazol promotes high androgen (male hormone) and low estrogen levels. It is not a first-line treatment because it has a number of significant side effects.

A majority of women taking this medication develop side effects from the drug, including

• weight gain,
• edema,
• decreased breast size,
• acne,
• oily skin,
• hirsutism (male pattern hair growth),
• deepening of the voice,
• headache,
• hot flashes,
• changes in libido, and
• mood changes.

• Follow-up visits will be necessary to monitor the woman's response to treatment and its possible side effects. The health care practitioner's will make recommendations regarding the frequency of follow-up visits.
• If a woman's symptoms persist despite therapy for PMDD, a health care practitioner may suggest a different medication or treatment. It is important to follow the health care practitioner's suggestions for treatment and follow-up visits.

Since PMDD is likely the result of a complex hormonal interaction and its cause is poorly understood, there is no known way to prevent PMDD from occurring.

If untreated, PMDD can significantly interfere with a woman's quality of life and her ability to function at work, school, or home. However, PMDD is a treatable condition, with most women reporting a reduction in symptoms with adequate medical treatment.

In addition, a number of different therapies are available should a given treatment be ineffective for an individual woman.