Premenstrual Dysphoric Disorder (PMDD)

Definition | Aetiology | Risk Factors | Clinical Presentation | Investigations | Management | When to Refer | References

Definition

Premenstrual Dysphoric Disorder (PMDD) is a severe form of premenstrual syndrome (PMS) characterised by significant emotional and physical symptoms that occur in the luteal phase of the menstrual cycle (the two weeks before menstruation) and typically resolve within a few days after the onset of menstruation. PMDD can have a substantial impact on a woman's quality of life, affecting relationships, work, and daily activities.

Aetiology

The exact cause of PMDD is not fully understood, but it is believed to involve a combination of hormonal, genetic, and neurochemical factors:

• Hormonal Fluctuations: Changes in oestrogen and progesterone levels during the menstrual cycle are thought to trigger symptoms in susceptible women. These hormones can affect neurotransmitter function, particularly serotonin.
• Serotonin Dysregulation: Reduced serotonin activity in the brain is associated with mood disorders and may play a role in the emotional symptoms of PMDD.
• Genetic Predisposition: A family history of PMDD or other mood disorders may increase the risk of developing PMDD.
• Psychosocial Stressors: Stressful life events and psychosocial stressors can exacerbate symptoms of PMDD.

Risk Factors

Several factors increase the likelihood of developing PMDD:

• Personal or Family History: A personal or family history of depression, anxiety, or other mood disorders.
• Hormonal Sensitivity: Sensitivity to normal hormonal fluctuations during the menstrual cycle.
• Stress: High levels of stress, which can exacerbate symptoms.
• Age: PMDD typically affects women in their late 20s to early 40s.
• Lifestyle Factors: Poor diet, lack of exercise, and substance abuse (e.g., alcohol, caffeine) may contribute to symptom severity.

Clinical Presentation

PMDD presents with a range of emotional and physical symptoms that occur in the luteal phase of the menstrual cycle and significantly impact daily functioning:

Emotional Symptoms

• Severe Mood Swings: Intense mood changes, including feelings of sadness, hopelessness, or tearfulness.
• Irritability or Anger: Increased irritability or anger, often leading to conflicts with others.
• Anxiety or Tension: Feelings of intense anxiety, nervousness, or tension.
• Depression: Persistent feelings of sadness, hopelessness, or low self-esteem.
• Decreased Interest: A marked decrease in interest in usual activities, such as work, hobbies, or social interactions.

Physical Symptoms

• Fatigue: Significant tiredness or lack of energy.
• Sleep Disturbances: Difficulty sleeping or sleeping too much.
• Appetite Changes: Overeating, cravings, or changes in appetite.
• Physical Discomfort: Symptoms such as breast tenderness, headaches, joint or muscle pain, and bloating.
• Concentration Difficulties: Trouble focusing or concentrating on tasks.

Investigations

The diagnosis of PMDD is primarily clinical, based on a detailed history and symptom tracking. Additional investigations may be conducted to rule out other conditions:

• Symptom Diary: A prospective daily record of symptoms over at least two menstrual cycles to confirm the timing and severity of symptoms relative to the menstrual cycle.
• Psychiatric Assessment: A mental health evaluation to assess for co-occurring mood disorders, such as depression or anxiety.
• Medical History and Physical Examination: To rule out other medical conditions that could mimic PMDD, such as thyroid disorders or chronic fatigue syndrome.
• Laboratory Tests: Blood tests such as thyroid function tests, full blood count (FBC), and hormone levels to exclude physiological causes of symptoms.

Management

The management of PMDD involves a combination of lifestyle modifications, pharmacological treatments, and psychological therapies:

Lifestyle Modifications

• Regular Exercise: Physical activity can help alleviate symptoms by reducing stress and improving mood.
• Dietary Changes: A balanced diet with reduced intake of caffeine, alcohol, and sugar may help manage symptoms. Increasing intake of complex carbohydrates and maintaining regular meal times can also be beneficial.
• Stress Management: Techniques such as mindfulness, meditation, and relaxation exercises to manage stress and reduce symptom severity.
• Sleep Hygiene: Establishing a regular sleep routine and creating a restful environment to improve sleep quality.

Pharmacological Treatments

• Selective Serotonin Reuptake Inhibitors (SSRIs): Medications such as fluoxetine, sertraline, or citalopram, taken either continuously or only during the luteal phase, are effective in reducing emotional symptoms of PMDD.
• Hormonal Therapies: Combined oral contraceptives (COCs) may help regulate hormonal fluctuations and reduce symptoms. Gonadotropin-releasing hormone (GnRH) agonists can be used in severe cases to suppress ovulation.
• Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): For managing physical symptoms such as pain or discomfort.
• Diuretics: Spironolactone may be used to reduce bloating and fluid retention associated with PMDD.

Psychological Therapies

• Cognitive Behavioural Therapy (CBT): Helps individuals identify and change negative thought patterns and behaviours, and develop coping strategies for managing PMDD symptoms.
• Supportive Counselling: Provides emotional support and guidance for managing the impact of PMDD on daily life and relationships.

When to Refer

Referral to a specialist or mental health service may be necessary in the following situations:

• Severe PMDD that does not respond to initial therapies or requires more intensive management.
• Presence of co-occurring mental health conditions, such as major depressive disorder or anxiety disorders.
• Significant impairment in daily functioning, including difficulties at work, in social settings, or in personal relationships.
• Need for specialised psychological therapies, such as CBT, that are not available in primary care settings.

References

1. NHS (2024) Premenstrual Dysphoric Disorder (PMDD). Available at: https://www.nhs.uk/conditions/premenstrual-dysphoric-disorder/ (Accessed: 26 August 2024).
2. National Institute for Health and Care Excellence (2024) Premenstrual Syndrome: Diagnosis and Management. Available at: https://www.nice.org.uk/guidance/ng195 (Accessed: 26 August 2024).
3. British Medical Journal (2024) Premenstrual Dysphoric Disorder: Clinical Review. Available at: https://www.bmj.com/content/350/bmj.h3917 (Accessed: 26 August 2024).

Back to Top