Premenstrual Dysphoric Disorder (PMDD)

Definition | Aetiology | Pathophysiology | Risk factors | Signs and symptoms | Investigations | Management

Definition

Premenstrual Dysphoric Disorder (PMDD) is a severe form of premenstrual syndrome (PMS) characterised by significant mood disturbances, irritability, and physical symptoms that interfere with daily functioning, occurring in the luteal phase of the menstrual cycle.

Aetiology

  • Hormonal fluctuations: sensitivity to changes in oestrogen and progesterone levels.
  • Neurotransmitter involvement: serotonin dysregulation contributing to mood symptoms.
  • Genetic predisposition: familial clustering of PMDD and mood disorders.
  • Psychosocial factors: stress, history of trauma, and psychiatric comorbidities.

Pathophysiology

  • Increased sensitivity to luteal phase hormonal fluctuations.
  • Reduced serotonin activity leading to mood instability.
  • Altered hypothalamic-pituitary-adrenal (HPA) axis function contributing to stress response.

Risk factors

  • Family history of PMDD or mood disorders.
  • Personal history of depression or anxiety.
  • High levels of chronic stress.
  • Hormonal contraceptive use (in some cases).

Signs and symptoms

  • Mood symptoms:
    • Severe irritability, anger, or mood swings.
    • Depression or feelings of hopelessness.
    • Anxiety or tension.
  • Physical symptoms:
    • Bloating and breast tenderness.
    • Fatigue and sleep disturbances.
    • Headaches and joint or muscle pain.
  • Symptoms resolve within a few days of menstruation onset.

Investigations

  • Clinical assessment: symptom tracking over at least two menstrual cycles.
  • Screening tools: Premenstrual Symptoms Screening Tool (PSST).
  • Blood tests: FBC, U&Es, LFTs, TFTs to rule out other medical causes.

Management

1. Lifestyle modifications:

  • Regular exercise and stress management techniques.
  • Dietary changes, including reducing caffeine, sugar, and alcohol.
  • Sleep hygiene education.

2. Pharmacological management:

  • First line: SSRIs (e.g., fluoxetine 20 mg daily or sertraline 50–150 mg daily), either continuously (preferred) or in the luteal phase (days 15–28 of the cycle).
  • Second line: COCP, preferably containing drospirenone for PMDD symptom relief. Alternatively, such as Microgynon 30 or Rigevidon taken continuously for better symptom control.
  • Gonadotropin-releasing hormone (GnRH) agonists for severe, treatment resistant PMDD, typically initiated by a specialist (e.g., gynaecologist or psychiatrist). For example, leuprolide or Lupron used to suppress ovarian hormone production, inducing a temporary menopausal state.

3. Psychological therapies:

  • Cognitive Behavioural Therapy (CBT) for mood and stress management.
  • Mindfulness and relaxation techniques.

4. Referral:

  • Gynaecology: if hormonal therapy is being considered.
  • Psychiatry: if significant mood disturbances persist despite treatment.
PsychiatrymypanotesPremenstrual Dysphoric Disorder (PMDD)