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Premenstrual Dysphoric Disorder

A woman’s period often announces itself in annoying ways—just ask any female between puberty and menopause. The signs can be physical, emotional or behavioral — a trio of symptoms known as PMS, that is infamous shorthand for premenstrual syndrome. According to the American College of Obstetricians and Gynecologists (ACOG), up to 85 percent of women in their childbearing years report PMS problems. And for the vast majority of them, the symptoms are generally mild and manageable.

Then there’s the woman whose menstrual cycle shifts her into overdrive. For one or two weeks before her period, she endures PMS with a wallop of mood misery thrown in for bad measure. That’s when PMS crosses the line into Premenstrual Dysphoric Disorder, or PMDD. This tornadic force of nature disrupts work and social lives and sends loved ones ducking for cover. Fortunately, for the 3 to 8 percent of women affected by PMDD, it’s only a temporary state—once the period starts, the PMDD resolves.

Comedians joke that hell hath no fury like a premenstrual woman. But make no mistake: PMDD is a certifiable mood disorder that can make life unbearable for those who suffer from it. In fact, some 16 percent of women diagnosed with the condition attempt suicide. There is nothing funny about that.

Causes and Risk Factors

Textbook case

The woman most susceptible to PMDD is in her 20s to mid-30s. It is likely that it runs in her family. There is a strong possibility of a history of a mood or anxiety disorder; in addition, there may also be a history of obesity or being overweight.

Babymaking biology

PMDD is most likely to occur during the luteal phase of the menstrual cycle. That’s the 14 days (or so) between when the ovary releases a ripe egg (ovulation) and bleeding begins if pregnancy doesn’t occur. During this time, the body produces estrogen and progesterone in abundance, which in turn sparks the brain receptors that control emotion and behavior. The effects of these sex hormones then ride downstream on brain chemicals (neurotransmitters) that trigger the mood and thought disturbances associated with PMDD.

Shocked systems

Post-Traumatic Stress Disorder — any past traumatic experience, especially sexual abuse — significantly increases the risk of developing PMDD.

Acute systems

Research suggests that women who develop PMDD have rather normal hormonal cycles—they just feel theirs more acutely than those who are symptom free.

Cranial clues

Certain brains may be more vulnerable to PMDD than others. Imaging studies suggest structural differences in grey matter volume and density in women with PMDD, compared to others.

Under study

Researchers don’t yet know what causes PMS and PMDD. They’re considering the effect of heredity; mind/body/behavior factors, such as stress; and the way sex hormones affect the central nervous system. This much is clear: shifting hormonal levels seem to flip the switch that turns PMDD symptoms on and off.

Diagnosing Premenstrual Dysphoric Disorder

The clinical checklist

According to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), it takes five or more of the following symptoms—at least one of them from each category—to make a provisional PMDD diagnosis. (That’s your doctor’s best guess until data confirms he’s right.) The symptoms must be present for most menstrual cycles in the past year.

The mood changes

  1. Abrupt mood swings, tearfulness, sensitivity to rejection
  2. Irritability, angry outbursts, relationship conflicts
  3. Feelings of depression, hopelessness, or worthlessness
  4. Anxiety or tension

The physical and behavioral changes

  1. Lost interest in previously enjoyable activities
  2. Difficulty concentrating
  3. Thirst/appetite changes and food cravings
  4. Sleepiness or insomnia
  5. A sense of loss of control
  6. Breast tenderness, aches and pains, and belly bloating or pain

Taken together, the problem symptoms must distress the woman to the point where her work, school or relationships suffer because of them.

Confirming the diagnosis

PMDD can be a slippery call to make because it looks a lot like other psychiatric illnesses. Like PMDD, an underlying depressive, bipolar, panic or personality disorder can appear to get worse before a period. Mood disorders in particular affect an estimated 40 percent of women who seek treatment for PMDD.

So, what’s a clinician to treat?

This is where it pays to pay attention. Most of the disorders that confound a PMDD diagnosis either pop up at irregular intervals or stay constant over time. PMDD, on the other hand, is reliably cyclical. Think of it this way: Premenstrual? Now you feel it. Get your period? Now you don’t.

Nor are PMDD symptoms present when the period goes absent. Pregnancy and menopause will halt PMDD in its tracks; a mood disorder will march on through any reproductive life event.

Producing the proof

The best way to confirm a PMDD diagnosis is to document a pattern of symptoms as they occur. So plan ahead. Write down how you feel every day for at least two months. Be sure to record the dates of your periods, too. Take the data you collect to your health care provider for her evaluation.

There’s a few good tools available to help you track your symptoms. One’s as good as the next, and your doctor can provide you with blank copies to fill out. These include:

  1. Calendar of Premenstrual Experiences (COPE)
  2. Daily Record of Severity of Problems (DRSP)
  3. Prospective Record of the Impact and Severity of Menstruation (PRISM)
Treating Premenstrual Dysphoric Disorder

It’s official: You’ve been diagnosed with PMDD. Now, what are your options?

The medication route

Antidepressants are often the first-line treatment for PMDD because they help moderate mood symptoms. Some women take them two weeks before the anticipated onset of symptoms; others take them all month long. Your clinician should help you weigh the pros and cons of both schedules.

Research suggests that 60 to 90 percent of PMDD patients respond well to a class of drugs that slow the reuptake of serotonin (SSRIs), a chemical messenger the brain produces to communicate with nerve cells. These antidepressants include:

  1. Celexa (citalopram)
  2. Prozac (fluoxetine)
  3. Effexor (venlafaxine)

Anafranil (clomipramine) is a type of older medications called Tricyclic Antidepressants (TCAs) that also help with PMDD.

Oral contraceptives (OCs) are another medication therapy to consider. This second-line treatment for PMDD works by stabilizing and regulating the reproductive hormones. While not all oral contraceptives are effective against PMDD, the FDA has approved Beyaz (drospirenone/ethinyl estradiol/levomefolate calcium) and Yaz (drospirenone/ethinyl estradiol) specifically for this purpose.

Women more than 35 years of age and who smoke are poor candidates for OC therapy. So are those with a history of a blood clot, stroke or migraine.

The talk therapy route

Cognitive Behavioral Therapy (CBT) focuses on how thoughts, feelings and behaviors can influence the way we experience the world, both mentally and physically. Studies show that CBT effectively treats mood and anxiety disorders. Because PMDD has similar symptom patterns to these illnesses, an understanding therapist could turn out to be both your health care provider and new best friend.

The can’t-hurt-might-help route

Regular aerobic exercise increases heart rate and lung function, and may relieve PMDD symptoms by reducing depression and fatigue. Just 30 minutes of brisk walking, running, cycling or swimming can do much to improve mood and energy levels. Be sure to exercise on most days, not just when you’re feeling unwell.

Healthful, common-sense eating habits might reduce mood swings and food cravings. Consider:

  1. Complex carbohydrates (whole grains, brown rice, beans and lentils)
  2. Calcium-rich foods (milk, yogurt, cheese and leafy greens such as kale)
  3. Going light on the fat, salt and sugar
  4. Limiting caffeine and alcohol (or avoiding them altogether)
  5. Smaller meals eaten more often to stabilize blood sugar levels

Dietary supplements with good research behind them are worth a try. A daily dose of calcium (1,000 – 1,200 mg) may improve both physical and mood symptoms. Magnesium might help beat back the water retention that leads to bloating. Vitamins D and B6 have been studied for use in PMDD, but the evidence is inconclusive. Be wary of so-called “natural” products, which often lack testing and adequate proof of their effectiveness. Always consult your health care provider before taking any supplement.

Managing Premenstrual Dysphoric Disorder

Batten down the hatches.

Pre-existing physical or mental disorders may grow fiercer in the days before the period starts. This is especially true of depression, anxiety, allergies, asthma, migraines and seizure disorders.

Ask your mom. And your grandmas. And all your aunts and girl cousins.

Here’s a good reason to trace the disorders in your family’s history—it may help establish a PMDD diagnosis. If females in your family tend to experience period-related gloom and doom, chances are that you will, too.

See a shrink.

Consult a gynecologist for a PMDD evaluation and a reference to a mental health professional. Go see one to get a definitive diagnosis. PMDD is a disease where the physical and psychological are virtually inseparable.

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