Pocket ObGyn – Premenstrual Dysphoric Disorder (PMDD) and Premenstrual Syndrome ( PMS)
See Abbreviations
Definition and Epidemiology (Am J Psych 2012;169(5):465)
- PMS in about 30% regularly cycling . PMDD affects 3–8% of w/
- Classification of premenstrual disorders is based on gradation of premenstrual symptomatology: Mild (premenstrual sx) ® mod PMS ® sev PMDD
- Proposed DSM-V diagnostic criteria for PMDD: 5 or more of the following during the week prior to menses, declining w/i a few days after the onset of At least 1 of the 5 sx must be a core symptom, representing 1 of the 1st 4 on the list. Marked affective lability, irritability, or markedly depressed mood or marked anxiety;
decreased interest in usual activities, difficulty in conc, lethargy, marked changes in appetite (overeating or food cravings), hypersomnia or insomnia, feeling over- whelmed, physical sx (breast tenderness, bloating, muscle or joint pain, or HA). Functional impairment in work, school, daily activities, & relationships.
Dx of exclusion (not exacerbation of another mood d/o like MDD, panic d/o, dys- thymic d/o, personality d/o). Not attributed to a substance, medication or gener- al medical condition.
Dx requires prospective documentation of sx for ³2–3 menstrual cycles.
- Dx of PMS: Timing of sx occurs before menses & declines w/ the onset of
1 or more of the following present, but no functional impairment:
Mild psychologic discomfort, bloating, wt gain, breast tenderness, periph swelling, aches/pains, ¯ conc, sleep disturbances, changes in appetite.
Etiology
- No specific mech identified.Variety of mood changes/destabilization involving serotonin, triggered by physiologic hormonal changes in susceptible
Initial Workup
- Hx, physical, CMP, CBC, serum Menstrual hx w/ an eval of regularity of menstrual cycles; ovulation is req for dx.
- A 2–3-mo prospective menstrual calendar: Document sx & relationship to menses; sx at the time of ovulation & decline w/ onset of menses; a symptom-free week occurs during the follicular
- DDx: Mood & personality disorders, domestic abuse, thyroid disorders, perimenopause, anemia, endometriosis, chronic fatigue syn, IBS, fibromyalgia
Treatment and Medications
- Goal to unaffected days & ¯ symptom severity ® psychosocial functioning
No effective medical rx for PMS in empirical studies. High placebo resps (30–80%). Recommend: Support, lifestyle changes, diet, relaxation, exercise in mild–mod PMS. Limited/no efficacy:Vit B6 100 mg/d (max dose),Vit E 400 IU/d, calcium 600 mg BID (¯ 48% vs. 30% in placebo in PMS sx) & magnesium 200–360 mg/d.
- SSRIs are 1st-line rx for PMDD (meta-analysis of RCT demonstrated 60% resp rate) (Obstet Gynecol 2008;111(5):1181): Fluoxetine 20 mg/d, paroxetine 20–30 mg/d, citalopram 20–30 mg/d & sertraline 50–150 mg/d. Clomipramine & venlafaxine may be also be Luteal phase only ® smaller rx effect than daily dosing (Obstet Gynecol 2008;111(5):1175).
• Other rxs for PMDD:
Alprazolam 0.25 mg TID or QID prn. Use limited by dependence risk.
Medical oophorectomy w/ GnRH agonists: Leuprolide (add back therapy if rx is continued >3–6 mo) & danazol (limited use d/t s/e).
Surgical oophorectomy last form of permanent therapy when all other rxs have failed & trial of medical oophorectomy successful.
Less effective: Oral contraceptives w/ drospirenone & a 4-d pill-free interval, diuretic w/ spironolactone