Premenstrual dysphoric disorder: How to alleviate her suffering
Accurate diagnosis, tailored treatments can greatly improve women’s quality of life
Mood charting aids diagnosis
A PMDD diagnosis requires prospective daily monitoring of symptoms for ≥2 consecutive months. Because only 25% to 35% of women who present with PMDD meet diagnostic criteria when prospective daily monitoring is used,20 it is important for patients to keep a daily diary of PMDD symptoms to distinguish the disorder from PMS (Box 2). The Prospective Record of the Impact and Severity of Premenstrual Symptoms calendar and the Daily Record of Severity of Problems (DRSPP)21 may help make the diagnosis.
The widely used DRSPP allows clinicians to quantify the severity of physical, emotional, and behavioral symptoms and may be the easiest to use in clinical practice because it creates a graphic representation of cyclical symptom changes. The DRSPP includes all PMDD symptoms and severity ratings21 and is recognized as a valid instrument for diagnosing PMDD. Another option is a revised visual analogue scale. Lastly, a new revised Premenstrual Tension Syndrome (PMTS) rating scale, which combines the PMTS Observer rating scale plus multiple visual analogue scales, shows promise as a tool to assess PMDD symptoms.
To distinguish premenstrual syndrome (PMS) from premenstrual dysphoric disorder (PMDD), premenstrual exacerbation of an underlying psychiatric disorder, general medical conditions, or other disorders with no association to the menstrual cycle, it is necessary to have patients conduct daily symptom charting over 2 menstrual cycles. This charting should include documentation of emotional, behavioral, and physical symptoms. PMDD can be differentiated from PMS by the severity and number of symptoms. In PMDD, 1 of the symptoms must be a mood disturbance (depressed, anxious, labile, and/or irritable). For a sample form used for PMDD charting, the Daily Record of Severity of Problems, see https://pmdd.factsforhealth.org/drsp/drsp_month.pdf.
Treatment options
Hormonal interventions. Attempts to treat PMS with progesterone during the luteal phase have been largely unsuccessful, although progesterone is approved to treat PMS in the United Kingdom. Long-acting gonadotropin-releasing hormone (GnRH) agonists are effective but result in medical menopause with its accompanying symptoms, which puts women at risk for osteoporosis.22 Approximately 60% to 70% of women with PMDD respond to leuprolide (a GnRH agonist), but it is difficult to predict who will respond; daily mood self-ratings of sadness, anxiety, and irritability predict a positive response to leuprolide with high probability.23 Side effects of GnRH agonists (hot flashes, night sweats, vaginal dryness, etc.) can be tempered by “adding back” some estrogen with a hormonal agent with progestational activity to reduce the risks of unopposed estrogen (ie, endometrial hyperplasia).24
Surgical bilateral oophorectomy is effective but extremely invasive, especially in younger women in whom removal of ovaries generally is inadvisable. Patients should receive a trial of a GnRH agonist before a surgical intervention, because oophorectomy may not reduce symptoms and is irreversible. Oophorectomy also would require hormone replacement therapy.
High-dose estrogen as transdermal patches or subcutaneous implants to inhibit ovulation is effective, but because of the risks of unopposed estrogen, a progestin would be needed. Risks of estrogen therapy (alone and in combination with progestins) include increased risk of endometrial cancer, coronary heart disease, breast cancer, stroke, and pulmonary embolism.25 Danazol, a synthetic androgen and gonadotropin inhibitor, effectively blocks ovulation, but side effects include hirsutism and possible teratogenicity.26 Although these hormonal manipulations may effectively treat PMDD, none are considered practical.
The use of combined oral contraceptives (estrogen and progestin) is common. Although continuous cycle oral contraceptives often are recommended for PMDD, limited evidence supports their use; studies have been mostly negative.27,28 A recent review of 4 studies of a continuous oral contraceptive (levonorgestrel 90 mcg/ethinyl estradiol 20 mcg) for PMDD and PMS had more promising results, although the results were highly variable among studies and a large placebo effect was observed.29
A combination oral contraceptive, drospirenone/ethinyl estradiol, is FDA-approved for treating PMDD in women seeking hormonal contraception because it has shown efficacy compared with placebo, with reported improvements in perceived productivity, social activities, and interpersonal relationships.30 The nature of hormone delivery (ie, a reduction in the pill-free interval from 7 to 4 days) in drospirenone/ethinyl estradiol may contribute to its efficacy because a reduced pill-free interval minimizes the degree of follicular recruitment and subsequent estrogen production and cyclicity seen with standard oral contraceptive.31
