Writer: Sabrina David
Introduction:
As a woman, have you ever noticed how differently you act a few days before your period, like being easily irritated, mood swings, bloating, anxiety, etc. Well, these symptoms are known as Premenstrual Syndrome (PMS). Sometimes, if you experience a severe form of these symptoms, it might occur due to factors like personal, academic or environmental stress. If these severe symptoms continue to occur regardless of stress, then you might have Premenstrual Dysphoric Disorder (PMDD), an intense form of PMS. This article, backed-up by scientific peer-reviewed journals, explains the difference between PMS and PMDD, signs and symptoms of PMDD, its etiology, its diagnostic tools and its current treatment options.
PMS VS PMDD:
PMS often occurs in the luteal phase of a woman’s menstrual cycle, which is the week before menstruation. It is often characterized by at least one emotional, behavioral, and physical symptom, such as breast tenderness, bloating, anxiety, headaches, irritability, etc. These symptoms are temporary and don’t negatively affect a woman’s life, and they are able to recover from it after the luteal phase (Tiranni and Nappi, 2022).
However, PMDD is a severe form of PMS, where a woman experiences intense emotional and physical symptoms due to her menstrual cycle, such as depression. It chronically affects their daily life, routine and overall well being. PMDD patients are at higher risk of suicide, developing an eating disorder, generalized anxiety disorder (GAD), bipolar disorder, decrease in sleep quality, and addictive behaviours like alcohol and nicotine use (Tiranni and Nappi, 2022). Furthermore, in the recent category of depressive disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), PMDD was added to the list. In 2019, it was also labeled as a gynecological diagnosis by the World Health Organization’s International Classification of Disease (ICD-11). PMDD occurs between 1.8% and 5.8% of women who are menstruating (Reilly et al., 2024).
Signs & Symptoms:
PMDD is a combination of psychological, emotional and physiological distress and an intense form of emotional and physical symptoms. Its presence requires at least one mood symptom, such as a depressed mood, anxiety, depression, lability or irritability, along with other symptoms like insomnia or hypersomnia, loss of interest, difficulty concentrating, feeling emotionally overwhelmed, overeating or food cravings. It significantly affects a woman’s relationships with her peers, routine, and overall well-being.
Testing:
In order to be diagnosed with PMDD, a woman needs to experience a total of 5 of the symptoms. These symptoms must occur during the luteal phase in the menstrual cycle for over a year and it causes significant distress regardless of academic, working and social experiences; they should not be influenced by medications or a chronic condition, but rather the menstrual cycle only itself. Its diagnosis consists of prospective daily ratings for at least 2 symptomatic cycles (Tianni and Nappi, 2022).
According to Takeda (2022), one must use one of the three screening tools to test for PMDD:
Premenstrual Symptom Screening Tool (PSST):
PSST is included in the DSM-5 PMDD criteria, which has a total of 17 items: 12 symptoms, such as “insomnia or hypersomnia” divided into “hypersomnia” or “insomnia” as separate symptoms; plus 5 items on functional impairment, such as difficulty concentration and in productivity.
Prementual Screening Questionnaire (PSQ):
In Japan, another screening tool was developed and it’s independent from PSST, known as Prementural Screening Questionnaire (PSQ). PSQ has a total of 14 items, which includes 11 premenstrual symptoms listed in the DSM-5 manual; the other 3 items analyze the disruption of one’s social reliability due to these symptoms. The PSQ is validated for psychometric properties and reliability, and overall a short-form of PSST.
The Diary Record of Severity of Problems (DRSP):
DRSP is the most universally used diagnostic tool, which is a dairy for recording and daily tracking of the symptoms. It is validated for reliability and validity.
Causes/Etiology:
Even though understanding of the root of PMDD is limited, it is well aware that symptoms don’t occur before menarche, during pregnancy, or after menopause; highlighting the involvement of hormonal fluctuations. To illustrate, leuprolide, a Gonadotropin-releasing hormone (GnRH) agonist, was used to suppress ovulation in PMDD patients. This reduces the premenstrual symptoms, but they can slightly recover from estrogen and progesterone replacement. During the first month of hormonal replacement, premenstrual symptoms tend to be more severe but decrease once hormone level stabilizes (Takeda, 2022). Hence, hormonal changes in the body is one of the causes of PMDD development.
Additionally, studies have shown the role of neurotransmitters and their involvement in PMDD etiology, specifically serotonin (5-HT) and gamma-aminobutyric acid (GABA). To begin, 5-HT, which helps regulate mood, sleep, appetite and so much more, decreases in the luteal phase before menstruation. Low 5-HT transmission in the brian results in mood and behavioral symptoms associated with PMDD, such as poor impulse control, irritability, depressed mood, and an increase in carbohydrate cravings. PMDD shares many symptoms with mood and anxiety disorders which are linked to abnormally low serotonergic levels (Steiner, 2000). Studies have shown that a decrease in tryptophan, a precursor of serotonin, in diets increases premenstrual symptoms, hence it is evident that serotonin is involved in the etiology of PMDD (Takeda, 2022). Furthermore, GABA is an inhibitory neurotransmitter in the central nervous system (CNS) , which helps to regulate stress and anxiety. In the luteal phase, progesterone increases which increases allopregnanolone (ALLO); ALLO is a positive allosteric modulator for GABA and acts as neuroactive steroid. Studies have shown that PMDD patients have a lower ALLO levels in the luteal phase, which enhances their anxiety and anxiety-related behaviors. Thus, indicating a link between the etiology of PMDD and lower GABA levels in the CNS (Takeda, 2022).
Treatment:
Antidepressants:
Serotonin-reuptake inhibitors (SSRIs) are often the first-line treatment for PMDD; often taking highly during the luteal phase. It quickly improves PMS/PMDD symptoms; often a few days within 4 weeks of treatment (Tranini et Nappi, 2022).
Hormone Therapy:
Oral contraceptives (OCPs) contain drospirenone and ethinyl estradiol, which helps in reducing PMS/PMDD symptoms. It suppresses ovulation while maintaining menstruation, which allows for a hormone-free period and a period withdrawal. GnRH agonists are so useful in reducing PMDD symptoms, but are not used as first-line treatment; its side effects are more risky compared to SSRIs or OCPs, such as vaginal dryness and bone loss similar to menopause (Takeda, 2022).
Vitamins and complementary medicine:
According to the peer-reviewed journal written by Takeda (2022), some effective vitamins and medicine to help reduce premenstrual symptoms are: 100 mg of vitamin B6 (pyridoxine), 1200 mg of calcium carbonate supplementation, vitex agnus castus (chasteberry). In addition, a herbal medicine used in Japan called Kampo, is also very effective in treating premenstrual symptoms.
Conclusion:
Overall, PMDD is the most intense form of PMS which a woman can experience, and it requires medical care. Its diagnostic is done via PSST, PSQ and DRSP. It is caused by hormonal and/or neurotransmission fluctuations; such as low serotonin levels. Treatment includes SSRIs, OCP and many more. Moreover, it’s important to bring awareness and educate everyone about PMDD to provide better and early management for this disorder, and improve a woman’s quality of life. If you know a woman who is unsure if she has PMS or PMDD, consulting her to a healthcare professional will be the best solution.
References:
Reilly, T. J., Patel, S., Unachukwu, I., Knox, C. L., Wilson, C. A., Craig, M. C., ... & Cullen, A. E. (2024). The prevalence of premenstrual dysphoric disorder: Systematic review and meta-analysis. Journal of Affective Disorders.
Steiner M. (2000). Premenstrual syndrome and premenstrual dysphoric disorder: guidelines for management. Journal of psychiatry & neuroscience : JPN, 25(5), 459–468.
Takeda T. (2023). Premenstrual disorders: Premenstrual syndrome and premenstrual dysphoric disorder. The journal of obstetrics and gynaecology research, 49(2), 510–518. https://doi-org.myaccess.library.utoronto.ca/10.1111/jog.15484
Tiranini, L., & Nappi, R. E. (2022). Recent advances in understanding/management of premenstrual dysphoric disorder/premenstrual syndrome. Faculty reviews, 11, 11. https://doi.org/10.12703/r/11-11
This article has been written by an individual not in the Medical Blogs team as an "Open Submission Article".
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