Premenstrual Dysphoric Disorder can turn your world upside down – but treatment can bring relief

For most women in their reproductive years, menstruation is not the happiest time of the month. Even more so when it’s accompanied by a whole range of physical and emotional changes  known as Premenstrual Dysphoric Disorder (PMDD) that may wreak havoc in a person’s personal, social and work life. Sadly, while PMDD often responds to effective and professional treatment, many women with PMDD do not seek treatment, and up to 90% may go undiagnosed. So says Dr Eileen Thomas, a specialist Psychiatrist at Akeso Clinic Milnerton.

What is PMDD?

“A reproductive disorder whereby women experience transient physical and emotional changes around the time of their period, PMDD is associated with a level of impairment that is similar to major depressive disorder and poorer quality of life compared with community norms, therefore it should be considered a serious health condition. PMDD can have adverse consequences on a woman’s social functioning, relationships, work productivity and healthcare use,” Thomas points out.

She adds that to be diagnosed with PMDD “a woman must experience at least five of 11 possible symptoms in the week before menstruation starts (the luteal phase). Symptoms must improve once menstruation has begun and the symptoms must be absent the week after menstruation has ended.  Women with PMDD report a normal mood and functioning during the follicular phase of the menstrual cycle (i.e. the first day of the menstrual cycle until ovulation).”

Difference between premenstrual syndrome (PMS) and PMDD

According to Thomas, no less than 75-90% of women experience premenstrual mood and physical changes.

“PMS is experienced by about 20% of menstruating women who have at least one physical or emotional symptom during the five days before menses. PMDD, on the other hand, occurs in about 3% to 8% of women with regular ovulatory cycles. Although PMS and PMDD criteria share mood and physical symptoms, more symptoms are required for a PMDD diagnosis and symptoms are often more severe,” she says.

Myths about PMDD

Common myths about PMDD are that it is not a real disorder or that the diagnosis was created by pharmaceutical companies to increase prescribing of medications, according to Thomas      .

“Some feminist theorists argue that inclusion of PDMM would essentially allow society to stigmatise women by pathologising a normal part of their physiological make-up. Further, this would only contribute to stereotypes about women as being emotionally unstable once a month. The truth about PMDD is, although a controversial new diagnostic category, it identifies a group of women who are suffering and for whom effective treatment exists.

PMDD prevalence

PMDD affects 3-8% of women in their reproductive years and symptoms usually emerge during a woman’s Twenties.” These symptoms may worsen over time; for example, it has been observed that some women may experience worsening premenstrual symptoms as they enter into menopause. Less commonly, PMDD may begin during adolescence.

“PMDD has been described globally in diverse cultural settings, even among women who are not generally aware of the disorder. As an example, similar rates of the disorder have been reported in Europe, Asia, Africa, South America and Mediterranean countries.

“PMDD was included as a new diagnostic category in the DSM-5 in May 2013 and it is hoped that its inclusion will attract more funding for research, and a better understanding of women’s reproductive health.”

Who is at risk for developing PMDD?

While any woman can develop PMMD, women with a personal or family history of depression, postpartum depression, or other mood disorders are particularly at risk. Women who experience abuse (emotional, physical or sexual) in early life places are at higher risk for PMS in the middle-to-late reproductive years, Thomas adds.

What are the symptoms of PMDD?

As defined in the American Psychiatric Association (APA) Diagnostic and Statistical Manual, Fifth Edition (DSM-5), one of required symptoms to make a diagnosis must come from this list of four:

irritability or anger;

anxiety and tension;

depressed mood or feeling hopeless, and

marked affective lability (e.g., mood swings; feeling suddenly sad or tearful or increased sensitivity to rejection).

“Other symptoms include difficulty concentrating, fatigue, changes in appetite or specific food cravings, sleep disturbances, feeling overwhelmed and physical symptoms such as breast tenderness or abdominal bloating.  These symptoms occur recurrently, typically in the same constellation-set and in the majority of menstrual cycles.”

What does a patient need to tell her doctor?

In order to establish the diagnosis, the clinician will request a woman to chart symptoms daily for two consecutive cycles. “Your doctor will also ask you about your medical and psychiatric history, medication and substance use. It is important to provide accurate and thorough information to distinguish PMDD from mimics, example dysmenorrhea,” Thomas stresses.

Treatment options for PMDD

Treatment comprises of both of pharmacological and non-pharmacological therapies. Treatment is tiered and individualised, dependent on factors such as the woman’s choice, contra-indications to certain medications, cost and contraception-needs, says Thomas.

Lifestyle changes

“In general, lifestyle changes can help to ameliorate symptoms. Although solid evidence is lacking, clinicians generally recommend that patients with PMS or PMDD decrease or eliminate the intake of caffeine, sugar and sodium. Other helpful lifestyle modifications include decreasing alcohol and nicotine use, ensuring adequate sleep and regular aerobic exercise. Herbal remedies include calcium carbonate and chaste berry.

Pharmacological treatment

“The first line pharmacological treatment to reduce both the physical and emotional symptoms is serotonergic antidepressant drugs, particularly selective serotonin reuptake inhibitors (SSRIs). In general, women respond to low doses of SSRIs, and this treatment response usually occurs rapidly, often within several days.

“Different dosing-regimens exist, whereby women may choose to take the antidepressant treatment continuously throughout the whole month, or only in the luteal phase (the week leading up to period).  Other pharmacological options include hormonal treatment such as oral contraceptives that contain drosperinone – an antidiuretic or short term anxiolytic use.

Concludes Thomas: “Treatment generally continues for duration of a women’s reproductive life.  If one considers that a female typically menstruates 300-500 times during her lifetime, timely identification and initiation of appropriate treatment, may prevent impairment. This, together with support and TLC from loved ones or spouses, can go a long way in improving the quality of life of PMDD sufferers.”

 

About Akeso Clinics

Akeso Clinics is a group of private in-patient psychiatric clinics that prides itself on providing individual, integrated and family-oriented treatment for a range of psychiatric, psychological and addictive conditions. Akeso Clinics offer specialised in-patient treatment facilities.

Please visit www.akeso.co.za or contact us on 011 447 0268 for further information.

In the event of a psychological crisis, please call 0861 4357 87 for assistance.

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SADAG runs the only toll-free suicide crisis line in SA: 0800 567 567 (open 7 days a week from 8:00 a.m. to 20:00 p.m.).

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