Premenstrual Syndrome (PMS) and Premenstrual Dysphoric Disorder (PMDD)

By Dr Ananya Mandal, MD

Premenstrual Syndrome (PMS)

PMS or premenstrual syndrome is a condition that manifests as emotional, physical and behavioral symptoms and affects women between their late 20’s to early 40’s. The condition is marked by the symptoms 5 to 10 days prior to beginning of the period and symptoms resolve once the period begins or within 4 to 7 days.

PMS is a relatively common condition and almost 75% women suffer from this condition at some point in their lives. Sometimes mood swings, behavioral changes and physical symptoms may be severe enough to affect normal life. (1-5)

Premenstrual Dysphoric Disorder (PMDD)

Premenstrual dysphoric disorder or PMDD is a more extreme or severe form of PMS. There may be hormonal shifts during a menstrual cycle resulting in:

  • mood swings,
  • fatigue,
  • headaches,
  • body aches,
  • menstrual cramps,
  • breast pain
  • abdominal bloating etc.

There are over 100 symptoms that characterize PMS and no two woman suffers a similar range of symptoms. Further symptoms may vary from month to month in many women.

Women with PMDD have severe depression symptoms, irritability, and tension just before their periods. These are more severe than PMS. PMDD may affect 3-8% women during their child bearing period of life.

Causes of PMS and PMDD

The exact cause of PMS and PMDD is still unclear. There are links of these disorders with hormonal changes and fluctuations as well as with the general psychological make-up of the woman. A brain chemical called serotonin levels are usually altered in women with PMDD.

Diagnosis of PMS and PMDD

Diagnosis of PMS and PMDD is usually made by looking at the symptom diary that the patient is asked to maintain over a period of three months. Clinical symptoms, onset day, duration and severity are recorded in the diary.

Diagnosis is also dependent on other medical conditions like migraine and asthma that are aggravated by PMS. A complete physical examination including examination of the pelvis is made.

Causes and Symptoms of PMDD

Those with PMDD may have underlying depressive illness, anxiety disorders, history of postpartum depression or mood disorders etc.

PMDD patients usually have more severe symptoms and may complain that their symptoms are severely incapacitating them and they are failing to lead a normal life.

There may be symptoms of anxiety, depression and Seasonal affective disorders (SAD) among women with PMDD.

Who is at Risk of PMDD?

Women who are at risk of PMDD are those who use excessive alcohol or caffeine, who are obese or overweight, do not exercise or who have a mother with a similar condition.

Diagnosis of PMDD based on DSM-IV-TR

The diagnosis of PMDD is made based on the guidelines laid by the Diagnostic and Statistical Manual of Mental Disorders – Text Revision IV (DSM-IV-TR). These include:

  1. In most of the menstrual cycles over last 5 years or more symptoms like the following must be present during the last week before periods:
    1. Markedly depressed mood, feelings of hopelessness
    2. Marked anxiety, tension or edginess
    3. Marked teariness or lability
    4. Marked anger or aggression
    5. Lack of interest
    6. difficulty concentrating
    7. Lethargy, tiredness
    8. Change of appetite – increase or decrease and specific food cravings
    9. Too much or too little sleep
    10. Feeling overwhelmed
    11. Physical symptoms of headaches, breast pain and swelling, joint and muscle pain, bloating etc.
  2. The changes markedly interfere with work or school or with usual social activities and relationships.
  3. Symptoms no exacerbation of underlying disorders like major depressive disorder, panic disorder or personality disorders
  4. All A, B and C criteria in at least 2 consecutive cycles to distinguish with PMS.

PMDD and other Mood Disorders

Usually women who have depressive or anxiety related symptoms all month long with worsening right before periods is indicative that she is suffering from another mood disorder and not PMDD.

There must be a clear interval of at least 7–10 days during each menstrual cycle when the symptoms of PMDD appear to arrive at the diagnosis.

Treatment of PMS and PMDD

Treatment of PMS and PMDD is usually symptomatic with advice for a healthy diet, avoidance of caffeine, salt, alcohol and smoking.

Regular aerobic and other stress reducing medication and exercise throughout the menstrual cycle is advised.

Calcium, magnesium, vitamin B6, folic acid and essential fatty acid supplements are often prescribed to women with PMS. They show benefits in women with PMS.

Some women with more severe symptoms may require oral contraceptive pills to regularize their hormonal fluctuations. Pain relievers like Aspirin or Ibuprofen may be used.

Those with PMDD additionally may require an antidepressant like as a selective serotonin-reuptake inhibitor (SSRI). This includes drugs like Fluoxetine, Paroxetine, Escitalopram etc. Cognitive behavioral therapy (CBT) may be used alone or with SSRIs.

PMS, PMDD and Mental Health

Nearly 10% of women with PMS and especially those with PMDD may have suicidal thoughts. Suicide in women with depression is likely after 14 days from the first day of last menstrual period.

This needs to be kept in mind and adequate treatment needs to be offered. There may be other problems like eating disorders and drug and alcohol abuse.

Reviewed by , BA Hons (Cantab)

Further Reading

Last Updated: Jul 31, 2012

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