US Pharm. 2010;35(9):17-18. 

A Severe Type of PMS

Premenstrual dysphoric disorder (PMDD) is an intense form of premenstrual syndrome (PMS) distinguished by significant mood changes and physical symptoms during the second half of the menstrual cycle. These symptoms are relieved shortly after menstruation begins, but reappear midway through the next cycle.

Some symptoms of PMDD are similar to those of PMS, including physical symptoms like bloating and breast tenderness. However, the emotional symptoms of PMDD resemble major depression (MD): fatigue, hopelessness, suicidal thoughts, lack of interest in daily activities, and poor sleep, as well as anxiety, anger, and irritability. These mood extremes have a disruptive effect on the woman's life.

Although the cause is not clearly understood, PMDD is probably linked to the hormonal fluctuations that occur between ovulation and menstruation--the last 2 weeks of the menstrual cycle. Diagnosis of the condition often is made after examining a daily symptom diary recorded over several months. The fact that PMDD causes serious mood changes not unlike MD makes it important to view the timing of symptoms in relation to the menstrual cycle. A careful history and physical examination can help eliminate other possible causes.

Although there is no cure for PMDD, symptoms can be treated, allowing sufferers to lead more normal lives throughout the month. Several medications have been approved for use in the treatment of mood symptoms of PMDD. These include some of the newer antidepressants, such as fluoxetine and sertraline, as well as drospirenone-containing birth control pills to control ovulation. Nonsteroidal anti-inflammatory drugs such as ibuprofen are useful for cramping, and diuretics often are prescribed to relieve fluid retention. Dietary changes, exercise regimens, and relaxation skills are useful therapies also. Many women benefit from nutritional supplements such as calcium, magnesium, and vitamin B6

Symptoms Are Much More Intense and Debilitating Than Those of PMS

Premenstrual syndrome (PMS) is a relatively common condition. Three-fourths of menstruating women report some degree of physical and/or emotional symptoms during the days leading up to menstruation. These symptoms may be physical, such as cramping, bloating, breast tenderness, headache, food cravings, and sleep disturbances. Women also may experience a number of psychological symptoms, including mood swings, anxiety, sadness, irritability, and trouble concentrating. Women with PMS experience several of these symptoms each month.

Premenstrual dysphoric disorder (PMDD) is much less common than PMS, with only about 5% of menstruating women reporting this far more serious condition. PMDD is classified as a psychiatric disorder similar to major depression (MD). Some doctors and researchers think that hormonal changes during the 2 weeks before menstruation worsen an already-present mood disorder, resulting in PMDD.

Differences Between PMS and PMDD

Although PMS and PMDD have some similarities, PMDD symptoms are much more intense, and in some women they resemble symptoms of MD. Diagnosis of PMDD is made based on the number of symptoms and their severity, along with the days they occur each month in relation to menstruation. There are no laboratory tests or other measurements to confirm the diagnosis. A physical examination is made to eliminate other causes of the symptoms, and a psychological examination is conducted to rule out the existence of other mood disorders.

PMDD symptoms are often debilitating, affecting daily routines and relationships with family and friends. Symptoms include pronounced fatigue, disinterest in previously enjoyable activities, feelings of hopelessness, spontaneous crying, suicidal thoughts, severe anxiety, irritability, difficulty concentrating, sleep problems, food cravings, and physical symptoms such as cramping, bloating, and breast tenderness. Symptoms appear about 2 weeks prior to menstruation and improve shortly after menstrual flow begins.

Although the cause of PMS and PMDD is not fully understood, these conditions probably are linked to fluctuations in hormone levels during the 10 to 14 days before menstruation.

Factors that increase a woman's chance of developing PMDD or that can make the condition worse include pre-existing mood disorders such as seasonal affective disorder, depression, anxiety, a family history of PMDD, and heavy caffeine or alcohol use.

Treating PMDD

The goals of treatment are to relieve PMDD symptoms and restore normal mood throughout the menstrual cycle. Several medications are approved specifically for the treatment of PMDD: newer antidepressants such as fluoxetine (Sarafem), sertraline (Zoloft), and controlled-release paroxetine (Paxil CR). These medications may be taken continuously throughout the month or only on the 10 to 14 days prior to each period. Birth control pills, especially the combination of drospirenone (progesterone) and ethinyl estradiol (estrogen) known as Yaz, may be effective for controlling the effects of ovulation on PMDD symptoms.

Calcium carbonate and vitamin B6 supplements have been shown to improve symptoms of PMDD. Ibuprofen is often used to relieve cramping, while diuretics are used to counteract fluid retention.

Regular exercise can have a positive effect on PMDD symptoms. Changes in diet also may help, including eliminating or cutting back on caffeine and alcohol while increasing fiber and carbohydrates. Training in coping skills and relaxation techniques may aid in easing PMDD symptoms.