Question

Research premenstrual dysphoric disorder

Answer 1

A sub group of women with severe pre menstrual dysphoric disorder will be offered additioanal research studies that focus on -

a) Identifying the endocrine changes that may be responsible for changes in mood and behaviour during the premenstrual period

b) evaluating treatments for PMS symptoms.

c) Identifying genetic factors in women with and without PMS.

Premenstrual dysphoric disorder (PMDD) is defined as a depressive disorder, is characterized by mood, appetite, energy, and cognitive changes that occur during the late luteal (premenstrual) phase of the menstrual cycle and remit shortly after the onset of menses. Symptoms are severe enough to interfere with functioning at home, school, or work. It occurs in an estimated 5% of women, and if left untreated, may become more severe and extend in duration over time. Based on current evidence, serotonergic dysfunction appears to be linked with its hormonal etiology, as selective serotonin reuptake inhibitors (SSRIs) demonstrate efficacy and safety. The role of overien steroids, prolactin, prostaglandins, mineralocorticoids, neurotransmitters, endogenous opiates, vitamin and mineral deficiencies, and psychological factors is unclear.

Requirements for Diagnosis of Premenstrual Dysphoric Disorder

1. Symptoms must occur during the week before menses and remit a few days after onset of menses. Five of the following symptoms must be present and include at least one of 1–4.

   1. Depressed mood or dysphoria

   2. Anxiety or tension

   3. Affective lability

   4. Irritability

   5. Decreased interest in usual activities

   6. Concentration difficulties

   7. Marked lack of energy

   8. Marked change in appetite, overeating, or food cravings

   9. Hypersomnia or insomnia

   10. Feeling overwhelmed

   11. Other physical symptoms (e.g., breast tenderness, bloating)

2. Symptoms must interfere with work, school, usual activities or relationships.

3. Symptoms must not merely be an exacerbation of another disorder

4. Criteria A, B, and C must be confirmed by prospective daily ratings for at least two consecutive menstrual cycles.

Prior to the initiation of treatment for PMS/PMDD, adequate screening for conditions such as depression, dysthymic disorder, generalized anxiety disorder, and hypothyroidism is essential. Patients' social circumstances and life histories should be queried. The latter queries are especially important given the association of PMS/PMDD with trauma and sexual abuse. Given that exacerbations of dysphoria and anxiety are linked to the use of alcohol and illegal drugs, patients' use of such substances should be evaluated during the clinical interview.

Diagnostic evaluation of PMS involves clinical evaluation and review of the patient's prospective daily charting of the timing, type, and rating of severity of symptoms for at least two menstrual cycles. Take a medical history to rule out cardiac, renal, or thyroid disease, collagen vascular disease, and diabetes. Also exclude other problems, including anemia, breast disease, dysmenorrhea, endometriosis, perimenopausal changes, or premenstrual exacerbation of allergies, arthritis, asthma, diabetes, irritable bowel syndrome, migraine, and seizure disorders. Determine whether the patient has premenstrual dysphoric disorder (PMDD), which affects 5%–10% of normally cycling women. Many women with severe PMS meet the diagnostic criteria for PMDD. PMS/PMDD must be differentiated from other psychiatric disorders (anxiety, depression, eating or personality disorders) because these disorders also cause symptoms in the follicular phase. Perform physical examination and laboratory testing as needed. Investigators have been unable to document specific changes in hormone levels, prolactin, aldosterone, endorphins, and glucose tolerance. There are no laboratory tests to diagnose PMS.

Review of treatment research fails to demonstrate consistently effective therapy, and the rate of response to placebo appears to be 50%. Numerous treatments have been advocated. Initial interventions are education and support, stress reduction, healthy nutrition, and regular exercise. Many women are reassured by chart review and can plan their schedules according to symptom severity, use relaxation exercises, join a support group, or participate in an exercise program to relieve stress. Eating complex carbohydrates (whole grains, beans, fresh fruits, vegetables) and low-protein foods and tapering caffeine intake, especially during the luteal phase, may diminish symptoms but efficacy remains unproved. Neither natural progesterone (in suppository or micronized oral preparations) nor synthetic progestins are effective for PMS.

if there are symptoms of PMDD or if PMS is severe and symptoms include psychosocial difficulties. When SSRIs do not work, an anxiolytic agent may be the next choice. Anovulation therapy with oral contraceptives (OCPs), danazol, and gonadotropin-releasing hormone (GnRH) agonists (goserelin acetate, leuprolide acetate, nafarelin acetate) can relieve symptoms of severe PMS, but unpleasant side effects are common and lead to discontinuance. OCPs appear to relieve PMS symptoms in about one third of women. Consider further evaluation or referral when the diagnosis is uncertain, another medical or psychiatric disorder is suspected, the patient is a risk to herself or others, or standard dosages of medications are ineffective in reducing symptoms.