A subgroup of women with premenstrual syndrome (PMS), estimated to be between 3-8 per cent, have symptoms primarily related to a serious mood disorder. This condition is a more severe variant of premenstrual syndrome (PMS), and is characterised by symptoms of irritability, anger, internal tension, dysphoria and mood lability. It is referred to as premenstrual dysphoric disorder (PMDD) and should be suspected when symptoms are rated as very severe in Table the ‘Menstrual symptom questionnaire’ (grading 4).

Symptoms of Premenstrual Dysphoric Disorder

An outline of the types and severity of symptoms required for this diagnosis was first described in an appendix to the 1994 Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) — see Table DSM-IV criteria for Premenstrual Dysphoric Disorder. For a diagnosis of premenstrual dysphoric disorder to be appropriate, the symptoms must be confirmed by prospective daily ratings during at least two consecutive symptomatic cycles. At least one of the symptoms must be severe depression, anxiety, mood lability or anger.

Table DSM-IV criteria for Premenstrual Dysphoric Disorder

A. In most menstrual cycles of the past year, five (or more) of the following symptoms, which begin during the last week of the luteal phase (after ovulation) and end in the follicular phase (menses), were present most of the time and absent in the week post menses. At least one of the symptoms must be 1, 2, 3 or 4.

1. markedly depressed mood; hopelessness; self-deprecating thoughts

2. marked anxiety, tension, feeling ‘keyed up’ or ‘on edge’

3. marked affective lability (feeling suddenly sad or tearful; increased sensitivity to rejection)

4. persistent and marked anger, irritability, or increased interpersonal conflicts

5. decreased interest in usual activities

6. difficulty concentrating

7. lethargy, easy fatigability, or marked lack of energy

8. marked change in appetite, overeating or specific food cravings

9. hypersomnia or insomnia

10. sense of being overwhelmed or out of control

11. physical symptoms such as breast tenderness or swelling, headaches, joint or muscle pain, bloating, weight gain

B. The disturbance markedly interferes with work, school, usual social activities, and relationships with others.

C. The disturbance is not merely an exacerbation of the symptoms of another disorder, such as major depressive disorder, panic disorder, dysthymic disorder, or a personality disorder.

D. Criteria A, B and C must be confirmed by prospective daily ratings during at least two consecutive symptomatic cycles.

Women with premenstrual dysphoric disorder are severely troubled by the mood changes that occur premenstrually, to the point of severe disruption to their ability to perform daily tasks at work or in the home, unlike women with premenstrual syndrome who may report the same symptoms but of a less disabling nature. The mood changes seen in both premenstrual dysphoric disorder (and PMS) must be differentiated from premenstrual magnification of an underlying major psychiatric disorder.

Treatment of Premenstrual Dysphoric Disorder

For women with premenstrual dysphoric disorder (PMDD), anti-depressant drugs are an appropriate consideration in keeping with the severity of their symptoms. The favoured medical treatment is the class of drugs known as selective serotonin reuptake inhibitors or SSRIs.

Trials involving Zoloft, Cipramil and Luvox were positive, indicating that many, if not all, of the SSRIs are likely to be beneficial in the management of premenstrual dysphoric disorder (PMDD). Efexor (venlafaxine), a new-generation anti-depressant that selectively inhibits serotonin and norepinephrine reuptake was also shown to be useful in the management of premenstrual dysphoric disorder (PMDD). Many of these drugs have been successful when used in the luteal phase only, and trials are ongoing to determine whether this is a realistic option for all women with premenstrual dysphoric disorder (PMDD).

Not all women are comfortable with the psychotropic drug option and will want to try herbal medication as a first line of treatment. It is questionable whether herbs will be effective for all cases of premenstrual dysphoric disorder (PMDD), given that symptoms can be very severe, and a decision to use herbs will need to be made on a case-by-case basis. Hypericum perforatum would be the herb of choice, and is frequently prescribed with Withania somnifera, an anxiolytic such as Lavandula officinalis, and a hormone-modulating herb such as Vitex agnus-castus. Unlike the SSRIs, this regime should be taken all month to bring about positive results, and if improvement has not occurred within two cycles, an alternative treatment should be sought.

Although the primary symptoms of premenstrual dysphoric disorder are mood-related, many women also experience other symptoms that may need management with the strategies outlined in the section on premenstrual syndrome — ‘A natural approach’ on site. Lifestyle and dietary changes are also important, as are recommendations that women with premenstrual dysphoric disorder seek appropriate counselling or psychotherapy.

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