PMDD

Bruce Tjaden, DO

Reproductive Endocrinology and Infertility

UKSM- Wichita

Excellent resources:

Yonkers: Premenstrual disorders. Am J Obstet Gynecol 2018

Scalea: Premenstrual Dysphoric DisorderPsychiatr Clin N Am 40 (2017) 201–216

ACOG: Guidelines for Women’s HealthCare A Resource Manual 4th Edition 2014

PMDD

Premenstrual psychological and somatic symptoms lie on a continuum of severity. It is estimated that about 85% of women experience at least one mild premenstrual symptom; 20% to 25% experience moderate to severe premenstrual symptoms (premenstrual syndrome or PMS), and about 5% meet diagnostic criteria for premenstrual dysphoric disorder (PMDD), the severest form of PMS.

PMDDPremenstrual molimina

Premenstrual syndrome (PMS)

Premenstrual dysphoria disorder (PMDD)

PMDD

• Premenstrual symptom severity varies from normative, mild premenstrual molimina, to severe and disabling symptoms.

• American Psychiatric Association published criteria for a severe clinical syndrome, premenstrual dysphoric disorder (PMDD), in its Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (2013)

• DSM-5 edition, PMDD was included for the first time in the main text, categorized as a depressive disorder.

PMDD

PMS and PMDD criteria share features such as symptom expression during the luteal phase of the cycle with a symptom-free period, as well as functional impairment in association with the condition

PMDD

• The criteria for PMS do not stipulate a minimum number of symptoms nor any particular symptom.

• The criteria for PMDD are more stringent than those for PMS and reflect the most severe end of the spectrum for premenstrual disorders.

PMDD

PMDD

PMDD

Many different emotional and physical symptoms are reported by women in the premenstrual period although the frequency of a handful of symptoms stands out.

• bloating, mood swings, lethargy, irritability, breast tenderness, anxiety/tension, and fear of being rejected*

• Symptoms were the most severe the day before and first day of menses.

* Arch Gen Psychiatry 2012;69:300-5.

PMDD

• Point prevalence of PMS in menstruating women was between 20-30%

• While rates of PMDD ranged from 1.2%- 6.4%

• Retrospective data show that both PMS and PMDD are present in women across the globe

PMDD: Risk factors

• Prevalence does not differ among various premenopausal age groups.

• PMS / PMDD is more prevalent in white than African American women, similar to other psychiatric diseases that may be influenced by cultural differences.

PMDD: Risk factors

• Dietary factors have shown to moderate the risk of PMS, although this may reflect the confounding influence of positive health habits in general.

• High intake of thiamine, riboflavin, non-hemeiron, and possibly zinc protect against PMS

• High potassium intake may increase the risk of PMS.

PMDD: Risk factors

• Adiposity and metabolic syndrome increase risk of PMS, particularly if women are >27.5 kg/m2

• Nicotine cigarettes

• Sexual abuse and trauma

PMDD: Risk factors

• If women has PMS there is a 70% chance her daughter will have PMS

• If a women doesn’t have PMS there is a 37% chance her daughter will have PMS

• Concordance rates that are higher among monozygotic than dizygotic twins

• There is a 93 percent concordance rate in monozygotic twins, compared with a rate of 44 percent in dizygotic twins.

PMDD: Etiology

PMDD: Etiology

• There is no question that PMS (PMDD) is related to menstrual cyclicity, thus the name.

• The question is “What is the link?”

PMDD: Etiology DIFFERENTIAL BEHAVIORAL EFFECTS OF GONADAL STEROIDS IN WOMEN WITH AND IN THOSE WITHOUT PREMENSTRUAL SYNDROMEThe New England Journal of Medicine Volume 338 Number 4 January 22, 1998

PMDD: Etiology

DIFFERENTIAL BEHAVIORAL EFFECTS OF GONADAL STEROIDS IN WOMEN WITH AND IN THOSE WITHOUT PREMENSTRUAL SYNDROMEThe New England Journal of Medicine Volume 338 Number 4 January 22, 1998

“The most striking finding in this study is that although women with premenstrual syndrome had few symptoms during ovarian suppression and recurrence of symptoms during ovarian steroid hormone replacement, the normal women had no perturbation of mood during either manipulation. These observations, in conjunction with the normal pituitary– gonadal function in these women, suggest that normal plasma concentrations of gonadal steroids can trigger an abnormal response — deterioration in mood state — in susceptible women”

Multiple other studies have reported that serum concentrations of gonadal hormones do not differ between women with PMDD and women without PMDD.

PMDD: Etiology

• Recent studies suggest that abnormalities or disturbances in neuro transmitters may play a key role in PMD

• Allopregnanolone

• Serotonin

PMDD: Etiology

• Recent growing interest focuses on the neurosteroid allopregnanolone (3a, 5a-tetrahydroprogesterone)

• Gamma-aminobutyric acid (GABA) system, one of the main inhibitory systems in the central nervous system.

• Allopregnanolone is a metabolite of progesterone implicated in mood disorders in both men and women.).

• Allopregnanolone is a strong positive modulator of GABA-A receptor,

• It is currently proposed that women with PMDD have reduced sensitivity at the GABA-A receptor complex, at the allopregnanolone, as well as at the benzodiazepine site.

PMDD: Etiology

• Numerous studies demonstrating the efficacy of serotonergic antidepressants support the role of serotonin in PMDD.

• The rapid onset of action of selective serotonin reuptake inhibitor (SSRIs) suggests a mechanism of action different than serotonin reuptake inhibition.

• It has been shown that SSRIs increase the level of central allopregnanolone in both rats and humans

PMDD: Etiology

In an important recent randomized controlled trial (RCT), when the conversion of progesterone to allopregnanolone was blocked by dutasteride(a 5a-reductase inhibitor), PMDD symptoms were significantly decreased, and there was no effect of dutasteride on the healthy controls.

PMDD: Diagnosis

• This requires a careful medical, gynecological, and psychiatric history that would include information on diet and exercise.

• Laboratory tests,• Gonadal steroid levels, generally are not useful unless one suspects

premature ovarian failure

• Thyroid indices can be obtained, clinically suspected

• Rule out underlying mood and anxiety disorders

• Symptom diary for TWO MONTHS– Daily Record of Severity of Problems

– Calendar of Premenstrual Experiences

PMDD: Management

ACOG: Guidelines for Women’s HealthCare A Resource Manual 4th Edition 2014

PMDD: Management

Psychiatr Clin N Am 40 (2017) 201–216

Premenstrual dysphoric disorder is a severe form of premenstrual syndrome.

A True

B False

PMDD is caused by...

A Stress

B Genetics

C Changes in barometric pressure

D The cause of PMDD is unknown

Blood test can determine if a woman suffers from PMDD.

A True

B False

Women can help their doctors achieve an accurate diagnosis of PMDD by...

A Being observed during a depressive episode

B Participating in a sleep study

C Tracking PMDD symptoms using a symptom chart

D None of the above

PMDD is not serious and medical attention is not necessary.

A True

B False

PMDD is not serious and medical attention is not necessary.

A True

B False

Which is more common?

A PMS

B PMDD

Which of the following is a treatment for PMDD?

A Antidepressants

B Cholesterol-lowering medications (statins) C Blood pressure medications

D All of the above

Which of the following is a treatment for PMDD?

A Antidepressants

B Oral contraceptive pills

C Dietary manipulation

D Cognitive Behavioral Therapy

E All of the above

With age, symptoms of PMDD decrease in intensity.

A True

B False

Many natural treatments and dietary supplements can ease the symptoms of PMDD.

A True

B False

Many natural treatments and dietary supplements can ease the symptoms of PMDD.

A True

B False

Some