The Menstrual Cycle and Mood: Premenstrual Dysphoric Disorder

The term premenstrual dysphoric disorder (PMDD) specifically defines a condition in which premenstrual psychiatric symptoms must involve impairment in function.1 The condition is estimated to affect 3% to 5% of women.2 Symptoms occur at regular intervals and are primarily confined to the luteal phase of the menstrual cycle. Ideally, the diagnosis is made with prospective mood tracking to ascertain clearly whether symptoms are cycle-related. PMDD is a relatively new term; older literature commonly defines a similar clinical condition as the mood symptoms associated with severe premenstrual syndrome (PMS).

Making a PMDD Diagnosis

Diagnostic criteria for PMDD include:1

• Occurrence of symptoms during most menstrual cycles for at least 1 week during the late luteal phase with remittance within days after menses begin.

• One or more of the following symptoms: depressed mood with feelings of hopelessness or self-critical thoughts; anxiety or tension; mood lability; anger or irritability.

• Five or more of the following symptoms: diminished interest in usual activities; difficulty concentrating; low energy; changes in appetite (including food cravings); changes in sleep; feeling overwhelmed; premenstrual physical symptoms (e.g., weight changes, water retention, breast or muscle pain, or cramps); interference with functioning or substantial distress.

Symptoms must interfere with normal daily function or cause substantial distress. The most consistently reported symptoms are anxiety, irritability, and labile mood (“mood swings”).3

The relation between menstrual cycle phase and occurrence of symptoms suggests that hormonal fluctuations have substantial effects on mood. Investigators have proposed that women with PMDD have particular vulnerability to respond pathologically to normal hormonal changes that occur throughout the menstrual cycle.3 Thus, normal ovarian function seems to trigger symptoms in some at-risk individuals.

Most ovulatory women experience some menstrual-cycle–associated symptoms. As many as 50% experience moderate-to-severe symptoms, and as many as 5% meet criteria for PMDD.2 Risk factors for PMDD include psychosocial stress and personal or family histories of psychiatric disorders.4

Treatments for PMDD

Selective serotonin reuptake inhibitors (SSRIs) and other antidepressants: SSRIs and venlafaxine are efficacious for treatment of women with PMDD5^,6. The condition often can be managed with lower doses than those typically used for major depression. Antidepressants can be prescribed in either continuous (i.e., daily) or intermittent (i.e., luteal-phase) dosing.7 Withdrawal symptoms are most likely with venlafaxine and paroxetine; thus, these two agents are better suited to continuous than intermittent dosing.

Hormonal therapies: Studies of combination estrogen-progestin oral contraceptives for treatment of women with PMDD have yielded inconsistent results. Most recently, combined oral contraceptives that contain drospirenone and estrogen have been studied specifically for PMDD, with some, but not all, placebo-controlled trials showing that this approach diminished PMDD symptoms.8 We do not know whether drospirenone-containing pills are more efficacious than other types of oral contraceptives. In general, women who are at risk for adverse events related to oral contraceptive use (e.g., smokers older than 35) are not good candidates for this intervention. For more information about medical eligibility for use of hormonal contraception, see the 2010 CDC guidelines. Other hormonal treatments that suppress ovulation (patch, vaginal ring, implant, or depot medroxyprogesterone acetate) have not yet been adequately studied within controlled trials in the context of PMDD.

Other treatments: Benzodiazepines are not substantially beneficial for treating women with PMDD.9 In a randomized controlled trial, calcium supplementation (1200 mg daily) ameliorated premenstrual symptoms (including mood-related symptoms).10 In one small study, ω-3 fatty acids (fish oil containing 1080-mg eicosapentaenoic acid and 720-mg docosapentaenoic acid daily) were significantly more efficacious than placebo in improving premenstrual symptoms in adolescent women.11 Regular exercise might help diminish premenstrual mood symptoms.12 Further study of these adjunctive treatment options is necessary to determine their efficacy definitively.

Conclusions

Prospective mood charting or journal recording can help establish the diagnosis of PMDD and can help women in determining relations between their menstrual cycles and mood symptoms. First-line treatment strategies include antidepressants (particularly SSRIs) and oral contraceptives. Some women with PMDD might also benefit from calcium or ω-3 fatty acid supplementation as well as regular exercise.