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Premenstrual Syndrome and Premenstrual Dysphoric Disorder WENDY S

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Premenstrual Syndrome and Premenstrual Dysphoric Disorder WENDY S Premenstrual Syndrome and Premenstrual Dysphoric Disorder WENDY S. BIGGS, MD, American Academy of Family Physicians, Leawood, Kansas ROBIN H. DEMUTH, MD, Michigan State University College of Human Medicine, East Lansing, Michigan Premenstrual syndrome is defined as recurrent moderate psychological and physical symptoms that occur during the luteal phase of menses and resolve with menstruation. It affects 20 to 32 percent of premenopausal women. Women with premenstrual dysphoric disorder experience affective or somatic symptoms that cause severe dysfunction in social or occupational realms. The disorder affects 3 to 8 percent of premenopausal women. Proposed etiologies include increased sensitivity to normal cycling levels of estrogen and progesterone, increased aldosterone and plasma renin activity, and neurotransmitter abnormalities, particularly serotonin. The Daily Record of Severity of Problems is one tool with which women may self-report the presence and severity of premenstrual symptoms that correlate with the criteria for premenstrual dysphoric disorder in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text revision. Symptom relief is the goal for treatment of premenstrual syndrome and premenstrual dysphoric disorder. There is limited evidence to support the use of calcium, vitamin D, and vitamin B6 supplementation, and insufficient evidence to support cognitive behavior therapy. Serotonergic antidepressants (citalopram, escitalopram, fluoxetine, sertraline, venlafaxine) are first-line pharmacologic therapy.Am ( Fam Physician. 2011;84(8):918-924. Copyright © 2011 American Academy of Family Physicians.) ▲ Patient information: remenstrual syndrome (PMS) is symptoms during the luteal phase of their A handout on premen- clinically diagnosed if certain symp- menstrual cycle without experiencing sub- strual syndrome, written toms that impair some facet of a stantial disruption to their daily func- by the authors of this 5 article, is provided on woman’s life occur only during the tioning. PMS, in which mild to moderate page 929. P luteal phase of the menstrual cycle (one week symptoms affect some facet of the woman’s before menstruation), and if other diagnoses life, occurs in 20 to 32 percent of premeno- that may better explain the symptoms are pausal women; the more severe symptoms excluded.1 Table 1 lists the physical, psycho- of PMDD affect 3 to 8 percent of pre- logical, and behavioral symptoms associated menopausal women.5 However, the preva- with PMS and premenstrual dysphoric disor- lence of PMDD varies substantially among der (PMDD).2,3 With PMDD, more severe and studies, likely because of different study debilitating affective symptoms impact the definitions for PMDD. Initially, PMS and patient’s relationships and social and occu- PMDD appeared to be limited to women in pational realms (Table 2).2 PMS and PMDD Western cultures, but more recent studies symptoms may recur with each ovulatory have demonstrated symptoms suggesting cycle until menopause, although the sever- that PMS and PMDD occur at similar rates ity and frequency of different symptoms may internationally.7-9 vary over time.3,4 Duration of symptoms each month averages six days, with severity usually Etiology peaking anywhere from two days before to The etiologies of PMS and PMDD are not the first day of the menstrual flow.5 PMS and definitive, but several theories are postu- PMDD have been shown to negatively affect lated. Women with PMS or PMDD appear relationships, work attendance, productivity, to be more physiologically sensitive to and and health care costs and utilization.6 express more symptoms with normal cycling levels of estrogen and progesterone.10 In Epidemiology women whose normal cycles were blocked Up to 80 percent of women report one or with administration of a gonadotropin- more physical, psychological, or behavioral releasing hormone (GnRH) agonist and who Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright © 2011 American Academy of Family Physicians. For the private, noncommercial ◆ 918 Americanuse of one Family individual Physician user of the Web site. All other rights reserved.www.aafp.org/afp Contact [email protected] for copyrightVolume questions 84, and/or Number permission 8 October requests. 15, 2011 Premenstrual Syndrome Table 1. Symptoms Associated with Table 2. Research Criteria for Premenstrual Premenstrual Syndrome and Premenstrual Dysphoric Disorder Dysphoric Disorder A. In most menstrual cycles during the past year, five (or more) Physical Psychological and Behavioral of the following symptoms were present for most of the Abdominal bloating Anger, irritability time during the last week of the luteal phase, began to remit within a few days after the onset of the follicular phase, and Body aches Anxiety were absent in the week postmenses, with at least one of the Breast tenderness Changes in appetite (overeating or symptoms being either 1, 2, 3, or 4: and/or fullness food cravings) 1. Markedly depressed mood, feelings of hopelessness, or Cramps, abdominal Changes in libido self-deprecating thoughts pain Decreased concentration 2. Marked anxiety, tension, feelings of being “keyed up” or Fatigue Depressed mood “on edge” Headaches Feeling out of control 3. Marked affective lability (e.g., feeling suddenly sad or Nausea Mood swings tearful or increased sensitivity to rejection) Swelling of Poor sleep or increased need for sleep 4. Persistent and marked anger or irritability or increased extremities Tension interpersonal conflicts Weight gain Withdrawal from usual activities 5. Decreased interest in usual activities (e.g., work, school, friends, hobbies) Information from references 2 and 3. 6. Subjective sense of difficulty in concentrating 7. Lethargy, easy fatigability, or marked lack of energy 8. Marked change in appetite, overeating, or specific food cravings were then given exogenous hormones, those with PMS 9. Hypersomnia or insomnia experienced more symptoms of sadness, anxiety, irrita- 10. A subjective sense of being overwhelmed or out of control bility, bloating, and impaired function than those with- 11. Other physical symptoms, such as breast tenderness or 10 out PMS. Premenstrual symptoms may alter as women swelling, headaches, joint or muscle pain, a sensation of transition toward menopause; however, women who “bloating,” weight gain experienced PMS appear to have greater risk of meno- note: In menstruating females, the luteal phase corresponds to pausal symptoms associated with hormonal fluctuations the period between ovulation and the onset of menses, and the follicular phase begins with menses. In nonmenstruating (study participants were most affected by hot flashes, females (e.g., those who have had a hysterectomy), the timing 11 depressed mood, poor sleep, and decreased libido). of luteal and follicular phases may require measurement of Increases in aldosterone and plasma renin activity are circulating reproductive hormones. the hypothetical mechanisms for PMS- and PMDD- B. The disturbance markedly interferes with work or school or associated fluid retention and bloating symptoms.12 with usual social activities and relationships with others (e.g., avoidance of social activities, decreased productivity and Neurotransmitters, particularly serotonin and g-amino- efficiency at work or school). 6 butyric acid, appear to be involved. Twin concordance C. The disturbance is not merely an exacerbation of the symptoms studies suggest a genetic predisposition.13 of another disorder, such as Major Depressive Disorder, Panic Disorder, Dysthymic Disorder, or a Personality Disorder Diagnosis (although it may be superimposed on any of these disorders). Clinical history is key to the diagnosis of PMS or D. Criteria A, B, and C must be confirmed by prospective daily ratings during at least two consecutive symptomatic cycles. (The PMDD. Other affective disorders such as depression diagnosis may be made provisionally prior to this confirmation.) and anxiety may have premenstrual cyclic worsening, but do not have the symptom-free interval during the Reprinted with permission from American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., text mid-follicular phase (days 6 through 10 of the men- revision. Washington, DC: American Psychiatric Association; 2000:774. strual cycle) needed for the clinical diagnosis of PMS or PMDD. Some medical or gynecologic conditions such as hypothyroidism, anemia, endometriosis, or physi- ologic ovarian cysts may replicate physical symptoms of Problems (Figure 1).14 Symptoms listed correspond to PMS. Physicians could check thyroid function or hemo- commonly used diagnostic criteria, such as the Diagnos- globin levels to rule out hypothyroidism and anemia, tic and Statistical Manual of Mental Disorders, 4th ed., text respectively. revision, for PMDD (Table 2).2 Because symptom chart- The American College of Obstetricians and Gyne- ing for two cycles entails a significant time commitment cologists suggests diagnosing PMS based on prospective for patients and a potential delay in diagnosis, one-time symptom diaries; many women will have non–luteal- or retrospective assessments of symptoms may be helpful. phase symptoms consistent with other medical or psycho- Administering the Daily Record of Severity of Problems logical disorders.1 One tool to chart symptoms associated on the first day of menses is not sufficient for making a with PMS and PMDD is the Daily Record of Severity of diagnosis (positive
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