Over the last decade, premenstrual syndrome (PMS) has received much attention from the media, lawyers, social activists, patients, and physicians, resulting in women seeking PMS-related health care in unprecedented numbers. Past research has been hampered by serious methodological problems, including retrospective rating of premenstrual symptoms; no agreed upon definition of the syndrome; mainly open, uncontrolled studies as opposed to double-blind placebo-controlled trials; and unsophisticated methods of patient selection.
DSM III-R (Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised) and, more recently, DSM IV have tried to address these methodological research issues by defining Premenstrual Dysphoric Disorder (PMDD). A diagnosis of PMDD is made when at least five of the following symptoms occur in the last week of the luteal phase (7 to 10 days before menstruation) and remit within a few days of the onset of menses (bleeding):
- Affective lability (shifting moods)
- Marked anger
- Irritability
- Tension
- Decreased interest in usual activities
- Fatigue
- Change in appetite
- Sleep problems
- Physical problems, such as bloating
For the condition to be diagnosed as PMDD, these symptoms must interfere with work, social activities and relationships and must be prospectively confirmed by daily rating of symptoms by the patient during at least two symptomatic menstrual cycles. A diagnosis of PMDD further requires that the disturbance is not merely an exacerbation of another psychiatric disorder such as major depression, dysthymia (a condition caused by a dysfunction of the thymus gland) or panic. Finally, underlying medical or gynecological conditions (such endometriosis, fibroids, menopause and endocrine abnormalities) which could account for symptoms must be ruled out.
Premenstrual dysphoric disorder occurs in approximately 5 percent of menstruating women and, to date, substantial evidence has accumulated linking the phenomenology of premenstrual syndrome and depression. Clinical evaluation should include a comprehensive review of the patient's symptoms and medical history, a physical, a gynecologic exam and basic laboratory tests (such as a complete blood count, electrolytes, liver and kidney profile and thyroid function tests). Psychiatric evaluation should focus on symptoms of depression, seasonal variation of depression, alcohol and drug use, early victimization and trauma, family history of affective disorder (a group of disorders characterized by a disturbance of mood, accompanied by a manic and depressive syndrome), alcoholism and current situational stresses.
Treatment
Many women gain relief from the symptoms of PMDD with education, validation of symptoms, and lifestyle changes, including exercise, vitamins, and a caffeine-free diet.
- Medications to treat PMDD can be divided into six categories:
- Ovulation suppressing hormones
- Progesterone
- Nutritional supplements
- Diuretics
- Psychopharmacologic agents (drugs affecting emotional states and physical activities associated with mental processes)--The principal psychopharmacologic agents which have been shown to be effective in controlled studies are alprazolam (Xanax), buspirone (BuSpar) and fluoxetine (Prozac).
- Melatonin suppressors
As always, we must be attentive to the need for individual and group psychotherapy, stress management, or marital therapy in patients with significant psychosocial stresses and conflicts.
References
- Bancroft J: The premenstrual syndrome: a reappraisal of the concept and the evidence. Psychological Medicine, Monograph Suppl. 24, 1993, Cambridge, University Press.
- Gitlin MJ, Pasnau RO: Psychiatric syndromes linked to reproductive functioning women: a review of current knowledge. Am J Psychiatry 146 (11):1413-1422, Nov. 1989.
- Gonsalves L, Domb J, Gidwani G: Depression, chronic fatigue, and premenstrual syndrome. Primary Care, WB Saunders Co., 18(2), June, 1991.
- Harrison WM, Endicott J, Nee J, Glick H, Rabkin JG: Characteristics of women seeking treatment for premenstrual syndrome. Psychosomatics, Vol. 30, Fall 1989, 405-411.
- Rausch JL, Perry BL: Treatment of premenstrual mood symptoms. Psychiatric Clinics of North America, Vol. 16(4), December 1993.
- Roy-Byrne PP, Hoban MC, Rubinow DR: The relationship of menstrually related mood disorders to psychiatric disorders. Clinical Obstetrics and Gynecology, Vol. 30(2), June 1987, 386-395.
- Rubinow DR, Roy-Byrne P: Premenstrual syndromes: overview from a methodologic perspective. Am J Psychiatry 141(2), February 1984, 163-172.
- Steiner M, et al: Fluoxetine in the treatment of premenstrual dysphoria. NEJM 1995; 332:1529-1534.
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