Premenstrual dysphoric disorder (PMDD) affects 2%–5% of menstruating people
This condition is characterized by the cyclical appearance of mood, cognitive, and somatic symptoms in the luteal phase (period from ovulation to menstruation), triggered by ovarian hormone fluctuation.1 People with PMDD are at higher risk of suicidal ideation than those without PMDD.2 Symptoms typically remit in pregnancy or menopause in the absence of ovulation but may worsen in perimenopause.3
Prospective symptom tracking is critical for accurate diagnosis
Patients should track symptoms daily for 2 or more menstrual cycles as retrospective measures are unreliable.1 Diagnosis relies on the presence of 5 or more symptoms (e.g., insomnia, lethargy, difficulty concentrating), including at least 1 mood symptom (e.g., depressed mood, anxiety, irritability, lability) during the premenstrual week. These symptoms must cause distress or impairment and resolve in the week after menstruation.1
The condition is underrecognized and often misdiagnosed
Diagnosis is often delayed many years because of misdiagnosis as bipolar disorder4 or premenstrual exacerbation of another mental disorder, such as depression.4,5 Diagnostic uncertainty should lead to consultation with a qualified mental health professional.
First-line PMDD treatments include antidepressants, oral contraceptives, and cognitive behavioural psychotherapy
Serotonergic antidepressants (e.g., sertraline, paroxetine, fluoxetine, clomipramine) have the strongest evidence, with effect onset within 24 hours.1 They can be taken continuously, with symptom onset, or at the start of the luteal phase. Cognitive behavioural therapy is also effective and may be a stand-alone treatment or combined with pharmacotherapy. Drospirenone-containing oral contraceptives are also a first-line treatment and can be considered for patients not desiring pregnancy, although they may be less effective than antidepressants.
Additional treatment options are available for patients with severe, treatment-refractory symptoms
Gonadotropin-releasing hormone agonists (e.g., leuprolide, triptorelin) that suppress ovarian hormones with stable hormone add-back should be considered for severe, refractory PMDD.1 Bilateral oophorectomy should be considered only as a last resort.1
Footnotes
Competing interests: Jennifer Gordon is the unpaid chair of the clinical advisory board for the International Association for Premenstrual Disorders. Erin Brennand reports salaried employment with Alberta Health Services for the role of Calgary Zone Department Head, Obstetrics & Gynecology, as well as research funding from the Canadian Institutes of Health Research and the Social Sciences and Humanities Research Council of Canada. No other competing interests were declared.
This article has been peer reviewed.
References
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