Pre Menstrual Syndrome (PMS) / Pre Menstrual Dysphoric Disorder (PMDD)

June 18, 2019
“Doctor, during those days, she is like a tigress! Why is she like this?” words of a terrified and confused husband!

What is Pre Menstrual Syndrome (PMS) / Pre Menstrual Dysphoric Disorder (PMDD)?

Premenstrual symptoms are a group of mood, behavioral, and physical indications that occur in a cyclic pattern prior to menstruation and then wane off after the menstrual period in women of reproductive age.

Approximately 70% to 90% of women in the reproductive age group complain of at least some premenstrual discomfort. Approximately one-third of these women have symptoms that are bothersome enough to qualify for the diagnosis of PMS. The most severe form of premenstrual symptom complex, PMDD, has been noted in 3% to 8% of these PMS cases.

When to diagnose PMS/PMDD?

At least 5 of the following 11 symptoms (including at least 1 of the first 4) should be present: (At least during 2 consecutive symptomatic menstrual cycles)

  • Markedly depressed mood, feelings of hopelessness, or self-deprecating thoughts
  • Marked anxiety, tension, feelings of being “keyed up” or “on edge”
  • Marked affective lability
  • Persistent and marked anger or irritability or increased interpersonal conflicts
  • Decreased interest in usual activities (eg, work, school, friends, and hobbies)
  • Subjective sense of difficulty in concentrating
  • Lethargy, easy fatigability, or marked lack of energy
  • Marked change in appetite, overeating, or specific food cravings
  • Hypersomnia or insomnia
  • A subjective sense of being overwhelmed or out of control
  • Other physical symptoms, such as breast tenderness or swelling, headaches, joint or muscle pain, a sensation of bloating, or weight gain.

These symptoms can be classified into 3 groups: Mood, Behavioral & Somatic (physical)

Mood:

  • Feeling sad, depressed, hopeless, worthless
  • Marked mood lability like mood swings; suddenly feeling sad or tearful
  • Increased irritability and or anger; frequent conflicts with family members or at work
  • Increased anxiety or the feeling of being on edge all the time

Behavioral:

  • Lack of energy, fatigability
  • Decreased interest in normal activities
  • Problems with concentration
  • Changes in appetite, either overeating or craving for a specific food
  • Changes in sleep pattern, either hypersomnia or insomnia
  • Feeling overwhelmed or out of control

Somatic:

  • Breast swelling or tenderness
  • Joint or muscle ache
  • A sensation of bloating or weight gain
  • Headaches

Do I have a risk for PMS/PMDD?

Strong risk with:

  • Smoking (increased risk with early onset of smoking and number of cigarettes)
  • Obesity (risk increases with an increase in BMI)
  • Genetics (suspected risk)

Why does it happen?

Role of hormones: Recent evidence suggests that reproductive hormone release patterns are normal in women with PMS/PMDD, but they have a heightened sensitivity to cyclical variations in levels of reproductive hormones.

Role of Neurochemicals: Serotonin (main neurotransmitter involved), GABA, Glutamate, and Beta Endorphin are implicated in PMS/PMDD.

Do I have a tool to screen PMS/PMDD?

Premenstrual Symptom Screening Tool (PSST): A questionnaire used to diagnose PMDD with 19 items which allow the patient to rate the severity of their symptoms.

What are the treatment options available to me?

Before going with medicines, let’s do:

Exercise: Increase the Beta-endorphin level thereby improve symptoms of PMS.

Diet: Increased intake of complex carbohydrates or proteins (legumes such as dried peas, beans and lentils, starchy vegetables such as sweet potatoes, corn and sweet peas, fruits especially with the skins and edible seeds are a sure way to reap the fiber benefits of a high complex carb diet. Nuts and seeds combined with dried fruit as high protein diet increase the Tryptophan levels and thereby increase Serotonin levels which will, in turn, improve the PMDD symptoms.

Stress management: Relaxation, Breathing exercises, Meditation, Yoga.

Medicines for PMS/PMDD:

Psychotropics:

Serotonin Reuptake Inhibitors (SRIs) like Clomipramine, Citalopram, Escitalopram, Fluoxetine, Paroxetine, Sertraline, and Venlafaxine. Beneficial effect of SRIs begins rapidly in PMDD whereas antidepressant effect takes several weeks. Thus, these medicines can be used intermittently from mid-cycle to menses to treat symptoms of PMDD as opposed to continuous treatment. Side-effects of SRIs are usually mild. Nausea is the most common adverse effect, but it usually wears off in a couple of days after starting the therapy.

Benzodiazepines like Xanax for symptoms like anxiety & insomnia. Risk of dependence is the main concern.

Hormone therapy: works by ovulation suppression

Hormone treatment: Indicated in severe PMS (medical menopause and resultant hot flushes &  increased risk for osteoporosis are the main concerns)

OCP (Oral Contraceptive Pills): Its efficacy in PMDD is not supported by strong evidence.

What are all the similar conditions that can confuse me?

Depressive disorder, Thyroid dysfunctions, Generalized anxiety disorder (GAD), Mastalgia are the common conditions that can get confused with PMDD.

Who all can help me?

GP, your family physician, Gynaecologist, Psychiatrist. It should be a multidisciplinary approach to get comprehensive care.

Understand, Accept and get Well.

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