Easing the burden of premenstrual dysphoric disorder

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Applied Evidence

Easing the burden of premenstrual dysphoric disorder

J Fam Pract. 2013 January;62(1):E1-E7

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References

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7. Freeman EW, Sondheimer SJ. Premenstrual dysphoric disorder: recognition and treatment. Prim Care Companion J Clin Psychiatry. 2003;5:30-39.

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9. Pearlstein TB, Bellew KM, Endicott J, et al. Paroxetine controlled release for premenstrual dysphoric disorder: remission analysis following a randomized, double-blind, placebo-controlled trial. Prim Care Companion J Clin Psychiatry. 2005;7:53-60.

10. Halbreich U, Petty F, Yonkers K, et al. Low plasma gamma-aminobutyric acid levels during the late luteal phase of women with premenstrual dysphoric disorder. Am J Psychiatry. 1996;153:718-720.

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12. Kaura V, Ingram CD, Gartside SE, et al. The progesterone metabolite allopregnanolone potentiates GABA(A) receptor-mediated inhibition of 5-HT neuronal activity. Eur Neuropsychopharmacol. 2007;17:108-115.

13. Girdler SS, Straneva PA, Light KC, et al. Allopregnanolone levels and reactivity to mental stress in premenstrual dysphoric disorder. Biol Psychiatry. 2001;49:788-797.

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17. Tschudin S, Bertea PC, Zemp E. Prevalence and predictors of premenstrual syndrome and premenstrual dysphoric disorder in a population-based sample. Arch Womens Ment Health. 2010;13:485-494.

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19. Girdler SS, Sherwood A, Hinderliter AL, et al. Biological correlates of abuse in women with premenstrual dysphoric disorder and healthy controls. Psychosom Med. 2003;65:849-856.

20. Miyaoka Y, Akimoto Y, Ueda K, et al. Fulfillment of the premenstrual dysphoric disorder criteria confirmed using a self-rating questionnaire among Japanese women with depressive disorders. Biopsychosoc Med. 2011;5:5.-

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Allopregnanolone, a metabolite of progesterone, produces anxiolytic, antiseizure, anesthetic, sedative, and hypnotic activity by enhancing GABA type A receptor-meditated inhibitory responses.^11,12 Lower levels of allopregnanolone during periods of altered central nervous system excitability, such as stress or ovulation, reduce the inhibitory effect of GABA and lead to irritability, insomnia, tension, and depression. Clinical studies have shown a positive correlation between the severity of PMDD and lower levels of allopregnanolone during the luteal phase.¹³

Hypothalamic-pituitary-adrenal (HPA) axis. PMDD is associated with the dysregulation of the HPA axis, as demonstrated by a comparative study that found a blunted response to adrenocorticotropic hormone and cortisol in the luteal phase after treadmill exercise stress testing in women with PMDD compared with non-PMDD women.¹⁴ The study provides strong evidence for dysregulation of the HPA axis in response to stress in women with PMDD.^14,15

Psychological factors. Although insufficient data are available to explain the role and impact of psychological stress in the pathogenesis of PMDD, several studies show that stress exacerbates PMDD.^16-18 Girdler and colleagues demonstrated that stressful life events such as sexual and physical abuse may be important determinants of PMDD with their finding that women with PMDD who had a history of abuse scored higher than controls on the Beck Depression Inventory and State-Trait Anxiety Inventory during the luteal phase.¹⁹

Do the symptoms interfere with relationships and work?

PMDD is diagnosed using the DSM-IV-TR criteria described previously.³ The symptoms must be severe enough to cause psychosocial impairment that interferes with relationships and social functioning at work, school, or other activities, and they should not be merely an exacerbation of another disorder.³

No objective diagnostic tests are available. Diagnosis depends on a thorough history and physical examination and exclusion of other conditions, including thyroid disorders, migraines, chronic fatigue syndrome, irritable bowel syndrome, seizures, anemia, endometriosis, perimenopause, and drug and alcohol abuse.² Laboratory tests should be ordered as clinically indicated and may include chemistry studies to assess electrolyte disturbances, a complete blood count to rule out anemia, and measurement of thyroid-stimulating hormone to rule out thyroid disease.

PMDD may coexist with psychiatric illness, particularly depression and anxiety disorders, and also dysthymia, panic disorders, bipolar disorders, and personality disorders.^4,20 The lifetime incidence of psychiatric conditions in women diagnosed with PMDD is 50% to 75%.²¹ Take care to differentiate PMDD from premenstrual exacerbations of chronic psychiatric illness.²⁰

FAST TRACK

It’s important to differentiate premenstrual dysphoric disorder from premenstrual exacerbations of chronic psychiatric illness.

Patients must prospectively record daily symptoms for at least 2 menstrual cycles to provide information about the severity and timing of symptoms.³ Standardized daily symptom calendars, such as the Calendar of Premenstrual Experiences and the Prospective Record of the Impact and Severity of Menstruation, are available to help differentiate luteal from nonluteal phase symptoms.^22,23 The Premenstrual Symptoms Screening Tool, or PSST, a simpler, more user-friendly tool developed by researchers at McMaster University in Canada, has been validated against prospective daily charting in some countries (TABLE 2).²⁴

TABLE 2
Premenstrual Symptoms Screening Tool

Please mark an “X” in the appropriate box.
Do you experience some or any of the following premenstrual symptoms which start before your period and stop within a few days of bleeding?
Symptom		Not at all	Mild	Moderate	Severe
1.	Anger/irritability
2.	Anxiety/tension
3.	Tearful/increased sensitivity to rejection
4.	Depressed mood/hopelessness
5.	Decreased interest in work activities
6.	Decreased interest in home activities
7.	Decreased interest in social activities
8.	Difficulty concentrating
9.	Fatigue/lack of energy
10.	Overeating/food cravings
11.	Insomnia
12.	Hypersomnia (needing more sleep)
13.	Feeling overwhelmed or out of control
14.	Physical sypmptoms: breast tenderness, headaches, joint/muscle pain, bloating, weight gain
Have your symptoms, as listed above, interfered with:
		Not at all	Mild	Moderate	Severe
A.	Your work efficiency or productivity
B.	Your relationships with co-workers
C.	Your relationships with your family
D.	Your social life activities
E.	Your home responsibilities
Scoring: The following criteria must be present for a diagnosis of premenstrual dysphoric disorder: At least 1 of items 1-4 must be severe At least 4 of items 1-14 must be moderate to severe At least 1 of items A-E must be severe. Reproduced with permission from Springer Science+Business Media. Steiner M, Macdougall M, Brown E. The premenstrual symptoms screening tool (PSST) for clinicians. Arch Womens Ment Health. 2003;6:203-209, Appendix 1.

What are the treatment options?

FAST TRACK

Ask patients to record daily symptoms for at least 2 menstrual cycles to provide information about the severity and timing of symptoms.

Therapy for PMDD is highly individualized and should target well-defined symptoms.^11,25 Treatment should begin with conservative management.^2,26 Conservative measures, such as diet and lifestyle modification, are considered first-line treatment, although supporting evidence is scarce.¹¹ Carbohydrate-rich foods such as brown rice and pasta and protein-poor diets have been found to alleviate symptoms, as has exercise.²⁶

Consider antidepressants and hormonal therapy