Recognizing and Treating Premenstrual Dysphoric Disorder

Premenstrual symptoms are extremely common among women of reproductive age. As many as 75% of women report minor or isolated premenstrual symptoms, up to 50% of women are estimated to have premenstrual syndrome (PMS), and 3% to 5% of women are considered to have severe PMS or premenstrual dysphoric disorder (PMDD) [1,2]. PMDD has been defined as a psychophysiological disorder in which both somatic and emotional disturbances are present [1]. These disturbances occur during the luteal phase of the ovulatory cycle and tend to persist for 10 to 14 days. Cessation of symptoms typically occurs 1 to 2 days before onset of menstruation, with a subsequent symptom-free period lasting 2 weeks on average. Although the exact cause of PMDD is not understood, it is thought that normal ovarian functioning triggers biochemical phenomena in the brains and the bodies of susceptible women, which in turn precipitate premenstrual symptomatology. Symptoms are prominent and patterned and cause significant distress. Controversy surrounds the diagnosis of PMDD, with health care professionals and others continuing to debate whether PMDD is a real condition. Premenstrual symptoms first appeared in the appendix of the DSM in 1987 as “late luteal-phase dysphoric disorder.” Clinical entities listed in the appendix are said to have insufficient information to warrant inclusion as an official category and require further study. When the DSM-IV was published in 1994, the disorder was renamed PMDD but remained in the appendix; the DSM-IV recommended that patients with the symptoms receive the diagnosis “depressive disorder not otherwise specified.” In 1998, a round table convened by the Society for Women’s Health Research reviewed the literature and concluded that PMDD was a distinct clinical entity, a position supported by the Food and Drug Administration Neuropharmacology Advisory Committee [3]. Some critics, however, hold that the diagnosis is harmful because it is used to label women with real, external problems (eg, battering, mistreatment) as mentally disordered [4]. Controversy has also surrounded the marketing of the first pharmacologic agent approved for the treatment of PMDD, Sarafem, which is fluoxetine with a new name and packaging. Studies suggest that PMS symptomatology exacts an emotional as well as economic toll, accounting for much school absenteeism and sick leave for working women [5,6]. Over 150 symptoms of PMDD have been described; primary care physicians need to be able to parse through such symptoms and make an accurate diagnosis so that appropriate treatment can be initiated.