Premenstrual Dysphoric Disorder

Premenstrual dysphoric disorder (PMDD)a is identified by a variety of physical and emotional symptoms that occur during the last week of the luteal phase of the menstrual cycle and that remit within a few days after the onset of the follicular phase. In most women, these symptoms occur in the week before, and remit within a few days after, the onset of menses. The disorder has also been reported in nonmenstruating women who have had a hysterectomy but who retain ovarian function. The diagnosis is given only when the symptoms are sufficiently severe to cause marked impairment in social or occupational functioning and have occurred during a majority of menstrual cycles in the past year (APA, 2000).

What is premenstrual dysphoric disorder (PMDD)?

PMDD is a severe form of a common problem called premenstrual syndrome, or PMS. About 75 percent of women of childbearing age have some PMS problems. About 2 to 10 percent of women in this age group have PMDD.

Predisposing Factors

1. Physiological

a. Biochemical. An imbalance of the hormones estrogen and progesterone has been implicated in the predisposition to PMDD. It is postulated that excess estrogen or a high estrogen-to-progesterone ratio during the luteal phase causes water retention and that this hormonal imbalance has other effects as well, resulting in the symptoms associated with premenstrual syndrome (Kaplan & Sadock, 1998).

b. Nutritional. A number of nutritional alterations have been implicated in the cause of PMDD. They include deficiencies in the B vitamins, calcium, magnesium, manganese, vitamin E, and linolenic acid (Frackiewicz & Shiovitz, 2001). Glucose tolerance fluctuations, abnormal fatty acid metabolism, and sensitivity to caffeine and alcohol may also play a role in bringing about the symptoms associated with this disorder.

Symptomatology (Subjective and Objective Data)

The American Psychiatric Association (2000) has identified the following symptoms as diagnostic for PMDD:

1. Markedly depressed mood, feelings of hopelessness, or self-deprecating thoughts

2. Marked anxiety, tension, feelings of being “keyed up” or “on edge”

3. Marked affective lability (e.g., feeling suddenly sad or tearful or increased sensitivity to rejection)

4. Persistent and marked anger or irritability or increased interpersonal conflicts

5. Decreased interest in usual activities (e.g., work, school, friends, hobbies)

6. Subjective sense of difficulty in concentrating

7. Lethargy, easy fatigability, or marked lack of energy

8. Marked change in appetite, overeating, or specific food cravings

9. Hypersomnia or insomnia

10. A subjective sense of being overwhelmed or out of control

11. Other physical symptoms, such as breast tenderness or swelling, headaches, joint or muscle pain, a sensation of “bloating,” weight gain

Other subjective symptoms that have been reported include (Doenges, Townsend & Moorhouse, 1998):

12. Cramps

13. Alcohol intolerance

14. Acne

15. Cystitis

16. Oliguria

17. Altered sexual drive

18. Forgetfulness

19. Suicidal ideations or attempts

How do I know if I have PMDD?

The symptoms of PMDD are:

  • Sadness and crying
  • Feeling nervous, anxious, and irritable
  • Strong cravings for certain foods
  • Problems paying attention and concentrating
  • Physical problems such as breast tenderness, headaches, joint or muscle pain and swelling or bloating
  • Trouble sleeping

These symptoms can affect your relationships and work ability. If you have some of these symptoms 10 to 14 days before your period and they improve when your period starts, you might have PMDD. Your family doctor can help you find out for sure.

What causes PMDD?

The exact cause of PMDD is not known. Changes in hormones related to your period may cause PMDD. Stressful life events and a family history of PMS or PMDD may increase your chances of getting PMDD.

How does my doctor find out if I have PMDD?

Your doctor will check your symptoms and the way they relate to your menstrual cycle. You might fill out a symptom chart (like the one below) for several weeks. There is no test that can diagnose PMDD.

How is PMDD treated?

Your doctor will ask you about how bad your symptoms are and will tell you about different treatments. For mild to moderate symptoms, your doctor may suggest changes in your diet and lifestyle. You might talk to a counselor about your PMDD symptoms and life stresses. Medicines may help with severe symptoms.

What medicines are helpful?

Certain medicines used to treat depression also treat PMDD. Selective serotonin reuptake inhibitors help by increasing the effect of a brain chemical called serotonin.

Does that mean I have depression?

No. These medicines work for both conditions.

How often do I have to take these medicines?

Some of these medicines you take for 10 to 14 days before each period.

What if these medicines do not work?

Your doctor knows about other treatments. After talking with you, your doctor might have you try something else.


Diagnosis and Treatment of Premenstrual Dysphoric Disorder by Subhash C. Bhatia, M.D., and Shashi K. Bhatia, M.D. (American Family Physician October 1, 2002)

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