Premenstrual Dysphoric Disorder

Contents

1. Two classification systems recognized the condition
2. Severity and timing separate it from premenstrual syndrome
3. The symptoms reach both mood and body
4. Hormone levels are normal, the response to them is not
5. Diagnosis depends on charting across cycles
6. Treatment is often found by trial

On January 1, 2022, premenstrual dysphoric disorder entered the international classification of diseases under gynecological conditions, placing a severe cyclical mood disorder among the menstrual disorders Candace Cooley has treated as an obstetrician and gynecologist. The listing came nine years after American psychiatry had recognized the condition, and both decisions were argued over. What they settled is that a predictable, disabling change in mood before menstruation can be a diagnosis in its own right, separate from the milder symptoms most women know.

Two classification systems recognized the condition

A 2022 commentary on PubMed Central records that the condition joined the eleventh revision of the international classification on January 1 of that year, after the American Psychiatric Association added it to the fifth edition of its diagnostic manual in 2013.³ The same authors describe the debate: patients and many psychiatrists pressed for the listing, while some psychologists, generalists and feminist scholars feared that ordinary hormonal change, or justified anger, would be relabeled as illness.³ The Guardian notes the case of a British woman who was given the diagnosis in 2000, well before either listing, by Katharina Dalton, the physician who coined the term premenstrual syndrome.⁸

Figure

How the diagnosis entered the classifications

1. 01
   2003A European medicines regulator declines PMDD as a treatment indication, partly because the diagnosis is absent from the international classification.
2. 02
   2013The American Psychiatric Association adds PMDD to the fifth edition of its diagnostic manual.
3. 03
   2022On January 1, PMDD enters the eleventh revision of the international classification, listed under gynecological diseases.

Severity and timing separate it from premenstrual syndrome

The American College of Obstetricians and Gynecologists explains that nearly every woman has had some premenstrual symptom, typically starting one to two weeks before a period and ending within about four days of it.² The disorder is diagnosed when five or more symptoms, at least one of them about mood, appear in the week before a period and ease in the week after, and when they are serious enough to interfere with work, study and close relationships. ACOG puts it at about 5 in 100 women of reproductive age, most often in their twenties and thirties.² Under the international definition, the symptoms must recur in most cycles over the past year and cause significant distress.³

Figure

Ordinary premenstrual symptoms and PMDD

	Premenstrual syndrome	Premenstrual dysphoric disorder
How common	Nearly every woman has had at least one symptom	About 5 in 100 women of reproductive age
Timing	Starts one to two weeks before a period, ends within about four days of it	The week before a period, easing in the week after
What defines it	Irritability, cramping, bloating or breast tenderness	Five or more symptoms, at least one of them a mood symptom
Effect on life	Annoying	Interferes with work, study and relationships

The symptoms reach both mood and body

The MedlinePlus encyclopedia entry lists loss of interest in daily life and relationships, fatigue, sadness or hopelessness, anxiety, a sense of being out of control, food cravings, mood swings with crying, panic attacks, and irritability or anger that spills onto other people, along with bloating, breast tenderness, headaches, joint and muscle pain, poor sleep and trouble concentrating.¹ Some women have suicidal thoughts, and MedlinePlus notes that suicide in women with depression is more likely in the second half of the cycle.¹ A 2014 National Institute of Mental Health notice describes the condition as a serious one with disabling symptoms, affecting roughly 2 to 5 percent of women of reproductive age.⁵

Hormone levels are normal, the response to them is not

The most cited biological finding is that women with the disorder do not have abnormal hormone levels. A 2017 National Institute of Mental Health release recounts that by the late 1990s its researchers had shown these women to be unusually sensitive to normal swings in estrogen and progesterone, and that switching those hormones off experimentally removed symptoms while adding them back brought the symptoms back.⁶ The 2017 study then found a gene complex, one that controls how cells respond to sex hormones and stress, behaving differently in cells taken from women with the disorder.⁶

A 2015 review by Liisa Hantsoo and C. Neill Epperson points to neurosteroids, hormone derived compounds that act on the brain’s calming signals, as a likely contributor, and describes the condition as distinct from other mood disorders in both its symptoms and its cyclical pattern.⁴ BBC News summarizes the current view as a severe reaction to the natural rise of progesterone and the fluctuation of estrogen in the days before menstruation.⁹

Diagnosis depends on charting across cycles

No physical examination or laboratory test can confirm the disorder. MedlinePlus describes a full history, a physical and pelvic examination, thyroid testing and a psychiatric evaluation to rule out other causes, with a calendar or diary of symptoms to show when they occur.¹

Figure

What the workup for PMDD includes

1. 01
   HistoryA complete medical history, including when symptoms start and stop.
2. 02
   ExaminationA physical examination that includes a pelvic examination.
3. 03
   Thyroid testingThyroid testing, one of the checks for other conditions.
4. 04
   Psychiatric evaluationAn assessment for other mood and anxiety conditions.
5. 05
   Symptom diaryA calendar of symptoms, their severity and how long they last, kept across cycles.

The 2022 commentary recommends that the diary be kept prospectively, since the line between the disorder and depression can blur.³ ACOG adds that symptoms present all month, not only before a period, call for screening for other mental health conditions.²

Missed and mistaken diagnoses are common in published accounts. The Guardian reports that up to one in 20 women of reproductive age may be affected while only a small fraction hold a formal diagnosis, and describes women first assessed for bipolar disorder before the timing of their symptoms pointed elsewhere.⁸ A family doctor quoted by the BBC described consultations of 10 or 15 minutes as too short to draw out a cyclical history.⁹

Treatment is often found by trial

MedlinePlus describes a healthy lifestyle and regular aerobic exercise as the base, with selective serotonin reuptake inhibitors, a class of antidepressant, as the usual medical option and cognitive behavioral therapy alongside or instead.¹ Hormonal treatments that steady or suppress the cycle are also used, and ACOG notes that a gynecologist may treat the condition directly or refer to a psychiatrist.² The Washington Post reports that even with approved treatments, patients often spend months or years finding a regimen that works.⁷ Which of these fits any one woman is a question for her own clinician.

The disorder belongs to a group of conditions in which the calendar is part of the evidence. A symptom diary that separates the week before a period from the rest of the month is what distinguishes it from depression, and the same habit of reading symptoms against the cycle is useful elsewhere in gynecology, including in polycystic ovary syndrome and endometriosis. The next entry, on adenomyosis, takes up another condition that is often first suspected from the pattern of the periods themselves.