Premenstrual dysphoric disorder
Encyclopedia
Premenstrual dysphoric disorder (PMDD) is a severe form of premenstrual syndrome, afflicting 3% to 8% of women. It is a diagnosis associated primarily with the luteal phase
of the menstrual cycle
. Up to one-third of women diagnosed with PMDD report residual symptoms into the first 2 or 3 days of the follicular phase
.
PMDD is a severe forms of PMS, premenstrual dysphoric disorder follows a predictable, cyclic pattern. Symptoms begin in the late luteal phase
of the menstrual cycle
(after ovulation) and end shortly after menstruation begins.
Emotional symptoms are generally present, and in PMDD, mood symptoms are dominant. Substantial disruption to personal relationships is typical for women with PMDD. Anxiety, anger, and depression may also occur. The main symptoms, which can be disabling, include
Common physical symptoms include:
Five or more of these symptoms may indicate PMDD.
also known as COMT, which is involved in regulating the function of the prefrontal cortex, a critical regulator of mood.
Previously, research showed that women with PMDD have an abnormal response to normal hormone levels, and, thus, are differentially sensitive to their own natural hormone changes.
There is objective correlational evidence of a neurological connection for PMDD distress. The self-rated cardinal mood symptoms of women suffering premenstrual dysphoria was found to be significantly correlated with the concomitant worsening of their brain serotonin precursors, measured by positron emission tomography
(PET).
While the cause of PMDD has not been definitively established, a leading theory suggests it is due to the lack of serotonin
(a neurotransmitter
) and mediated by the fluctuations of the levels of sex hormones (progesterone
, estrogen
, and testosterone
) in the luteal phase of the menstrual cycle.
Supporting the hypothesized important role of serotonin
, a number of selective serotonin reuptake inhibitor
s (SSRIs) have been shown in clinical trials to effectively treat the mood component of PMDD when taken during the dysphoric phase.
Women with PMDD but have never experienced major depressive disorder (MDD) have lower sensitivity and response to stress and pain than people with MDD. This suggests that PMDD is a separate disease from MDD.
Unipolar depression, anxiety disorder
s, and other Axis I disorders are more common in women with premenstrual dysphoric disorder (PMDD) than in women without PMDD.
in its May 1993 revision of the DSM-IV. It is not recognized as a disorder in the DSM-IV. PMDD was moved from a position the DSM-IV in the appendix of the manual to a "disorder requiring further study."
PMDD is accepted as an illness by the Food and Drug Administration
(FDA) but has not as yet been listed as a separate disorder in the World Health Organization
's International Classification of Diseases
. In 2003, the manufacturer of Prozac (fluoxetine) was required by the Committee for Proprietary Medicinal Products to remove PMDD from the list of indications for fluoxetine sold in Europe. The committee found that
In Australia, although PMDD is recognized by the Therapeutic Goods Administration
, SSRIs are not reimbursed for it under the Pharmaceutical Benefits Scheme
.
Some commentators suggest that PMDD (along with heart disease
, borderline high blood pressure, mild hypercholesterolemia
, social anxiety disorder
, restless leg syndrome, and female sexual dysfunction) has been marketed by pharmaceutical companies in order to increase the demand for treatments. Some psychiatrists and women's groups say that labeling this severe form of PMS as a psychiatric disorder, rather than a physical disorder, is stigmatizing. Psychologist Peggy Kleinplatz
has criticized the diagnosis as part of a trend in medicalization
of normal human behavior.
Lifestyle changes such as regular exercise and a well balanced diet may ameliorate some of the effects of PMDD. There is some evidence that vitamin B6
can alleviate symptoms.
Certain SSRIs provide relief as well. The U.S. Food and Drug Administration (FDA) has approved four medications for the treatment of PMDD: Fluoxetine
(available as generic or as Prozac or Sarafem), sertraline
(Zoloft), paroxetine
(Paxil) and escitalopram oxalate (Lexapro).
L-tryptophan, a serotonin precursor, was found in two studies to provide significant relief when supplemented daily in a large dose.
Luteal phase
The luteal phase is the latter phase of the menstrual cycle or the estrous cycle . It begins with the formation of the corpus luteum and ends in either pregnancy or luteolysis...
of the menstrual cycle
Menstrual cycle
The menstrual cycle is the scientific term for the physiological changes that can occur in fertile women for the purpose of sexual reproduction. This article focuses on the human menstrual cycle....
. Up to one-third of women diagnosed with PMDD report residual symptoms into the first 2 or 3 days of the follicular phase
Follicular phase
The follicular phase is the phase of the estrous cycle, during which follicles in the ovary mature. It ends with ovulation. The main hormone controlling this stage is estradiol....
.
Symptoms
PMDD is a severe form of premenstrual syndrome (PMS).PMDD is a severe forms of PMS, premenstrual dysphoric disorder follows a predictable, cyclic pattern. Symptoms begin in the late luteal phase
Luteal phase
The luteal phase is the latter phase of the menstrual cycle or the estrous cycle . It begins with the formation of the corpus luteum and ends in either pregnancy or luteolysis...
of the menstrual cycle
Menstrual cycle
The menstrual cycle is the scientific term for the physiological changes that can occur in fertile women for the purpose of sexual reproduction. This article focuses on the human menstrual cycle....
(after ovulation) and end shortly after menstruation begins.
Emotional symptoms are generally present, and in PMDD, mood symptoms are dominant. Substantial disruption to personal relationships is typical for women with PMDD. Anxiety, anger, and depression may also occur. The main symptoms, which can be disabling, include
- feelings of deep sadness or despair, and suicide ideation
- feelings of intense tension or anxiety
- increased intense sensitivity to rejection or criticism
- panic attacks
- rapid and severe mood swings, bouts of uncontrollable crying
- lasting irritability or anger, increased interpersonal conflicts; typically sufferers are unaware of the impact they have on those close to them
- apathy or disinterest in daily activities and relationships
- difficulty concentrating
- chronic fatigue
- food cravings or binge eating
- insomnia or hypersomnia; sleeping more than usual, or (in a smaller group of sufferers) being unable to sleep
- feeling overwhelmed or feelings of being out of control
- increase or decrease in sex drive
- increased need for emotional closeness
Common physical symptoms include:
- breast tenderness or swelling, heart palpitations, headaches, joint or muscle pain, swollen face and nose
- an altered view of one's body - a sensation of 'bloating', feeling fat or actual weight gain.
Five or more of these symptoms may indicate PMDD.
Genetic links and possible causes
In 2007, the first significant genetic finding in premenstrual dysphoric disorder was reported. Variants in the estrogen receptor alpha gene that are associated with PMDD. Women with these genetic variants were more likely to suffer from PMDD. They also discovered that this association is seen only in women with a variant form of another gene, Catechol-O-methyl transferaseCatechol-O-methyl transferase
Catechol-O-methyltransferase is one of several enzymes that degrade catecholamines such as dopamine, epinephrine, and norepinephrine. In humans, catechol-O-methyltransferase protein is encoded by the COMT gene...
also known as COMT, which is involved in regulating the function of the prefrontal cortex, a critical regulator of mood.
Previously, research showed that women with PMDD have an abnormal response to normal hormone levels, and, thus, are differentially sensitive to their own natural hormone changes.
There is objective correlational evidence of a neurological connection for PMDD distress. The self-rated cardinal mood symptoms of women suffering premenstrual dysphoria was found to be significantly correlated with the concomitant worsening of their brain serotonin precursors, measured by positron emission tomography
Positron emission tomography
Positron emission tomography is nuclear medicine imaging technique that produces a three-dimensional image or picture of functional processes in the body. The system detects pairs of gamma rays emitted indirectly by a positron-emitting radionuclide , which is introduced into the body on a...
(PET).
While the cause of PMDD has not been definitively established, a leading theory suggests it is due to the lack of serotonin
Serotonin
Serotonin or 5-hydroxytryptamine is a monoamine neurotransmitter. Biochemically derived from tryptophan, serotonin is primarily found in the gastrointestinal tract, platelets, and in the central nervous system of animals including humans...
(a neurotransmitter
Neurotransmitter
Neurotransmitters are endogenous chemicals that transmit signals from a neuron to a target cell across a synapse. Neurotransmitters are packaged into synaptic vesicles clustered beneath the membrane on the presynaptic side of a synapse, and are released into the synaptic cleft, where they bind to...
) and mediated by the fluctuations of the levels of sex hormones (progesterone
Progesterone
Progesterone also known as P4 is a C-21 steroid hormone involved in the female menstrual cycle, pregnancy and embryogenesis of humans and other species...
, estrogen
Estrogen
Estrogens , oestrogens , or œstrogens, are a group of compounds named for their importance in the estrous cycle of humans and other animals. They are the primary female sex hormones. Natural estrogens are steroid hormones, while some synthetic ones are non-steroidal...
, and testosterone
Testosterone
Testosterone is a steroid hormone from the androgen group and is found in mammals, reptiles, birds, and other vertebrates. In mammals, testosterone is primarily secreted in the testes of males and the ovaries of females, although small amounts are also secreted by the adrenal glands...
) in the luteal phase of the menstrual cycle.
Supporting the hypothesized important role of serotonin
Serotonin
Serotonin or 5-hydroxytryptamine is a monoamine neurotransmitter. Biochemically derived from tryptophan, serotonin is primarily found in the gastrointestinal tract, platelets, and in the central nervous system of animals including humans...
, a number of selective serotonin reuptake inhibitor
Selective serotonin reuptake inhibitor
Selective serotonin re-uptake inhibitors or serotonin-specific reuptake inhibitor are a class of compounds typically used as antidepressants in the treatment of depression, anxiety disorders, and some personality disorders. The efficacy of SSRIs is disputed...
s (SSRIs) have been shown in clinical trials to effectively treat the mood component of PMDD when taken during the dysphoric phase.
Women with PMDD but have never experienced major depressive disorder (MDD) have lower sensitivity and response to stress and pain than people with MDD. This suggests that PMDD is a separate disease from MDD.
Unipolar depression, anxiety disorder
Anxiety disorder
Anxiety disorder is a blanket term covering several different forms of abnormal and pathological fear and anxiety. Conditions now considered anxiety disorders only came under the aegis of psychiatry at the end of the 19th century. Gelder, Mayou & Geddes explains that anxiety disorders are...
s, and other Axis I disorders are more common in women with premenstrual dysphoric disorder (PMDD) than in women without PMDD.
Status and controversy
Originally called late luteal phase dysphoric disorder (LLPDD), the disorder was renamed PMDD by the American Psychiatric AssociationAmerican Psychiatric Association
The American Psychiatric Association is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the most influential worldwide. Its some 38,000 members are mainly American but some are international...
in its May 1993 revision of the DSM-IV. It is not recognized as a disorder in the DSM-IV. PMDD was moved from a position the DSM-IV in the appendix of the manual to a "disorder requiring further study."
PMDD is accepted as an illness by the Food and Drug Administration
Food and Drug Administration
The Food and Drug Administration is an agency of the United States Department of Health and Human Services, one of the United States federal executive departments...
(FDA) but has not as yet been listed as a separate disorder in the World Health Organization
World Health Organization
The World Health Organization is a specialized agency of the United Nations that acts as a coordinating authority on international public health. Established on 7 April 1948, with headquarters in Geneva, Switzerland, the agency inherited the mandate and resources of its predecessor, the Health...
's International Classification of Diseases
ICD
The International Statistical Classification of Diseases and Related Health Problems is a medical classification that provides codes to classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or disease...
. In 2003, the manufacturer of Prozac (fluoxetine) was required by the Committee for Proprietary Medicinal Products to remove PMDD from the list of indications for fluoxetine sold in Europe. The committee found that
...PMDD is not a well-established disease entity across Europe... There was considerable concern that women with less severe pre-menstrual symptoms might erroneously receive a diagnosis of PMDD resulting in widespread inappropriate short and long-term use of fluoxetine.
In Australia, although PMDD is recognized by the Therapeutic Goods Administration
Therapeutic Goods Administration
The Therapeutic Goods Administration is the regulatory body for therapeutic goods in Australia . It is a Division of the Australian Department of Health and Ageing established under the Therapeutic Goods Act 1989 ...
, SSRIs are not reimbursed for it under the Pharmaceutical Benefits Scheme
Pharmaceutical Benefits Scheme
The Pharmaceutical Benefits Scheme or PBS is a program of the Australian Government that provides subsidised prescription drugs to residents of Australia. The PBS ensures that all Australians have affordable and reliable access to a wide range of necessary medicines.-History:The PBS was established...
.
Some commentators suggest that PMDD (along with heart disease
Heart disease
Heart disease, cardiac disease or cardiopathy is an umbrella term for a variety of diseases affecting the heart. , it is the leading cause of death in the United States, England, Canada and Wales, accounting for 25.4% of the total deaths in the United States.-Types:-Coronary heart disease:Coronary...
, borderline high blood pressure, mild hypercholesterolemia
Hypercholesterolemia
Hypercholesterolemia is the presence of high levels of cholesterol in the blood. It is not a disease but a metabolic derangement that can be caused by many diseases, notably cardiovascular disease...
, social anxiety disorder
Social anxiety disorder
Social anxiety disorder , also known as social phobia, is an anxiety disorder characterized by intense fear in social situations causing considerable distress and impaired ability to function in at least some parts of daily life...
, restless leg syndrome, and female sexual dysfunction) has been marketed by pharmaceutical companies in order to increase the demand for treatments. Some psychiatrists and women's groups say that labeling this severe form of PMS as a psychiatric disorder, rather than a physical disorder, is stigmatizing. Psychologist Peggy Kleinplatz
Peggy Kleinplatz
Peggy J. Kleinplatz is a Canadian clinical professor, psychologist, and sexologist whose work often concerns optimal sexuality, opposition to the medicalization of human sexuality, and outreach to marginalized groups.- Life and career :...
has criticized the diagnosis as part of a trend in medicalization
Medicalization
Medicalization is the process by which human conditions and problems come to be defined and treated as medical conditions and problems, and thus come under the authority of doctors and other health professionals to study, diagnose, prevent or treat...
of normal human behavior.
Treatment
The primary goal of treatment is to reduce the woman's suffering and the disruption to her social relationships.Lifestyle changes such as regular exercise and a well balanced diet may ameliorate some of the effects of PMDD. There is some evidence that vitamin B6
Vitamin B6
Vitamin B6 is a water-soluble vitamin and is part of the vitamin B complex group. Several forms of the vitamin are known, but pyridoxal phosphate is the active form and is a cofactor in many reactions of amino acid metabolism, including transamination, deamination, and decarboxylation...
can alleviate symptoms.
Certain SSRIs provide relief as well. The U.S. Food and Drug Administration (FDA) has approved four medications for the treatment of PMDD: Fluoxetine
Fluoxetine
Fluoxetine is an antidepressant of the selective serotonin reuptake inhibitor class. It is manufactured and marketed by Eli Lilly and Company...
(available as generic or as Prozac or Sarafem), sertraline
Sertraline
Sertraline hydrochloride is an antidepressant of the selective serotonin reuptake inhibitor class. It was introduced to the market by Pfizer in 1991. Sertraline is primarily used to treat major depression in adult outpatients as well as obsessive–compulsive, panic, and social anxiety disorders in...
(Zoloft), paroxetine
Paroxetine
Paroxetine is an SSRI antidepressant. Marketing of the drug began in 1992 by the pharmaceutical company SmithKline Beecham, now GlaxoSmithKline...
(Paxil) and escitalopram oxalate (Lexapro).
L-tryptophan, a serotonin precursor, was found in two studies to provide significant relief when supplemented daily in a large dose.
See also
- Premenstrual syndrome (PMS) and/or Premenstrual Tension (PMT)