Premenstrual Dysphoric Disorder

Premenstrual dysphoric disorder is a severe form of premenstrual syndrome. Mood symptoms (marked irritability, anger, depressed mood, anxiety and mood swings) are severe enough to disrupt work, school and relationships. They appear in the week before menses and settle within a few days of its start.

It is diagnosed when at least 5 of 11 symptoms are present, with at least one a mood symptom, in most cycles of the past year, confirmed by a daily diary.

It affects a minority of women, and matters because it carries a risk of suicidal thoughts, and responds to serotonergic drugs.

• Risk factors: past depression, anxiety, trauma, family history, stress, smoking, obesity.
• Symptoms are cyclical and absent in the week after the period.
• Suicidal thoughts are more frequent in women with this disorder.

Women have severe mood swings, tearfulness, irritability, anger, hopelessness, anxiety, difficulty concentrating, fatigue, appetite change, poor sleep, feeling overwhelmed, and physical symptoms (breast tenderness, bloating, joint pain) before menses, with relief within a few days of its start.

• Marked functional impairment in the luteal phase.
• Complete or near complete remission in the week after menses.
• Differential diagnosis: premenstrual syndrome, major depression with premenstrual worsening, bipolar disorder, generalised anxiety disorder, borderline personality disorder, perimenopause, thyroid disease, substance misuse, medication effect, anaemia.
• Complications: suicidal thoughts and attempts, relationship breakdown, job loss, substance misuse, depression, reduced quality of life.

The diagnosis needs a daily symptom record for 2 cycles and exclusion of other disorders.

• Prospective daily record of symptoms (for example a standard daily rating form) for at least 2 consecutive cycles showing the luteal pattern.
• Mental state examination with screening for depression (PHQ-9), anxiety (GAD-7), bipolar disorder and suicide risk.
• Thyroid stimulating hormone, full blood count, urine hCG; follicle stimulating hormone if age is above 40 years.
• Review of drugs, alcohol and contraceptive use.

The principle is first line serotonergic drug treatment with psychological therapy, and ovarian suppression for resistant disease.

• Supportive: cognitive behavioural therapy for 6 to 12 sessions; regular aerobic exercise; sleep hygiene; reduced caffeine and alcohol; symptom diary; education for partner and family; safety planning for suicidal thoughts.
• Pharmacological:
• Fluoxetine 20 mg oral once daily (maximum 60 mg daily).
• Sertraline 50 mg oral once daily (start 25 mg, maximum 150 mg daily).
• Escitalopram 10 mg oral once daily (maximum 20 mg daily).
• Paroxetine controlled release 12.5 mg oral once daily (maximum 25 mg daily).
• Each of these is given either continuously or from day 14 to the first day of bleeding.
• Combined oral contraceptive pill with drospirenone 3 mg and ethinylestradiol 20 micrograms oral once daily for 24 days then 4 days free.
• Goserelin 3.6 mg subcutaneous every 28 days for up to 6 months with tibolone 2.5 mg oral once daily as add back for resistant disease.
• Elemental calcium 1200 mg (as carbonate) oral once daily.
• Pyridoxine 50 mg oral once daily (maximum 100 mg daily).
• Procedures: bilateral oophorectomy with hysterectomy for severe disease that has failed all other treatment, after a test of ovarian suppression and when childbearing is complete.
• Special groups:
• Women with bipolar disorder need a mood stabiliser before any antidepressant, with specialist review.
• Women planning pregnancy or who are pregnant have cognitive behavioural therapy, and sertraline only if the benefit outweighs the risk.
• Breastfeeding women use sertraline.
• Women with migraine with aura, hypertension or previous clot avoid oestrogen containing pills.
• Red flags: suicidal thoughts or plans, self harm, psychosis, mania, symptoms throughout the cycle, no response to two serotonergic drugs.
• Follow-up: review at 2 weeks after starting treatment and each month for 3 months; diary at each visit; stop or reduce the drug after 6 to 12 months if symptoms are controlled; review for relapse; specialist referral for resistant disease.