Premenstrual dysphoric disorder

For patient information click here

Overview
Premenstrual dysphoric disorder (PMDD) is a severe form of premenstrual syndrome, afflicting 8% of all women. It is a mood disorder associated with the luteal phase of the menstrual cycle.

Symptoms
PMDD is similar to premenstrual syndrome (PMS), but differs from it in severity and in that it requires treatment, because it interferes with the sufferer's ability to function in her environment. The cardinal symptom--surfacing between ovulation and menstruation, and disappearing within a few days after the onset of the bleeding--is irritability (PMID 11571794). Anxiety, anger, and depression may also occur. The main symptoms, which can be disabling, include
 * feelings of sadness or despair, or possibly suicidal thoughts
 * feelings of tension or anxiety
 * panic attacks
 * mood swings, crying
 * lasting irritability or anger that affects other people
 * disinterest in daily activities and relationships
 * trouble thinking or focusing
 * tiredness or low energy
 * food cravings or binge eating
 * having trouble sleeping
 * feeling out of control
 * physical symptoms, such as bloating, breast tenderness,
 * headaches, and joint or muscle pain

You must have five or more of these symptoms to be diagnosed with PMDD. Symptoms occur during the week before your period and go away after bleeding starts.

Background and controversy
Originally called late luteal phase dysphoric disorder (LLPDD), the disorder was renamed PMDD by the American Psychiatric Association in its May 1993 revision of the DSM-IV. PMDD was moved from a position in the appendix of the manual to a "disorder requiring further study." While few would prefer to leave disabling and treatable symptoms untreated, some groups of psychiatrists and women's groups object to the labeling of a severe form of PMS as a psychiatric disorder.

PMDD is accepted as illness by the Food and Drug Administration (FDA) but has not as 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 "...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." PMDD is not listed on the Australian Pharmaceutical Benefits Scheme.

Some commentators suggest that PMDD (along with social anxiety disorder, restless leg syndrome, and female sexual dysfunction) has been marketed by pharmaceutical companies in order to increase the demand for treatments.(PMID 16597181). Of course the marketing of a cure is no proof that the underlying condition does not exist, or that the distress of the sufferers is not real.

There is, in fact, significant evidence of a neurological foundation. The self-rated cardinal mood symptoms of women suffering premenstrual dysphoria was found to be strongly correlated with the concomitant worsening of their brain serotonin function measured objectively by Positron emission tomography (PET) (PMID 16515859).

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 (PMID 16515859).

Supporting the hypothesized important role of serotonin, a number of selective serotonin reuptake inhibitors (SSRIs) have been proven in clinical trials to effectively treat the mood component of PMDD when taken during the dysphoric phase.

Treatment
Lifestyle changes may ameliorate some of the effects of PMDD, and certain SSRIs provide relief as well. The U.S. Food and Drug Administration (FDA) has approved three medications for the treatment of PMDD: Fluoxetine (also known as Prozac), was approved by the U.S. Food and Drug administration for PMDD in 2000. Sertraline (Zoloft) was approved in 2002, and Paroxetine HCI (Paxil) has also been approved by the FDA. The patent for Fluoxetine has expired, but Eli Lilly was able to obtain a new patent for its use in the treatment of PMDD, which has since marketed heavily under the trade name Sarafem. However Fluoxetine is now available as a generic in the same doses used in Sarafem, with the generic price generally a fraction of the cost for branded Sarafem.