Premenstrual Dysphoric Disorder (PMDD) The more severe form of premenstrual disorder, referred to as premenstrual dysphoric disorder (PMDD), occurs in 2% to 9% of menstruating women.[4] A diagnosis of PMS requires the presence of only 1 of the more than 100 symptoms; however, the diagnostic criteria for PMDD, as stated in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, (DSM-IV, 1995) stipulate a minimum of 5 symptoms, one of which must be a mood symptom (feeling sad, feeling tense, marked lability, irritability).[5] These symptoms must regularly occur during the last week of the luteal phase, and the symptoms disappear completely shortly after the onset of menstruation. In addition, the DSM-IV specifies that these symptoms must cause a significant impairment in lifestyle and relationships.[5]

Symptoms are confirmed by prospective daily ratings during at least 2 consecutive symptomatic cycles. Commonly used daily rating scales include: the Daily Record of Severity of Problems (DRSP) form,[6] the Premenstrual Record of Impact and Severity of Menstruation (PRISM) calendar,[7] the Calendar of Premenstrual Experiences (COPE),[8] and visual analogue scales that are used to measure changes over time in response to treatment for the symptoms of mood disturbances.[9]

When a woman presents with premenstrual complaints, it is important to take a complete history that includes: Family history of psychiatric disorders Rule out other gynecological problems such as endometriosis Rule out other medical conditions such as thyroid disease, which may mimic PMDD symptoms Relationship between PMDD and depression. Several studies have shown that women with PMDD are at a higher risk for developing a major depressive episode than women who do not have premenstrual complaints.[10] It has also been suggested that between 30% and 60% of those women with major depression experience a worsening of symptoms premenstrually.[11] It is important to note, however, that PMDD and major depressive disorder are 2 distinct clinical entities.

Treatment for PMDD. The method of treatment is dependent on the severity of symptoms. For mild cases, in which patients do not meet the DSM-IV criteria, nonpharmacologic treatments should be the first-line of treatment. Lifestyle changes -- such as diet modifications (reducing salt, caffeine, and alcohol intake); stress-reduction techniques; exercise; counseling; and education -- should be emphasized. Pharmacotherapy is indicated for those women with moderate symptoms who do not respond to lifestyle changes alone, and has been demonstrated to be very effective in the treatment of PMDD. In particular, the selective serotonin reuptake inhibitor (SSRI) class of antidepressants is a successful means of treatment for women suffering from PMDD. Fluoxetine has been widely studied and has been found to be superior to placebo in decreasing the symptoms of irritability, tension, and dysphoria.[9,12-15] Although fluoxetine is the only treatment for PMDD, which is pending approval by the FDA, there is also a growing body of literature to support the effectiveness of other SSRIs, such as paroxetine[16-17] and sertraline.[18-19] Other antidepressants, such as clomiprimine and nefazodone, have yielded positive results in small clinical trials.[20-21] Buspirone has also been found to be effective in a select few patients.[22]

For women who do not respond to or cannot tolerate antidepressant medications, hormonal therapies, such as gonadotropin-releasing hormone (GnRH) agonists, estradiol, and danazol, are occasionally taken to ameliorate PMDD symptoms. However, the side-effect profile of these therapies makes them less desirable for the treatment of PMDD. GnRH agonists, which work by suppressing the menstrual cycle, induce side effects that mimic menopause and may increase the occurrence and severity of osteoporosis.[1] Women taking estradiol must concurrently be treated with progestin to prevent endometrial hyperplasia.[1] Similarly, danazol has a severe side-effect profile, due to its androgenic and antiestrogenic properties, and may affect menstrual cycle length.[1]

Dr.AlexWaserman

dralwaro@hotmail.com
Viña del MAR, Valparaiso
Chile