PMDD

IS IT PMS OR PMDD?

Patient-physician communication gets answers

Professor of Psychiatry and obstetrics and Gynecology, Rush Medical College Chicago, Illinois

With increasing frequency, women’s health care providers are being asked to diagnose and treat mental health problems. In this insightful interview, Nada L. Stotland, MD, MPH, describes some of these issues and the controversies facing clinicians as they tread into what could be uncertain territory. Focusing on premenstrual disorders, Dr Stotland offers practical advice for evaluating and treating patients, and addressing their concerns.

SRM: How are premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) different from each other?

NLS: PMS is an umbrella term rather than a defined disorder or condition. It has been characterized by more than 100 different emotional, behavioral, and physical signs and symptoms that include, basically, anything that makes a woman “feel lousy” premenstrually.

With such a loose definition, PMS studies are difficult to compare. However, since many people believed that cyclical mood symptoms warranted further research, it was necessary to develop criteria by which to study them. That is how PMDD came to be defined (TABLE). In the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), PMDD is among the “mood disorders not otherwise classified or specified,” and its criteria are in the appendix called “Criteria Sets and Axes for Further Study.” In essence, PMDD is both in and out of the DSM-IV.

Menstrual symptoms exist on a spectrum, which poses a general problem in medicine: At what point is it pathological? What blood pressure is hypertension? How much menstrual bleeding is abnormal? Without designating a cutoff, it is not possible to offer people treatment, to be reimbursed, etc.

The definition of PMDD in an appendix of the DSM-IV addresses methodological barriers to study, but also presents clinicians with challenges in making this diagnosis.

Research Criteria for Premenstrual Dysphoric Disorder

SRM: What do you see as some of the risks and benefits of classifying PMDD as a mental disorder?

NLS: Attribution is a problem. To what do women attribute unpleasant feelings and behaviors? Most people in the United States believe that women are affected by premenstrual symptoms. Many women believe that the mood symptoms they experience are cyclic and related to the premenstrual period. However, data collected through prospective daily ratings have shown that for most women, the mood symptoms they experience are not confined to the premenstrual period.^1,2 Many women who think they are experiencing cyclical mood symptoms may actually be experiencing something else, such as a mood or anxiety disorder.

Furthermore, mood changes and irritability occur in men as well as women. One study charted mood changes and irritability in men over the course of a month.² The highs and lows they experienced were comparable to what women experience. However, they were not cyclical and have not been considered a disorder.

An estimated 3% to 8% of women meet the criteria for PMDD.³ The classification of PMDD as a mental disorder is controversial for a couple of reasons. For one, it means that 3% to 8% of women might be labeled “mentally ill.” If that many women cannot concentrate or get along with their coworkers for several days every month, should employers screen all their female job applicants? Second, some of the criteria are entirely based on a woman’s perception of her own ability to function: a subjective sense of difficulty concentrating or being overwhelmed. We never quantify the extent of the dysfunction, and subjective ratings may be insufficient to establish its occurrence.²

Conversely, if there were no criteria for PMDD and it were not accepted as a diagnosis, it could not be studied. That would be doing a disservice to women who may have this disorder.

SRM: How do you work up a patient who reports having PMS or PMDD?

NLS: The first thing I ask is, “What makes you think so?” By asking a patient to describe her signs and symptoms, I can begin a conversation about her general mental health. Depression is very common among women; every patient should be screened for it. Screening instruments such as The Hamilton Depression Rating Scale (HAM-D) or Beck Depression Inventory (BDI) are useful for that purpose. There is also a relationship between abuse and reporting feelings of having PMS.⁴ Asking about difficulties at home or work must be part of the workup or you risk making an inaccurate diagnosis.

It is important to take a complete history and physical examination as well. Patients should be questioned explicitly about how often they experience symptoms: sometimes, much of the time, or all the time. Remember, one criterion for PMDD is that the symptoms are absent in the week after menses.

Clinicians should ask about a patient’s age at onset of symptoms and their course. Onset of PMDD is usually after puberty.⁵ It tends to have an ongoing course, although some people believe that bearing a child attenuates symptoms.

It may be helpful to inquire whether the patient experiences other conditions, such as migraines or seizures, that wax and wane with the menstrual cycle. Cycling the dose of medication or using other interventions can minimize the risk of these premenstrual episodes.

SRM: What are the pros and cons of prospective daily ratings to confirm the presence and timing of PMDD symptoms?

NLS: The DSM-IV criteria state that the presence of symptoms should be “confirmed by prospective daily ratings during at least 2 consecutive, symptomatic cycles.” The diagnosis may be made provisionally prior to this confirmation. In practice, patients are often resistant to waiting that long for a diagnosis. The provisional diagnosis is a loophole that allows a clinician to make a diagnosis and begin treating without the daily ratings; however, if you do that, you will never be certain of the diagnosis.

Making an accurate diagnosis has implications for treatment. Major depression, which is often confounded with PMDD, occurs in episodes of about 9 months.⁶ If a patient is experiencing an episode of depression, you might be able to discuss stopping her medication some months after she recovers. When selective serotonin reuptake inhibitors (SSRIs) are used for PMDD, treatment may be given daily or limited to the luteal phase of the menstrual cycle. Without a clear diagnosis, a clinician cannot be sure which course to take.

Patients should be encouraged to keep a daily record for 2 months. I recommend using 2 separate day-to-day calendars: one to chart the cycle, the other to chart the symptoms. If a patient plots her cycle and moods on the same calendar or one where she looks at a whole month at time, she is likely to feel worse on the days when she thinks she should feel worse.

SRM: Would you discuss some of the options for treating PMDD?

NLS: There are 3 SSRIs (paroxetine, sertraline, and fluoxetine) and 1 combination oral contraceptive (drospirenone/ethinyl estradiol) that have been FDA-approved to treat PMDD. For a patient with a history of depression, I would be inclined to try an SSRI. However, if her depression occurred postpartum or there were other indications that her mood symptoms were related to hormonal fluctuations, I might suggest that the patient try an oral contraceptive, assuming she does not desire fertility.

In some cases, the SSRIs can be prescribed for use only during the luteal phase of the menstrual cycle. This has been shown to work for PMDD,^7-10 but it remains a mystery why. It often takes 2 to 6 weeks for an antidepressant to work in the treatment of depression. Therefore, it is surprising that a patient taking an anti-depressant for PMDD experiences the benefits so quickly. There are various theories to explain this that could turn out to have implications for the treatment of depression or our understanding of what happens during the menstrual cycle that affects a woman’s mood.^11-13

SRM: In your experience, are patients reluctant to accept a diagnosis of mental illness, such as PMDD?

NLS: For some people, PMDD is an easier diagnosis to accept than depression. Although it is waning, there remains a stigma about having mental illness. Women may accept that their mood disorder is based on hormonal fluctuations, whereas they would be reluctant to acknowledge that they are actually depressed. Even though PMDD and depression can be treated with the same medications, we as clinicians should not conflate the 2 disorders. If a patient is truly depressed, it is important to work with her on accepting that diagnosis and appropriate treatment.

Patients may have misconceptions about the SSRI medications they are taking for PMDD, particularly those prescribed by their gynecologist or family physician. I have heard patients say, “It has the same active ingredient as an anti-depressant, but there is something else in it for my PMS.” If a clinician decides to prescribe an SSRI, it is important to clarify this misconception with patients. This is a good opportunity to discuss risks and benefits. Many patients given prescriptions for SSRIs never fill them, and many who do fail to take the prescribed course.

SRM: The SSRIs carry black box warnings and have received a lot of press attention lately. How do you reassure women about the risks associated with the use of these medications?

NLS: Patients usually are concerned about addiction and suicide. Concerns about addiction arise because SSRIs are taken every day. I explain to patients that being addicted to a drug actually means that a person craves it, wants more and more of it, and gets in trouble because of it—none of which apply to SSRIs. SSRIs work by changing brain chemistry. When the medication is stopped, the brain has to readjust; this is why we taper patients off SSRIs.

There was not a single suicide in the studies that the FDA reviewed before adding the black box warning.¹⁴ The FDA used the term “suicidality,” which means suicidal thoughts, plans, and behaviors, none of which—in those studies—resulted in any person dying. However, this distinction was not made, and the root of the word used in the black box warnings is suicide, so that is what most people think when they hear that term.

In fact, after those black box warnings were imposed, the number of prescriptions went down. There are indications that shortly afterward, the number of suicides went up.¹⁵ The cause-and-effect are not proven, but this has been reported for 2 consecutive years now. Untreated depression carries a high risk of disability and a considerable risk of suicide.

A patient who has been prescribed an SSRI should be followed more closely than is usual with some other medications commonly prescribed in primary care. This helps to ensure compliance with the treatment, particularly in the beginning when the side effects are at their worst and patients have not begun to experience the benefits. I ask my patients to call me within 2 or 3 days of starting the medication and to come back after a week.

As an aside, with mood disorders, the symptoms do not all diminish at the same rate. Sometimes the realization that a patient feels better is the last thing to happen. She will say she still feels bad but then acknowledge that she is sleeping better or eating more. I like to point out the progress she is making and then encourage her to stay with the treatment.

SRM: Should lifestyle modifications be recommended to patients with PMDD?

NLS: Lifestyle modifications have been studied for the treatment of PMS. None have been proven effective in randomized, double-blind studies, but many things make people feel better: exercise, cutting down caffeine, practicing good nutrition, minimizing stress, and taking B vitamins as supplements.^16-18 These are sensible, healthful measures in any case, so if part of their effect is placebo, that is fine.

It is a good idea to ask specifically—and in a nonjudgmental way—whether patients are taking supplements or other items they purchased at a health food store. When you ask about what medications they are taking, often patients do not even think to mention supplements. However, they can interact with the medications you may be prescribing.

Summary

Menstrually related symptoms bring many patients to primary or gynecologic care. It is important to use these visits as an opportunity for a full health evaluation; to rule out other mental and physical causes of distress; to verify that the symptoms meet criteria for PMDD; and to closely follow patients started on treatment with SSRIs, whether for depression or PMDD.

Disclosure: Dr Stotland reports no commercial or financial interests or other relationships wtih any company that provides medically related services.

Sexuality, Reproduction & Menopause ©2008 Quadrant HealthCom Inc.