PMS and PMDD
Premenstrual Mood Changes
Many women in their reproductive years experience transient physical and emotional changes around the time of their period. In fact, at least 75% of women with regular menstrual cycles report unpleasant physical or psychological symptoms premenstrually. For the majority of women, these symptoms are mild and tolerable. However, for a certain group of women, these symptoms can be disabling and may cause significant disruption in their lives.
Premenstrual Syndrome (PMS)
First introduced in the 1950s, the term “PMS” has been widely used by the popular press and thus has been variably defined. PMS typically refers to a general pattern of physical, emotional, and behavioral symptoms occurring 1-2 weeks before menses and remitting with the onset of menses. PMS is common, affecting from 30-80% of women of reproductive age. The most common physical symptoms include abdominal bloating, headaches, muscle and joint pain, and breast tenderness. The behavioral symptoms most commonly observed in women with PMS are fatigue, forgetfulness, poor concentration, and mild mood changes, including irritability and depressed mood.
- Sensitivity to rejection
- Sense of feeling overwhelmed
- Social withdrawal
- Lethargy or fatigue
- Sleep disturbance (usually hypersomnia)
- Appetite disturbance (usually increased)
- Abdominal bloating
- Breast tenderness
- Headaches (read more about menstrual migraines)
- Muscle aches, joint pain
- Swelling of extremities
Premenstrual Dysphoric Disorder (PMDD)
Premenstrual dysphoric disorder (PMDD) is a more severe form of premenstrual syndrome affecting 3-8% of women in their reproductive years. In contrast to PMS, PMDD is characterized by more significant premenstrual mood disturbance. The most common symptom is irritability; however, many women also report depressed mood, anxiety, or mood swings. These symptoms emerge one to two weeks preceding menses and resolve completely with the onset of menses. By definition, this mood disturbance results in marked social or occupational impairment, with its most prominent effects in interpersonal functioning.
PMDD is a psychiatric diagnosis and is considered to be one of the mood disorders, classified in the DSM-IV-TR as “depressive disorder not otherwise specified.” Typically PMDD emerges in women in their 20’s and may worsen over time; it has been observed that some women may experience worsening premenstrual symptoms as they enter into menopause. Less commonly, PMDD may begin during adolescence, and case reports suggest that treatments effective for adult women can also be helpful to adolescents with PMDD.
An estimated 40% of women who seek treatment for PMDD actually have a premenstrual exacerbation of an underlying mood disorder (major depressive disorder, bipolar disorder) rather than PMDD. PMDD can be distinguished from other affective disorders primarily by the cyclical nature of the mood disturbance. Unlike other mood disorders, mood symptoms are only present for a specific period of time, during the luteal phase of the menstrual cycle (the last 2 weeks before menses). Additionally, these mood symptoms do not occur in the absence of a menstrual cycle, as during reproductive events such as pregnancy or menopause.
The best way to confirm the diagnosis of PMDD is by prospective daily charting of symptoms. Women with PMDD should experience a symptom-free interval between menses and ovulation. Although there is no consensus about the best instrument by which to confirm the diagnosis of PMDD, two well-validated scales for the recording of premenstrual symptoms include the Calendar of Premenstrual Experiences (COPE) and the Prospective Record of the Severity of Menstruation (PRISM).
What Causes PMS and PMDD?
Although the etiology of PMS and PMDD remains uncertain at present, researchers now concur that these disorders represent biological phenomena rather than purely psychological events. Recent research indicates that women who are vulnerable to premenstrual mood changes do not have abnormal levels of hormones or some type of hormonal dysregulation, but rather a particular sensitivity to normal cyclical hormonal changes.
Fluctuations in circulating estrogen and progesterone cause marked effects on neurotransmitters in the brain; specifically serotonergic, noradrenergic and dopaminergic pathways. In particular, accumulating evidence implicates the serotonergic system in the pathogenesis of PMS and PMDD. Recent data suggest that women with premenstrual mood disorders have abnormal serotonin neurotransmission, which is thought to be associated with symptoms such as irritability, depressed mood and carbohydrate craving.