Young women seeking treatment for Premenstrual Syndromes (PMS and PMDD Premenstrual Syndrome and Premenstrual Mood Disorders) are frequently seen by psychiatrists for mood and anxiety related issues.
PREMENSTRUAL MOOD CHANGES
Many women (at least 75%) in their reproductive years experience transient physical and emotional changes around the time of their monthly periods. Usually, these symptoms are mild and tolerable. However, in some cases these symptoms can be disabling and may cause significant dysfunction in their lives.
Mood changes in Premenstrual phase can present as the milder form: PMS Premenstrual Syndrome or the severe form: PMDD Premenstrual Dysphoric Disorder.
The milder form : Premenstrual Syndrome (PMS)
Premenstrual Syndrome or ‘PMS,’ is a common condition. It affects nearly 30-80% of women of reproductive age, consisting of some physical, emotional and behavioral symptoms occurring 1-2 weeks before menses and improving with the onset of menses. PMS symptoms are moderate and only mildly interfering in daily functions.
The severe form: Premenstrual Dysphoric Disorder (PMDD)
Premenstrual Dysphoric Disorder (PMDD) is a more severe form of premenstrual syndrome characterized by significant premenstrual mood disturbance, often with prominent mood reactivity and irritability. PMDD results in marked social or occupational impairment, with its most prominent effects in interpersonal functioning. PMDD affects 3-8% of women in their reproductive years.
How to diagnose PMS/ PMDD?
There is no single laboratory test to diagnose PMS. Diagnosis is based on clinical presentation and a thorough psychiatric evaluation, supplemented with tests as needed . The best way to confirm the diagnosis of PMDD is by prospective daily charting of symptoms. Women with PMDD will experience a symptom-free interval between menses and ovulation (luteal phase). Several well-validated scales for the recording of premenstrual symptoms include:
What Causes PMS and PMDD?
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 central neurotransmission, specifically serotonergic, noradrenergic and dopaminergic pathways. Recent data suggest that women with premenstrual mood disorders have abnormal serotonin neurotransmission. This is thought to be associated with symptoms such as irritability, depressed mood and carbohydrate craving.
After the diagnosis of PMS or PMDD has been made through exclusion of other medical and psychiatric conditions, as well as by prospective daily ratings of symptoms, treatment can be initiated.
Mood Charting: Keeping a monthly mood chart can be informative and even therapeutic for many women. In addition to helping with the diagnosis, many women feel better if they can identify the relationship between their cycles and mood changes, and also anticipate days that they may be at risk for mood worsening.
Lifestyle modifications: For all women, simple lifestyle changes in diet, exercise and stress management are encouraged. These modifications have no associated risks and may provide significant benefits. Lifestyle changes include regular frequent small balanced meals rich in complex carbohydrates and low in sodium, fat, caffeine, regular exercise, smoking cessation, alcohol restriction, regular sleep.
Nutrition: For patients with mild physical and emotional symptoms of PMS, a trial of nutritional supplements, including calcium, magnesium, and vitamin B6 may also be considered.
Stress management and CBT: Simultaneously non pharmacologic methods like stress reduction, anger management, cognitive behaviour therapy, marital and couples therapy, patient education, and light therapy may be beneficial. Some women report that in their PMS phase past emotional issues resurface; counselling can be beneficial in these circumstances.
SSRI medications: Patients with PMDD or who fail to respond to conservative methods may require medications typically a Selective serotonin reuptake inhibitors (SSRIs) like fluoxetine, citalopram, sertraline or clomipramine. SSRI medications can be dosed on a continuous or intermittent schedule, depending on the patient’s preference and on the severity of her symptoms.
GnRH Agonists: For severe symptoms that fail to respond to any of the above strategies, medications that suppress ovulation, such as a GnRH agonist, may be considered. GnRH agonists may induce a chemical menopause that is associated with troubling side effects and possible long-term consequences. They are not first-line agents for treatment of PMS or PMDD and should be used cautiously.