CE/CME / PEER REVIEWED

Premenstrual Dysphoric Disorder: Diagnosis and Management in Primary Care

Clinician Reviews. 2018 December;28(12):40-45

References

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013.
2. Rapkin AJ, Lewis EI. Treatment of premenstrual dysphoric disorder. Womens Health (Lond). 2013;9(6):537-556.
3. Pearlstein T. Treatment of premenstrual dysphoric disorder: therapeutic challenges. Expert Rev Clin Pharmacol. 2016;9(4):493-496.
4. Zielinski R, Lynne S. Menstrual-cycle pain and premenstrual conditions. In: Schuiling KD, Likis FE, eds. Women’s Gynecologic Health. Burlington, MA: Jones & Bartlett Learning; 2017:556-573.
5. Hofmeister S, Bodden S. Premenstrual syndrome and premenstrual dysphoric disorder. Am Fam Physician. 2016;94(3):236-240.
6. Yonkers KA, Simoni MK. Premenstrual disorders. Am J Obstet Gynecol. 2018;218(1):68-74.
7. Yang M, Wallenstein G, Hagan M, et al. Burden of premenstrual dysphoric disorder on health-related quality of life. J Womens Health (Larchmt). 2008;17(1):113-121.
8. Craner JR, Sigmon ST, McGillicuddy ML. Does a disconnect occur between research and practice for premenstrual dysphoric disorder (PMDD) diagnostic procedures? Women Health. 2014;54(3):232-244.
9. Hong JP, Park S, Wang HR, et al. Prevalence, correlates, comorbidities, and suicidal tendencies of premenstrual dysphoric disorder in a nationwide sample of Korean women. Soc Psychiatry Psychiatr Epidemiol. 2012;47(12): 1937-1945.
10. Martinez PE, Rubinow PR, Nieman LK, et al. 5α-reductase inhibition prevents the luteal phase increase in plasma allopregnanolone levels and mitigates symptoms in women with premenstrual dysphoric disorder. Neuropsychopharmacology. 2016;41:1093-1102.
11. Baller EB, Wei SM, Kohn PD. Abnormalities of dorsolateral prefrontal function in women with premenstrual dysphoric disorder: A multimodal neuroimaging study. Am J Psychiatry. 2013;170(3):305-314.
12. Comasco E, Sundström-Poromaa I. Neuroimaging the menstrual cycle and premenstrual dysphoric disorder. Curr Psychiatry Rep. 2015;17:77.
13. Reid RL. Premenstrual dysphoric disorder (formerly premenstrual syndrome) [Updated Jan 23, 2017]. In: De Groot LJ, Chrousos G, Dungan K, et al, eds. Endotext [Internet]. South Dartmouth, MA: MDText.com, Inc; 2000.
14. Htay TT. Premenstrual dysphoric disorder clinical presentation. Medscape. https://emedicine.medscape.com/article/293257-clinical#b3. Updated February 16, 2016. Accessed February 7, 2018.
15. Epperson CN, Hantsoo LV. Making strides to simplify diagnosis of premenstrual dysphoric disorder. Am J Psychiatry. 2017;174(1):6-7.
16. FDA. Sarafem. www.accessdata.fda.gov/drugsatfda_docs/label/2006/021860lbl.pdf. Accessed February 15, 2018.
17. FDA. Paxil CR. www.accessdata.fda.gov/drugsatfda_docs/label/2004/20936se2-013_paxil_lbl.pdf. Accessed February 15, 2018.
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19. Yonkers KA, Kornstein SG, Gueorguieva R, et al. Symptom-onset dosing of sertraline for the treatment of premenstrual dysphoric disorder: a randomized trial. JAMA Psychiatry. 2015;72(10):1037-1044.
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PATIENT PRESENTATION/HISTORY

PMDD is an individual experience for each woman.^3,4 However, women with PMDD generally present with a history of various psychiatric and somatic symptoms that significantly interfere with their occupational or social functions (to be discussed in the Diagnosis section, page 42).^1-4 The reported symptoms occur in predictable patterns that are associated with the menstrual cycle, intensifying around the time of menstruation and resolving immediately after onset of menstruation in most cases.^1-4

Many psychiatric and medical conditions may be exacerbated during the luteal phase of the menstrual cycle and thus may mimic the signs and symptoms of PMDD (see Table 1).^1,4 Therefore, the pattern and severity of symptoms should always be considered when differentiating PMDD from other underlying conditions.^1,2,4,5

It is also important to distinguish PMDD from PMS, a condition with which it is frequently confused. The latter manifests with at least one affective or somatic symptom that is bothersome but not disabling.^4,5 An accurate differential diagnosis is important, as the management of these two conditions differs significantly.^4,5

ASSESSMENT

PMDD assessment should include thorough history taking, with emphasis on medical, gynecologic, and psychiatric history as well as social and familial history (including PMDD and other psychiatric disorders); and physical examination, including gynecologic and mental status assessment and depression screening using the Patient Health Questionnaire (PHQ-9).^2,4,13,14 The physical exam is usually unremarkable.¹⁴ The most common physical findings during the luteal phase include mild swelling in the lower extremities and breast tenderness.¹⁴ Mental status examination, however, may be abnormal during the late luteal phase—albeit with orientation, memory, thoughts, and perceptions intact.^13,14

LABORATORY WORKUP

There is no specific laboratory test for PMDD; rather, testing is aimed at ruling out alternative diagnoses.^4,14 Relevant studies may include a complete blood count to exclude anemia, a thyroid function test to exclude thyroid disorders, a blood glucose test to exclude diabetes or hypoglycemia, and a ß hCG test to exclude possible pregnancy.^4,14 Hormonal tests (eg, for FSH) may be considered for younger women with irregular cycles or for those younger than 40 with suspected premature menopause.^4,14

Continue to: DIAGNOSIS

Premenstrual Dysphoric Disorder: Diagnosis and Management in Primary Care

References

PATIENT PRESENTATION/HISTORY

ASSESSMENT

LABORATORY WORKUP

Pages

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