Premenstrual dysphoric disorder
Premenstrual dysphoric disorder is a severe, cyclic mood disorder in which at least five of eleven affective and somatic symptoms recur during the luteal week of most menstrual cycles over 12 months and remit within about a week of menses onset. Diagnosis is clinical. First-line treatment is a selective serotonin reuptake inhibitor such as sertraline 50 mg or fluoxetine 20 mg daily, dosed continuously or only during the luteal phase.
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What this article covers
- Overview
Definition: premenstrual dysphoric disorder (PMDD) is a severe, cyclic mood disorder in which marked affective and somatic symptoms recur during the luteal phase of ovulatory menstrual cycles and remit shortly after menses begins.
- Epidemiology
Population affected: PMDD occurs in women of reproductive age; because symptoms are defined relative to the luteal phase of the cycle, the disorder is not expected outside of ovulatory cycling.
- Risk factors
Reproductive-age, ovulatory cycling: required substrate for the disorder; symptoms track the luteal phase of an ovulatory cycle, so a woman who is not cycling (prepubertal, pregnant, or postmenopausal) does not develop new PMDD symptoms.
- Pathophysiology
Luteal-phase timing: symptoms arise in the luteal phase (roughly days 15 to 28 of a 28-day cycle), when the corpus luteum produces estrogen and progesterone that prepare the endometrium; as the…
- Clinical features
Diagnostic symptom threshold: at least 5 of 11 characteristic symptoms in the week before menses, including at least 1 core symptom: marked affective lability, marked irritability or anger, marked…
- Differential diagnosis
Premenstrual syndrome: unlike PMDD, premenstrual syndrome is physical-symptom-predominant, with milder impairment that does not reach the work, school, or relationship disruption PMDD requires.
- Diagnosis
Diagnostic basis: PMDD is a clinical diagnosis, confirmed when a patient reports at least 5 of the 11 characteristic symptoms, including at least 1 core affective symptom, occurring during the luteal…
- Management
First-line, start an SSRI: begin sertraline 50 mg PO once daily or fluoxetine 20 mg PO once daily; either agent can be dosed continuously through the whole cycle or intermittently, restarting at the…
- Complications
Recurrent functional and relationship impairment: cycle-by-cycle disruption of work, school, and relationships is intrinsic to untreated PMDD and, by definition, distinguishes it from milder premenstrual syndrome.
- Prognosis
Recurrent by definition: PMDD requires the symptom pattern to recur during most cycles over 12 months, so untreated symptoms return every cycle rather than resolving on their own.
- Prevention
Confirm cyclicity before daily commitment: track symptoms prospectively across cycles so that luteal-phase-only dosing, rather than unnecessary continuous daily dosing, can be used once the luteal…
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