PMDD or PMS: Is there a difference?

Are you bothered by intense:

Irritability ____  Tiredness ___  Tension ___  Sensitivity ___ Sadness ___ Bloating ___ Breast Tenderness ___ Food Cravings ___

Feelings of being overwhelmed ____  Sudden mood changes for no reason ____

Do these symptoms cause problems with your:

Work ____  Social activities ____  School ____  Relationships (family, friends, etc.) _____

Do these problems go away soon after your period starts?

Yes ____  No ____

If you've checked some of these, discuss your answers with your doctor to help determine if you have PMDD.

Symptoms can vary from cycle to cycle.  That is why it is recommended you keep a daily record for both your mood and physical symptoms and how you're feeling for two or three periods to help discussions with your doctor.

How to know if you have PMS or PMDD*

_{1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition. Washington, DC  American Psychiatric Association, 1994}

_{2. Gise LH. The Premenstrual Syndromes.  In: Sciarra JJ. Ed. Gynecology and Obstetrics. Rev ed. Philadelphia PA: Lippincott-Raven 6:1-14, 1997}

You must have at least five or more of the 11 symptoms listed below. These must be present most of the time during each occurrence.  At least one or more of these symptoms must be severe depressed mood, tension, mood swings, or irritability. 

• Depressed mood
• Tension
• Mood swings
• Irritability
• Decreased interest in usual activities
• Lack of energy
• Insomnia or hypersomnia
• Physical symptoms such as bloating and breast tenderness
• Difficulty concentrating
• Marked change in appetite
• Feeling overwhelmed

*For some women, premenstrual symptoms can actually mask symptoms of depression.  If the severe mood symptoms do not go away within a few days of menstruation, be sure to tell your healthcare provider.

Background Information On Premenstrual Dysphoric Disorder (PMDD)

Premenstrual dysphoric disorder (PMDD) affects 3 percent to 5 percent of menstruating women and is characterized by severe mood and physical symptoms around a woman's menstrual cycle, including irritability, tension, low mood and anxiety, bloating and breast tenderness. PMDD symptoms appear the week or two prior to menstruation and remit following the onset of the menstrual cycle, and are severe enough to interfere with a woman's everyday activities or relationships.^1,2,3

Diagnosing PMDD

The diagnosis of PMDD is clearly defined:

Symptoms must occur during the week or two before the menstrual period and remit soon after the onset of the menstrual period.

At least five or more of 11 specified symptoms must be present most of the time during each symptomatic phase.  These include:

- Depressed mood                               
- Mood swings
- Irritability
- Decreased interest in usual activities
- Difficulty concentrating
- Lack of energy
- Marked change in appetite
- Insomnia or hypersomnia
- Feeling overwhelmed
- Physical symptoms such as bloating and breast tenderness
- Tension 

One or more of these symptoms must be depressed mood, tension, mood swings, or irritability.

These symptoms must be present during most menstrual cycles in a year, and must interfere with everyday activities or relationships.

The symptoms are not merely an exacerbation of symptoms of another disorder.

All the above should be confirmed during at least two consecutive menstrual cycles.^1,4

Differentiating PMDD from major depression and the more common PMS

PMDD is different from the more common PMS and from other mood and physical disorders.

PMDD and Depression

While some symptoms of PMDD and major depression overlap, they are distinct clinical entities: 

PMDD-related symptoms (both mood and physical) have a defined cyclical pattern, tied to the menstrual cycle, which remit within a few days of the onset of the menstrual period. 

Girls prior to menarche and pregnant and post-menopausal women cannot experience symptoms of PMDD, nor can males.^1,3

Depression-related symptoms can persist for weeks, months or years and are not related to the menstrual cycle.¹

The pattern of response to drug therapy is different in patients with PMDD and major depression. PMDD patients respond within the first menstrual cycle to selective serotonin reuptake inhibitor (SSRI) treatment. Patients with depression typically get symptom relief within the first week or two of treatment; although it usually takes four to six weeks to attain a full therapeutic response.¹

PMDD and PMS

PMDD is not PMS. While PMS and PMDD patients experience mood and physical symptoms, the mood symptoms in PMDD predominate and cause social impairment.

A study presented at the most recent annual meeting of the American Psychiatric Association showed that PMDD broadly affects women’s lives. According to the study, there is a consistent and strong relationship between symptom burden and interference in all domains of a woman’s life.  Women who have PMDD reported significantly more interference in their relationships with their husbands and children than women who have the more common PMS.¹⁰

Possible causes for PMDD

The pathophysiology of PMDD is not fully understood, but research observations suggest that normal cyclical changes in female hormones may interact with neurotransmitters, including serotonin, that may result in the mood and physical symptoms of PMDD.⁵

Diagnosis and Treatment
Because there is no laboratory test for PMDD, qualified health care professionals should begin the diagnostic process by ruling out —through a personal history, a physical and a laboratory examination — syndromes (thyroid disorder, chronic fatigue syndrome, lupus, mood and anxiety disorders, etc.) that could mimic the symptoms of PMDD.^1,6

Dietary and lifestyle changes — high carbohydrate meals, low consumption of salt and caffeine, exercise and stress reduction — are often the first-line treatment for women with mild symptoms.⁷  For women who do not respond to lifestyle modifications, mineral supplements or over-the-counter medications, like anti-inflammatory drugs, could be used to alleviate physical symptoms of PMDD.  However, these treatments do not appear to be effective in treating the emotional symptoms.⁶ 

For women who do not respond to non-medical approaches, drug therapy should be considered.  Recent treatment guidelines published by the American College of Obstetricians and Gynecologists recommend SSRIs as the initial drugs of choice for the treatment of severe mood and physical premenstrual symptoms.  Fluoxetine is the most studied drug of this group.⁹

Overcoming stigma
In the 1999 consensus paper published in the Journal of Women's Health and Gender-Based Medicine, a 14-member panel of health care experts concluded that PMDD is a distinct clinical entity and that specifically evaluated and approved medications are needed to treat this disorder. They agreed that strong data exist to support the use of SSRIs in treating PMDD.

Women, however, do face barriers to diagnosis and treatment.  There is often a stigma attached to any condition that is associated with the menstrual cycle. Many women who do not seek treatment for the mood and physical symptoms of PMDD accept their symptoms as an inevitable consequence of the menstrual cycle which cannot be addressed.¹⁰

Some women view seeking treatment for PMDD as a sign of weakness.  Additionally, physicians aren’t traditionally trained to recognize the signs and symptoms of PMDD—symptoms are often dismissed as just a “part of being a woman.”  Therefore, help is often neither sought nor offered. 

References:

1. Endicott J, Amsterdam, J, Eriksson E, et al: Is Premenstrual Dysphoric Disorder a Distinct Clinical Entity?  J of Women’s Health & Gender-Based Medicine.  1999;8(5):663-679.

2. Endicott J, Johnson SR, Keye WR: Helping the Patient with PMS.  Patient Care.  February 15, 1990:44-68.

3. Schmidt P, Nieman LK, Danaceau MA, et al: Differential Behavior Effects of Gonadal Steroids in Women With and Those Without Premenstrual Syndrome.  N Engl J Med.  1998;338:209-216.

4. Gold JH, Endicott J, Parry BL, et al: Late Luteal Phase Dysphoric Disorder.  In: Widiger TA, Frances AJ, Pincus HA, eds: “Late Luteal Phase Dysphoric Disorder” DSM-IV Sourcebook.  Vol 2.  Washington, D.C.; American Psychiatric Press, 1996:317-394.

5.  Rubinow D, Schmidt, P: The Treatment of Premenstrual Syndrome – Forward into the Past.  N Engl J Med.  1995;332:1574-1575.

6. Muzina KS, Gonsalves L: Commonly Asked Questions About Premenstrual Dysphoric Disorder.  Cleve Clin J Med.  1998;65:142-149.

7. Endicott J: Severe Premenstrual Dysphoria: Differential Diagnosis and Treatment.  J Am Med Women’s Assoc.  1998;53:170-175.

8. Johnson S: Premenstrual Syndrome Therapy.  Clin Obstet Gynecol. 1998;41:405-421.

9. American College of Obstetricians and Gynecologists: ACOG Practice Bulletin, Clinical Management Guidelines for Obstetrician-Gynecologists, “Premenstrual Syndrome” Number 15, April 2000.

10. Robinson R, Swindle, RW: Three Approaches to Assessing Premenstrual Symptom Severity: Effect on Social Functioning and Treatment Seeking Behaviors.  Presented at the 153^rd Annual Meeting of the American Psychiatric Association, May 2000, Chicago, Ill.

Lack of Awareness About Severe Form of PMS Affects Millions - PMDD:  Why Do So Few Women Seek Help?

According to a survey commissioned by the Society for Women’s Health Research, there is low awareness about premenstrual dysphoric disorder (PMDD), which may be causing women to suffer needlessly.  The survey found that 84 percent of respondents, including those with the most severe symptoms, had never heard of PMDD. 

Key Survey Findings 

• 45% of respondents have never discussed PMS with their doctors

• The 24% of respondents who described their symptoms as strong or severe were among those who were unaware

• 24% of respondents who described their symptoms as strong or severe felt their doctors would not take their complaints seriously

Stigma about premenstrual symptoms may prevent women from seeking diagnosis and treatment 

For decades, women have been told to “just live with” their premenstrual symptoms.  However, PMDD – a condition more severe than PMS and whose symptoms can be quite debilitating – affects 3 to 5 percent of American women in their childbearing years.  The American College of Obstetrics and Gynecology has recently issued treatment guidelines for PMDD.

Premenstrual Symptom Severity: Impact on Social Functioning and Treatment-Seeking Behaviors, Journal of Women’s Health and Gender-Based Medicine, October 2000

Study Highlights

PMS and premenstrual dysphoric disorder (PMDD) have a far greater negative impact on women’s lives than was previously acknowledged, according to a seminal study recently published in the Journal of Women’s Health & Gender-Based Medicine.

Highlights from the study include:

• Severe PMS and PMDD have a societal impact that was previously not measured or considered. Severe PMS and PMDD impact women’s lives as well as their partners’, children’s and friends’ lives. Previously, research focused on the symptoms associated with PMDD, and not on the social impact of the disorder.

• The study showed that women do not mention bothersome premenstrual symptoms, especially mood symptoms, to their doctors unless asked. It is vital that doctors ask their female patients specific questions about their premenstrual symptoms.

• Regardless of severity of symptoms, women have negative attitudes when it comes to dealing with their premenstrual symptoms.

• The study concludes that written self-report screenings under-identify women experiencing PMS or PMDD and recommends a simple screening tool can help doctors identify which patients may be suffering from PMDD – helping them monitor these women to make an accurate diagnosis.