Definition and Diagnosis
Premenstrual dysphoric disorder is a severe form of premenstrual syndrome characterized by marked mood lability, irritability, dysphoria, and anxiety, along with physical symptoms, occurring in the final week before menses onset, improving within a few days of menses starting, and becoming minimal or absent in the week post-menses.
Epidemiology
PMDD is estimated to affect a meaningful minority of menstruating individuals, distinct from the much larger proportion who experience milder premenstrual syndrome. Onset can occur at any point after menarche, and symptoms typically persist until menopause unless treated.
Risk Factors
Risk factors include a personal or family history of mood disorders, particularly major depressive disorder and postpartum depression, heightened sensitivity to normal hormonal fluctuations, high stress levels, and a history of trauma. Genetic factors affecting sensitivity to progesterone metabolites are also implicated.
Symptoms and Subtypes
Core features include marked affective lability, irritability or anger, depressed mood, and anxiety or tension, together with somatic symptoms such as breast tenderness, bloating, joint or muscle pain, and appetite changes, all confined to the luteal phase and substantially improving after menses begins.
Diagnosis
Diagnosis under DSM-5-TR requires at least five symptoms present in the final week before menses, with at least one being an affective symptom, confirmed prospectively across at least two symptomatic menstrual cycles using daily symptom ratings rather than retrospective recall alone.
Treatment
First-line treatment is SSRIs, which can be taken continuously or restricted to the luteal phase, given their rapid effect on premenstrual mood symptoms. Combined oral contraceptives (particularly those containing drospirenone), lifestyle measures, and, for severe refractory cases, GnRH agonists are additional options.
Prognosis
Most individuals experience significant symptom relief with SSRI treatment or hormonal management, though symptoms typically recur if treatment is stopped. The condition tends to persist until menopause but generally responds well to sustained treatment.
Reference
American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.).