Agatha is a 24-year-old woman with no past medical history who presents for a new patient appointment. She is a medical student who recently moved to California from the east coast. She feels extremely emotional – crying often, feeling sad and depressed, overwhelmed, tired, and anxious. She is second guessing her decision to pursue medicine and isolating herself from her classmates. However, she does not always feel this way. These feelings and thoughts start about 5 days before her period and go away the day after she starts bleeding. She has always been “more emotional” and bloated around her periods, but nothing like what’s been happening the past 6 months.
How do you diagnose premenstrual dysphoric disorder (PMDD)?
Premenstrual dysphoric disorder (PMDD) is the severe end of premenstrual syndrome (PMS) and affects 2-5% of women (ACOG 2023). On average, women with PMDD experience 3000 symptomatic days and 3.8 years of disability during their reproductive years (ACOG 2023). Most women with PMDD do not seek diagnosis or treatment (Wakil 2012). PMDD symptoms typically continue until menopause, when they naturally resolve. They commonly worsen in the late reproductive years. Women with PMDD are also at higher risk for developing mood disorders during the menopausal transition.
To meet the DSM-5 criteria for PMDD, a patient must have at least 1 affective symptom and 5+ total symptoms in the week before menses (during the luteal phase, when estrogen is declining and progesterone peaks and down-trends). These symptoms must start to improve within a few days of the start of menses (when estrogen begins to rise again, progesterone is low), and become minimal or absent in the week after menses (Raffi 2017).
| Affective symptoms | Other symptoms |
| Marked lability of affect (e.g. sudden sadness, tearfulness, or sensitivity to rejection) Marked irritability (e.g. increased anger or increased interpersonal conflicts) Marked depressed mood (e.g. hopelessness, feeling “empty,” or self-deprecating thoughts) Marked anxiety (e.g. tension, feeling “keyed up,” or “on edge”) | Decreased interest in usual activities (e.g. work, hobbies, friends, school) Difficulty concentrating Lethargy, marked low energy, easy fatigability Marked change in appetite, overeating, food cravings Hypersomnia or insomnia Feeling overwhelmed or out of control Physical symptoms (e.g. breast tenderness or swelling, joint or muscle pain, bloating, weight gain) |
To diagnose PMDD, the treating clinician should 1) evaluate PMDD symptoms, with prospective monitoring for at least 2 months to confirm the diagnosis, 2) rule out premenstrual exacerbation (PME) of another mental health disorder, and 3) consider alternative medical illnesses to explain the symptoms.
If a patient’s symptoms seem to fit a PMDD diagnosis, give her the provisional diagnosis of PMDD and ask her to track her symptoms prospectively. Recording symptoms prospectively is a critical part of the diagnosis of PMDD. After prospective tracking, it is not uncommon for the provisional diagnosis of PMDD to change to major depression (MDD) or generalized anxiety disorder (GAD) or to learn that mood symptoms correlate more closely with life stressors than with menses. I like to print out 2 copies of the Daily Record of Severity of Problems (DRSP) to give to the patient in the clinic. For patients who prefer tracking on smart phones rather than paper, there are phone apps available.
In PMDD the symptoms fluctuate consistently and predictably with the luteal phase of menstrual cycles and resolve soon after the start of menses. In contrast, patients with premenstrual exacerbations (PME) of another disorder like MDD may have worsening of their symptoms during the week prior to their periods, but the symptoms will not resolve after menstruation (Hofmeister 2016).
Other medical and mental health illnesses that can worsen in the premenstrual phase include migraines, seizures, depressive and bipolar disorders, anxiety disorders, bulimia nervosa, and substance use disorders. Side effects from hormonal treatments can also produce overlapping symptoms with PMDD.
For Agatha, you clarify the symptoms she is experiencing: lability of affect, depressed mood, self-deprecating thoughts, feeling empty, easy fatigability, decreased interest in usual activities, and bloating. She hasn’t tracked them prospectively, but it seems like her symptoms are most severe in the week before her period and then resolve fully after her period starts. She has been able to get through medical school thus far because of this fluctuation – if she felt this poorly all the time, she would have had to take a leave or consider dropping out. You ask her about any thoughts of self-harm or harm towards others (she reports none) and consider non-psychiatric causes of her symptoms (none were applicable).
You give Agatha a provisional diagnosis of PMDD, explain the rationale for prospective tracking, and give her 2 copies of the Daily Record of Severity of Problems (DRSP), which you print out in the clinic for her. You schedule a follow up in 2-3 months to review the mood tracking, confirm the diagnosis, and discuss treatment options.
Look out for a future PsychSnap on PMDD treatment.
Key Points
- Symptoms of PMDD are of comparable severity (but not of duration) to those of other mental health disorders, including MDD and GAD.
- Symptoms of PMDD fluctuate consistently and predictably with menstrual cycles; patients with premenstrual exacerbations (PME) of their underlying mental health condition may have worsening of their symptoms with periods, but symptoms will not resolve by the end of menstruation.
- Confirming a provisional PMDD diagnosis requires daily prospective symptom ratings for at least 2 menstrual cycles.
References
ACOG. Management of Premenstrual Disorders. Obstetrics and Gynecology. 2023;142(6):1516-1533.
Hofmeister S. Premenstrual Syndrome and Premenstrual Dysphoric Disorder. Am Fam Physician. 2016;94(3):236-240.
Raffi, E. The Etiology of Premenstrual Dysphoric Disorder: 5 Interwoven Pieces. Current Psychiatry. 2017;16(9):20-28.
Wakil L, Meltzer-Brody S, Girdler S. Premenstrual dysphoric disorder: How to alleviate her suffering. Current Psychiatry. 2012;11(4):22-37.