Premenstrual Dysphoric Disorder (PMDD) Diagnosis

PMS and PMDD

• Premenstrual Syndrome (PMS) and Premenstrual Dysphoric Disorder (PMDD) are being discussed.
• These conditions are explored in terms of definitions, diagnostic criteria according to ACOG and APA (DSM), symptoms, and clinical presentations.
• The prevalence and age range of women affected by PMS and PMDD, as well as risk factors, genetic predisposition, and nutritional deficiencies are evaluated.
• Meticulous evaluation, differential diagnosis, and support for patients with PMS/PMDD is needed.
• It is important to rule out other medical and mental health conditions, including psychiatric disorders, and involve an interprofessional team in providing care.
• Tools like the Daily Record of Severity of Problems (DRSP), prospective questionnaires, and symptom diaries are crucial for assessment and diagnosis.
• Monitoring symptoms during at least two menstrual cycles is essential.
• PMS and PMDD impact quality-of-life, work productivity, and healthcare utilization.
• Contributing factors to development and recurrence include hormonal changes and past traumatic events.
• Comprehensive history taking, detailed physical examinations, and symptom diaries help diagnose PMS and PMDD.
• Ruling out other conditions like hypothyroidism and anemia is important in clinical history.

Menstrual Cycle Phases

• The menstrual cycle can be divided into these phases:
  • Menstruation (Day 1)
  • Follicular phase
  • Ovulation (Day 14)
  • Luteal phase (Day 28)
• The primary follicle develops into a mature follicle and then ruptures.
• Hormones fluctuate across the menstrual cycle.
  • Estrogen, follicle-stimulating hormone (FSH), luteinizing hormone (LH), and progesterone are key hormones.

Premenstrual Disorders

• Premenstrual syndrome (PMS): Cyclical and repetitive physical and behavioral changes causing distress and impaired function during the luteal phase.
• Premenstrual dysphoric disorder (PMDD): Severe mood and physical symptoms start one to two weeks before menses (during the luteal phase), and subside within days of menses onset.
• Premenstrual exacerbation (PME): Premenstrual worsening of symptoms of another disorder like MDD, GAD, IBS, migraines, or asthma in the luteal phase, which is not an official DSM diagnosis.
• PMDD is seen as a severe extension of PMS.

Epidemiology and Prevalence

• 70-90% of women report experiencing at least one symptom during the luteal phase.
• 47.8% of reproductive-aged women worldwide are affected by PMS.
• Approximately 20% of women with PMS experience symptoms that disrupt their daily activities.
• In the US, 20-32% of premenopausal women are affected by PMS.
• In the US, 3-8% of women are affected by PMDD, and the rate is highest among female university students.
• Premenstrual mood and anxiety symptoms across the world were found to be between 25.99 and 70.82, from 2022 data using Flo mobile app.
  • Flo mobile app data taken from users aged 18-55 years.

Etiology of PMS

• Physiological, psychosocial, and hormonal factors all play a role.
• Suspected altered sensitivity to normal hormonal fluctuations.
• Genetic predisposition is possible.
• Association trends are seen in family and twin studies.
• Genetic influences mediated phenotypically through neurotransmitters and neuroreceptors.
• Nutrient deficiencies of calcium, magnesium, manganese, vitamins D, B6, E, and linoleic acid have reported in females with PMS. However, results are inconsistent in controlled studies.
• Risk factors include stress, high BMI, history of trauma or stressful life events, domestic violence, substance abuse, affective disorders (MDD, postpartum depression), and caffeine consumption.

Etiology of PMDD

• A suspected altered central nervous system (CNS) sensitivity exists to normal hormonal fluctuation during the menstrual cycle.
• Females with PMDD have normal levels of gonadal steroid hormones (estrogen, progesterone). However, they have enhanced amygdala and diminished fronto-cortical activation in response to emotional stimuli.
• A genetic predisposition is possible.
• Approximately 31.5-56% heritability is seen, association trends in family and twin studies.
• Candidate genes include Estrogen Receptor-1 (ESR1), ESR2 gene, and Serotonin 1A receptor C(-1019) G polymorphism.
• 30-76% of females with PMDD have a history of depression with significant comorbidity.

Symptom Categories

• Cognitive/behavioral symptoms: Aggression, irritability, anger, lethargy, anxiety, mood lability, depression, panic attacks, fatigue, poor concentration, forgetfulness, reduced coping skills, and hostility.
• Physical symptoms: Acne, headache, appetite change, craving sweets, hot flashes, bloating, fluid retention, oliguria, muscle aches, breast pain or swelling, nausea and vomiting, constipation, pelvic heaviness or pressure, dizziness or vertigo, and weight gain.

PMS Predictability Based on Symptoms

• Odds ratios were found between 0.83 and 1.08 for various symptoms.
• Statistically significant symptoms (p < 0.05) are shown in bold.
  • Aches (1.05), anxiety/tension (1.07), food cravings (1.07), mood swings (1.08), no interest in usual activities (1.07).

Symptom Timing

• Onset can occur any time after menarche until menopause.
• Symptoms rarely occur in adolescence.
• Symptom incidence is highest in the late 20s to early 30s.
• Symptoms recur with each ovulatory cycle.
• Transgender individuals can have PMS or PMDD, as can anyone with ovaries.
• The severity and frequency of symptoms can vary over time.
• Symptom duration averages 6 days per month.

PMS Diagnosis - ACOG Criteria

• At least one affective or somatic symptom must be present during the 5 days prior to menses.
• The symptoms must disappear within 4 days of the onset of menses in each of the 3 previous menstrual cycles.
• Affective symptoms: Angry outbursts, anxiety, confusion, depression, irritability, social withdrawal.
• Somatic symptoms: Abdominal bloating, breast tenderness/swelling, headache, joint or muscle pain, swelling of extremities, weight gain.
• Symptoms should occur in the absence of pharmaceutical therapy, hormone injection, or drug/alcohol use.
• Symptoms must occur reproducibly during 2 cycles of prospective recording.
• The patient must exhibit identifiable dysfunction in social, academic, or work performance.

PMDD Diagnosis - DSM-5 Criteria

• In the majority of menstrual cycles, at least 5 symptoms must be present in the final week before the onset of menses. Symptoms start to improve within a few days after the onset of menses, and become minimal or absent in the week post-menses.
• One or more of the following symptoms must be present:
  • Marked affective lability (e.g. mood swings, feeling suddenly sad or tearful, or increased sensitivity to rejection)
  • Marked irritability or anger or increased interpersonal conflicts
  • Marked depressed mood, feelings of hopelessness, or self-depreciating thoughts
  • Marked anxiety, tension, and/or feelings of being keyed up or on edge
• One or more additional symptoms must be present to reach a total of five symptoms, combined with symptoms from Criterion B:
• Decreased interest in usual activities (e.g. work, school, friends, hobbies)
• Subjective difficulty in concentration
• Lethargy, easy fatigability, or marked lack of energy, marked change in appetite; overeating; or specific food cravings
• Hypersomnia or insomnia
• Physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of "bloating" or weight gain
• The symptoms in Criteria A-C must have been met for most menstrual cycles in the preceding year.
• The symptoms are associated with clinically significant distress or interference with work, relationships, school, usual social activities.
• The disturbance is not merely an exacerbation of the symptoms of another disorder, such as major depressive disorder. Other exclusions may apply to panic disorder, persistent depressive disorder (dysthymia), or personality disorder; though these may co-occur.
• Criterion A should be confirmed by prospective daily ratings during at least 2 symptomatic cycles.
  • The diagnosis may be made provisionally before this confirmation.
• The symptoms are not attributable to the physiologic effects of a substance or another medical condition (e.g. hyperthyroidism).

Symptom Assessment and Monitoring tools

• Retrospective Questionnaires:
  • Premenstrual Symptom Screening Tool (PSST)
  • Premenstrual Assessment Form (PAF)
  • Rating Scale for Premenstrual Tension Syndrome (PMTS)
• Prospective Symptom Tracking/Diaries:
  • Daily Record of Severity of Problems (DRSP)
  • Calendar of Premenstrual Experiences (COPE)
  • Premenstrual Experience Assessment (PEA)
  • Menstrual Distress Questionnaire (MDQ)
  • Prospective Record of the Impact and Severity of Menstrual Symptomatology (PRISM)

Premenstrual Symptoms Screening Tool (PSST)

• This is a tool with scaled measures to see how premenstrual symptoms begin before a period and within few days of bleeding.
• It evaluates symptoms like anger, anxiety, tearfulness, depression, focus, energy, cravings, sleep, feeling like you are out of control, and physical symptoms like breast tenderness/bloating.
• It also evaluates how these symptoms interfere with efficiency such as work/family/home setting and productivity.
• The following criteria must be present for a diagnosis of PMDD: One of irritability/anger/anxiety/depression is severe, at least 4 out of the prior symptoms are moderate, and at least one of the work/family/home factors is severe.
• The following criteria must be present for a moderate diagnosis of PMS: One of irritability/anger/anxiety/depression is moderate, aat least 4 out of the prior symptoms are moderate, and at least one of the work/family/home factors is moderate.
• The PSST is validated to identify from PMS/PMDD.
  • For a diagnosis of PMS/PMDD, PSST has:
  • 79% sensitivity
  • 1.18 LR +
  • 0.63 LR -
  • For a PMS diagnosis, PSST has:
  • 81.4% PPV
  • 30.0 NPV

Prospective Questionnaire

• Accurate to diagnose PMS and PMDD
• Patients may overestimate their symptoms but tracking may reveal symptoms to be erratic or exacerbated in the luteal cycle
• The Daily Record of Severity of Problems (DRSP) downloadable form can monitor the severity of irritable symptoms (ranging from not at all to extreme)

Daily Record of Severity of Problems (DRSP)

• This is questionnaire is a way of assessment of symptoms and there impacts. It evaluates factors relating to:

  • Anger
  • Mood
  • Energy
  • Appetite
  • Sensitivity
  • Sleep
  • Breast tenderness/swelling, bloating
  • Headache and muscle/joint pain
  • The impacts from work/school efficiency, hobbies/social life, and relationships

• Suggests PMS with a total sore of 50 in the first day of menses

• For a diagnosis of PMDD in the week prior to menses, the person would score at least 4 with 1 being considered as an impairment for at least 2 days and should correlate with a daily rating assessment

• For diagnosis an average score of 3 should be considered for an alternative diagnosis

• It is a valid questionnaire with 24 items grouped with 11 distinct symptoms and 3 for functional impairment.

Carolina Premenstrual Assessment Scoring System (C-PASS)

• This is a diagnostic tool used to create a diagnosis for PMDD with DSM-5.
• It will use daily symptom ratings from daily record of severity of problems (DRSP) for 2 cycles and is typically used in research.
• Compares data from days -7 to 1 of premenstrual week with days 4 to 10 of postmenstrual week.

Differential Diagnosis

• Symptoms may be due to psychiatric, medical, gynecological, or psychosocial causes.
• Conditions to consider include dysmenorrhea, endometriosis, physiologic ovarian cysts or polycystic ovary syndrome, hypothyroidism (sometimes hyper),anemia, fibrocystic breast changes, diabetes, chronic fatigue syndrome, and perimenopause
• Other consideration may include substance abuse disorders, affective disorders (anxiety, depression), migraine headaches, irritable bowel syndrome, arthritis or arthralgia, and anorexia or bulimia.
• Adverse effects can be related to oral contraceptive (OCP) use.

Differentiating With Symptom Timing

• Symptom tracking is crucial for distinguishing between these conditions.
  • Pain with menstrual flow indicates dysmenorrhea.
  • Pain at any time in the menstrual cycle, especially intense pain with menstrual flow potentially indicates endometriosis.
  • Menstrual irregularity, acne, elevated androgens, and ovarian cysts indicate polycystic ovaries.
  • Non-cyclic fatigue, mood changes, and weight changes indicate hypothyroidism.
  • Non-cyclic fatigue, mood changes, weakness, and difficulty concentrating indicate anemia.
  • pain can vary throughout the cycle while discomfort increased in the premenstrual phase of fibrocystic breast changes
  • increased/change in appetite, urination and weight indicate diabetes.
  • Life stage symptoms that may persist suggest perimenopause.
  • Absence of symptom-free week in follicular phase suggests affective disorder.
  • More persistent effects on mood, headache, breast tenderness, nausea and weight during oral contraceptive intake.

Anemia (Iron-Deficiency)

• This is a condition causing lower than normal level of red blood cells (hemoglobin).
• 10% of menstruating females have an increased risk related to GI bleeds, menorrhagia, low iron diet
• Fatigue, tachycardia, and palpitations are signs of potential iron-deficiency
• Diagnosis can be shown through bloodwork with a CBC
• Treat underlying cause and give oral replacement

Primary Hypothyroidism (Overt)

• This endocrine disorder is an elevated serum thyroid stimulating homocides TSH and thyroxine(FT4).
  • About 0.3% of adults present with autoimmune disease and the other related syptoms.
  • Key identifiers are weight gain, fatigue, lethargy, depression weakness, and headaches.
  • This can be diagnosed through serum assessment and TSH, FT4 levels and thyroid levels that indicate autoimmune.
  • T4 replacement is a key management for this issue.

Major Depressive Disorder (MDD and Unipolar)

• This disorder is depressive which shows history of depression, 5 symptoms of depression, and lasting for at least 2 consecutive weeks with a median age of 30.
• Common with females related to genetics/anxiety/substance use.
• Screening with dysphoria, anhedonia, and appetite changes with fatigue with guilt shown on a DSM-5 criteria assessment.
• Managed with patient education/referral to psychotherapy/psychiatry for 25 times increased risk of suicide and all-cause 52% mortality.

Diagnosis of PMS/PMDD

• Clinical history is key, and other conditions must be ruled out.
• No laboratory evaluation is recommended to rule in or confirm diagnosis.
• The PSST can screen for PMS and PMDD.
• It is important to follow with 2 months of prospective monitoring of symptoms for diagnosis.

Physical Examination and Lab Investigation tests

• Are used to rule out other pathologies that may have similar symptoms
  • Anemia/Hypothyroidism
  • Perimenopause/PCOS
  • Diabetes or possible substance abuse
  • Fibrocystic breast changes, general anxiety
• Typically unremarkable physical examination, but rare cases of physical exam do show edema

Burden of Illness

• An average woman has 459 - 481 cycles and ~6.2 days of severe PMS symptoms leading to about 2800 days or 7.1 years of suffering

Impact on Women

• PMS/PMDD has negative effects relating to:
  • Relationship
  • Marital dissatisfaction
  • Work: absenteeism and less productivity
  • Medical attention and healthcare quality

Prognosis

• Recurring
• Tend to recur after stopping treatment for most but except with oophorectomy.
• Leading to increased psychology issues with high rates of suicidality
• Predictors for ideation vs attempts vary in family history, age, income, and medical history

Monitoring treatment

• Subjectively managed and monitored from symptom patterns with the ability to monitor and educate so patients achieve goal.
• About 2 to 3 cycles of this will show improvement.
• Effective when the symptoms begin to reduce about 50% during the luteal phase.
• Multi-disciplinary team and their care must be involved in the healthcare to sustain the patients by communicating among eachother.

Diagnostic Steps for PMS vs PMDD vs PME

• “Do your symptoms change across your cycle?” to assess for moderate-severe changes
• Follow-up with the evaluation to see which conditions aligns
• PMS: 1 somatic and 1 affective symptom present
• PMDD: 5 more symptoms that more-severe
• PME: chronic symptoms begin getting worse

Diagnosis (ACOG)

• Requires at least 2 symptoms, with one being effective and another being somatic.
• Must show impairment
• Using daily readings, confirm diagnosis.

Diagnosis (DSM-5)

• Requires at least 5 or more symptoms on emotional component
• Must show impairment
• Using daily readings, confirm diagnosis.

Management Summary

• The cause of the PMS and PMDD are unknown however, a high sensitivity to abnormal hormonal changes is considered. Symptom/medical evaluations are critical to diagnosis and manage the issue. untreated has lead to death and morbidity rates. PMS/PMDD can also effect interpersonal/work balance in all settings and requires a multi-discilinary method for support and care.

These flashcards cover the diagnostic criteria for Premenstrual Dysphoric Disorder (PMDD) according to the DSM-5. Key areas include the number of symptoms, required criteria, and differentiation from major depressive disorder. Questions address symptom tracking and additional information needed for diagnosis.