Premenstrual dysphoric disorder

Premenstrual dysphoric disorder (PMDD) is a severe form of premenstrual syndrome, afflicting 8% of all women^{[citation needed]}. It is a mood disorder associated with the luteal phase of the menstrual cycle.

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Symptoms

PMDD is similar to premenstrual syndrome (PMS), but differs from it in severity. Treatment is recommended because PMDD interferes with the sufferer's ability to function in her environment. The cardinal symptom--surfacing between ovulation and menstruation, and disappearing within a few days after the onset of the bleeding--is irritability (PMID 11571794). Anxiety, anger, and depression may also occur. The main symptoms, which can be disabling, include^[1]

• feelings of sadness or despair, or possibly suicidal thoughts
• feelings of tension or anxiety
• panic attacks
• mood swings, crying
• lasting irritability or anger that affects other people
• disinterest in daily activities and relationships
• trouble thinking or focusing
• tiredness or low energy
• food cravings or binge eating
• having trouble sleeping
• feeling out of control
• physical symptoms, such as bloating, breast tenderness, headaches, and joint or muscle pain

Five or more of these symptoms may indicate PMDD. Symptoms occur during the week before the menstrual cycle and go away when the bleeding starts.

Background and controversy

Originally called late luteal phase dysphoric disorder (LLPDD), the disorder was renamed PMDD by the American Psychiatric Association in its May 1993 revision of the DSM-IV. PMDD was moved from a position in the appendix of the manual to a "disorder requiring further study."^[2][3] While no one denies the reality of the suffering caused by PMDD, or advocates withholding treatment if a woman desires it, some psychiatrists and women's groups object to the labeling of a severe form of PMS as a psychiatric disorder.

PMDD is accepted as illness by the Food and Drug Administration (FDA) but has not as been listed as a separate disorder in the World Health Organization's International Classification of Diseases. In 2003, the manufacturer of Prozac (fluoxetine) was required by the Committee for Proprietary Medicinal Products to remove PMDD from the list of indications for fluoxetine sold in Europe.^[4] The committee found that

...PMDD is not a well-established disease entity across Europe... There was considerable concern that women with less severe pre-menstrual symptoms might erroneously receive a diagnosis of PMDD resulting in widespread inappropriate short and long-term use of fluoxetine.^[5]

PMDD is not listed on the Australian Pharmaceutical Benefits Scheme. ^[6]

Some commentators suggest that PMDD (along with heart disease, social anxiety disorder, restless leg syndrome, and female sexual dysfunction) has been marketed by pharmaceutical companies in order to increase the demand for treatments.^[7]

There is evidence of a neurological foundation for PMDD distress. The self-rated cardinal mood symptoms of women suffering premenstrual dysphoria was found to be strongly correlated with the concomitant worsening of their brain serotonin precursors, measured objectively by Positron emission tomography (PET) (PMID 16515859).

While the cause of PMDD has not been definitively established, a leading theory suggests it is due to the lack of serotonin (a neurotransmitter) and mediated by the fluctuations of the levels of sex hormones (progesterone, estrogen, and testosterone) in the luteal phase of the menstrual cycle (PMID 16515859).

Supporting the hypothesized important role of serotonin, a number of selective serotonin reuptake inhibitors (SSRIs) have been proven in clinical trials to effectively treat the mood component of PMDD when taken during the dysphoric phase.

Treatment

Lifestyle changes may ameliorate some of the effects of PMDD, and certain SSRIs provide relief as well.^[8] The U.S. Food and Drug Administration (FDA) has approved three medications for the treatment of PMDD: Fluoxetine (also known as Prozac), was approved by the U.S. Food and Drug administration for PMDD in 2000. Sertraline (Zoloft) was approved in 2002, and Paroxetine HCI (Paxil) has also been approved by the FDA. The patent for Fluoxetine has expired, but Eli Lilly was able to obtain a new patent for its use in the treatment of PMDD, which has since marketed heavily under the trade name Sarafem.^[9] However Fluoxetine is now available as a generic in the same doses used in Sarafem, with the generic price generally a fraction of the cost for branded Sarafem. L-tryptophan, a serotonin precursor, was found to provide significant relief in one study when supplemented daily in a large dose of (six grams) per day.^[10]

References

1. ^ "Premenstrual Syndrome" ("What is Premenstrual Dysphoric Disorder (PMDD?)"
2. ^ Laurence, Leslie. "Psychiatric group scruitinzes categorizing form of PMS", Chicago Tribune, 1993-05-16. 
3. ^ Lehman, Betsy. "A little revision is creating a big furor", Boston Globe, 1993-05-10. 
4. ^ Ray Moynihan (2004-02-14). "Controversial disease dropped from Prozac product information". BMJ 328.
5. ^ European Agency for the Evaluation of Medicinal Products, Committee for Proprietary Medicinal Products (2003-06-13). Summary Information...for Prozac and associated names.
6. ^ Sertraline (Zoloft), fluoxetine (Lovan, Prozac) for premenstrual dysphoric disorder (PMDD) National Prescribing Service Limited. (Australia)
7. ^ http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0030198&ct=1&SESSID=d0c4ae9e966c4ec416e4ea241d60077b | Disease Mongering in Drug Promotion: Do Governments Have a Regulatory Role? Barbara Mintzes Citation: Mintzes B (2006) Disease Mongering in Drug Promotion: Do Governments Have a Regulatory Role? PLoS Med 3(4): e198 doi:10.1371/journal.pmed.0030198 Published: April 11, 2006 Copyright: © 2006 Barbara Mintzes. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Synopsis available: (PMID 16597181) (Noting e.g. Pfizer, the Manufacturer of Lipitor, engaged in attempts to increase Lipitor sales by making more consumers aware of heart disease through marketing and advertising)
8. ^ http://www.4women.gov/FAQ/pms.htm
9. ^ Jennifer Daw (2002-10-09). "Is PMDD real?" 33. American Psychological Association Monitor on psychology.
10. ^ A placebo-controlled study of the effects of L-tryptophan in patients with premenstrual dysphoria. PMID 10721042

See also

• Premenstrual syndrome (PMS)

Possible resource for 8% statistic: American Psychiatric Association. DSM-III-R Diagnostic and Statistical Manual of Mental Disorders. 3rd edition, Revised. American Psychiatric Press, Washington, DC; 1987