Advances in the diagnosis and treatment of premenstrual dysphoria

The recent inclusion of research diagnostic criteria for premenstrual dysphoric disorder (PMDD) in the DSM-IV recognises the fact that some women in their reproductive years have extremely distressing emotional and behavioural symptoms premenstrually. Through the use of these criteria, PMDD can be differentiated from premenstrual syndrome (PMS) which has milder physical symptoms, i.e. breast tenderness, bloating, headache and minor mood changes. PMDD can also be differentiated from premenstrual exacerbation of a current psychiatric disorder of medical condition, although some women may meet criteria for a dual diagnosis. Epidemiological surveys have estimated that as many as 75% of women with regular menstrual cycles experience some symptoms of PMS. PMDD, on the other hand, is much less common. It affects only 3 to 8% of women in this group, but it is more severe and exerts a much greater psychological toll. These women report premenstrual symptoms that seriously interfere with their lifestyle and relationships. The aetiology of PMDD is largely unknown but the current consensus seems to be that normal ovarian function (rather than hormone imbalance) is the cyclical trigger for PMDD-related biochemical events within the CNS and other target organs. The serotonergic system is in close reciprocal relationship with the gonadal hormones and has been identified as the most plausible target for interventions. Thus, beyond the conservative treatment options such as lifestyle and stress management, and the more extreme interventions that eliminate ovulation altogether, the selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors (SSRIs) are emerging as the most effective treatment options for this population. Results from several randomised placebo-controlled trials in women with PMDD, with predominantly psychological symptoms of irritability, tension, dysphoria and lability of mood, have clearly demonstrated that the SSRIs have excellent efficacy and minimal adverse effects. More recently, several preliminary studies indicate that intermittent (premenstrually only) treatment with SSRIs is equally effective in these women and, thus, may offer an attractive treatment option for a disorder that is itself intermittent.