Premenstrual dysphoric disorder

Differentiate between premenstrual syndrome and premenstrual dysphoric disorder with respect to pathophysiology, clinical presentation, and treatment. 

Describe the clinical presentation of amenorrhea, menorrhagia, anovulatory bleeding, dysmenorrhea, and premenstrual dysphoric disorder. 

Premenstrual syndrome (PMS) is a constellation of symptoms including mild mood disturbance and physical symptoms that occur prior to menses and resolve with initiation of menses. It is estimated that up to 70% of menstruating women experience symptoms of PMS. However, a spectrum of premenstrual mood disturbances exists and the most severe is premenstrual dysphoric disorder (PMDD). Approximately 4% to 7% of women have PMDD. A summary of the American Psychiatric Association s criteria for PMDD is as follows1,21 ... 

TREATMENT PREMENSTRUAL SYNDROME AND PREMENSTRUAL DYSPHORIC DISORDER... 

BMD, bone mineral density NSAID, non-steroidal anti-inflammatory drug OCs, oral contraceptives PCOS, polycystic ovary syndrome PMDD, premenstrual dysphoric disorder. 

Ross LE, Steiner M. A biopsychosocial approach to premenstrual dysphoric disorder. Psychiatr Clin North Am 2003 26(3) 529-546. 

Premenstrual dysphoric disorder Severe psychiatric mood disorder with marked affective symptoms causing significant interference in work or relationships that is temporally associated with the luteal phase and not caused by an underlying psychiatric disturbance. 

The current SSRIs in the United States inclnde fluoxetine, fluvoxamine, sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), and escitalopram (Lexapro). All effectively treat major depression. In addition, one or more of the SSRIs has been shown effective in the treatment of dysthymic disorder, the depressive phase of bipolar disorder, premenstrual dysphoric disorder, panic disorder, social phobia, obsessive-compnlsive disorder, bnlimia nervosa, and binge-eating disorder. 

In addition to their proven efficacy in the treatment of all types of depression, the SSRIs have been shown to be the drugs of choice in the treatment of panic disorder, obsessive-compulsive disorder, bulimia nervosa, and as an adjunct to the treatment of alcohol withdrawal and relapse prevention, premenstrual dysphoric disorder and post-traumatic stress disorder. The usefulness of these drugs in treating such a diverse group of disorders reflects the primary role of serotonin in the regulation of sleep, mood, impulsivity and food intake. 

Premenstrual dysphoric disorder (PMDD) Fluoxetine Sarafem only), paroxetine (controlled-release), sertraline. 

The selective serotonin reuptake inhibitors (SSRI) have been used in adults for a wide variety of disorders, including major depression, social anxiety (social phobia), generalized anxiety disorder (GAD), eating disorders, premenstrual dysphoric disorder (PMDD), post-traumatic stress disorder (PTSD), panic, obsessive-compulsive disorder (OCD), trichotillomania, and migraine headaches. Some of the specific SSRI agents have an approved indication in adults for some of these disorders, as reviewed later in this chapter. The SSRIs have also been tried in children and in adults for symptomatic treatment of pain syndromes, aggressive or irritable ( short fuse ) behavior, and for self-injurious and repetitive behaviors. This chapter will review general aspects of the SSRIs and discuss their approved indications in children and adolescents. 

FDA, Food and Drug Administration GAD, general anxiety disorder OCD, obsessive-compulsive disorder PMDD, Premenstrual dysphoric disorder PTSD, post-traumatic stress disorder SRI, serotonin reuptake inhibitor SSRI, selective serotonin reuptake inhibitor. 

In four instances, the agency has invoked this rule at the time of approval of supplements for new indications for psychotropic drugs already approved for other psychiatric indications. It was noted in the approval letters for these supplements that, since the drugs in question would likely be used in children and/ or adolescents with the newly approved indications, the FDA required the sponsors of these products to conduct studies that would be pertinent to such use in the pediatric population. Since the products were ready for approval in adults, the FDA deferred the required pediatric studies to a future date. Alternatively, sponsors could make an argument for waiver of the requirement. The drug products and indications for which the FDA has required studies under the Pediatric Rule are as follows paroxetine for social anxiety disorder sertraline for post-traumatic stress disorder (PTSD) olanzapine for acute mania in bipolar disorder and fluoxetine in premenstrual dysphoric disorder (PMDD). 

Freeman, E. W. (2004). Luteal phase administration of agents for the treatment of premenstrual dysphoric disorder. CNS Drugs 18, 453-468. 

Pearlstein TB, Halbreich U, Batzar ED, et al Psychosocial functioning in women with premenstrual dysphoric disorder before and after treatment with sertraline or placebo. J Clin Psychiatry 61 101-109, 2000... 

Yonkers KA, Halbreich U, Freeman E, et al Symptomatic improvement of premenstrual dysphoric disorder with sertraline treatment a randomized controlled trial. Sertraline Premenstrual Dysphoric Collaborative Smdy Group. JAMA 278 983-988, 1997... 

In this text, the focus of our discussion is on the last issue. To illustrate the problem, we consider the effect of gender on drug pharmacokinetics (see Chapter 3, Chapter 5, Chapter 7, Chapter 10, and Chapter 12) and then address two important gender-related questions the use of medications during pregnancy and the drug treatment of premenstrual dysphoric disorder (see Chapter 14). 

A related issue is premenstrual dysphoric disorder (PMDD), which affects 3% to 8% of women in their reproductive years. Unlike the much milder and more prevalent premenstrual syndrome (PMS), PMDD is characterized by the following symptoms ... 

Yonkers KA, Brown WA. Pharmacologic treatments for premenstrual dysphoric disorder. Psychiatr Ann 1996 26 596-589. 

Some of the growth in antidepressant use may be related to the broad application of these agents for conditions other than major depression. For example, antidepressants have received FDA approvals for the treatment of panic disorder, generalized anxiety disorder (GAD), post-traumatic stress disorder (PTSD), and obsessive-compulsive disorder (OCD). In addition, antidepressants are commonly used to treat pain disorders such as neuropathic pain and the pain associated with fibromyalgia. Some antidepressants are used for treating premenstrual dysphoric disorder (PMDD), mitigating the vasomotor symptoms of menopause, and treating stress urinary incontinence. Thus, antidepressants have a broad... 

Halbreich U et al Are there differential symptom profiles that improve in response to different pharmacological treatments of premenstrual syndrome/premenstrual dysphoric disorder CNS Drugs 2006 20(7) 523. [PMID 16800714]... 

Fluoxetine hydrochloride is most recognized as an antidepressant, but it is also used to relieve symptoms of premenstrual dysphoric disorder (PMDD) (premenstrual syndrome). These symptoms include mood swings, tension, bloating, irritability, and breast tenderness. Eh Lilly began marketing fluoxetine hydrochloride as Sarafem in 2000 for treating PMDD. 

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