Most of us are aware of premenstrual syndrome (PMS). PMS is an endocrine condition affecting women’s psychological, behavioural and physical wellbeing during the luteal phase of menstruation. This phase refers to the time from ovulation to the onset of menstruation. Around 90% of women experience an unpleasant collection of physical and psychological symptoms during PMS, such as bloating or stomach pain, mood swings, anxiousness or irritability, breast tenderness, changes in appetite, headaches, and acne. However, up to 8% experience more severe and distressing symptoms on the PMS continuum ─ premenstrual dysmorphic disorder (PMDD).
What is PMDD?
PMDD straddles the experiences of a hormonal disorder and a mental health disorder. It is comprised of disruptive physical and emotional manifestations, that, unlike PMS, result in severe functional impairment and a reduction in a woman’s quality of life. Emotionally, PMDD may present through a variety of symptoms, including severe mood swings, panic attacks, loss of interest in relationships and activities, irritability, binge eating, changes in sleep patterns and feelings of tension, anxiety, despair, and suicidal ideations. Physically, back and joint pain, cramps, headaches, breast swelling, joint or muscle pain, reduced libido, bloating and other gastrointestinal issues are commonly experienced. Whilst PMS is often manageable, PMDD is on the severe end of the PMS spectrum and necessitates the attention of a medical professional.
Understanding PMDD: The Causes
Whilst the aetiology and pathophysiology of PMDD remain largely unknown, various studies have highlighted the involvement of GABAergic and serotonergic systems. It is important to note that unlike PMDD and other mood disorders, PMS is unrelated to dysregulated neurotransmitter levels. Both PMS and PMDD are recognised to be caused by a hormonal event ─ the production of progesterone from the ovaries following ovulation. Progesterone and its metabolites are vital for the formation of new neurons, reduction of neuroinflammation and maintaining cholesterol levels within a normal range. However, in PMDD, increased progesterone metabolites are produced by the corpus luteum (the cellular mass formed in the ovaries following release of a mature ovum from an ovarian follicle) and in the brain following ovulation brain bind to the neurosteroid site on the GABA receptor. This binding changes the receptor configuration, resulting in a reduction of GABA-mediated inhibition. This inhibition is an “off switch” to the central nervous system and reduces regulation of mood and cognitive functioning, which can trigger the onset of negative mood symptoms in the luteal phase of the menstrual cycle. Other symptoms of PMDD are also likely attributed to this abnormal response to progesterone metabolites. The symptoms of PMDD resolve with menstruation when progesterone levels fall, solidifying that high progesterone levels following ovulation contribute to disease pathophysiology.
Alongside this, a deficiency in serotonergic brain functioning has been reported. Decreased serotonin levels are implicated in PMS-like symptoms. Promisingly, agents administered that increase brain serotonin levels, such as selective serotonin reuptake inhibitor (SSRI) antidepressants, have been efficacious in attenuating patient symptoms.
Incidence and Prevalence
PMDD affects females of reproductive potential and is more common than what is currently assumed. Whilst approximately 3–8% of women have been estimated to suffer from PMDD globally, determined by strict diagnostic criteria, it is likely to be much higher. Up to 13–18% may not meet the official PMDD diagnostic criteria, but experience disabling PMDD-related symptoms ─ so much so that the reduction in their quality of life is similar to that of a major depressive disorder. Whilst the prevalence varies amongst ethnic groups and cultural locations, the epidemiology and incidence rates are difficult to predict due to the highly variable frequency reported across studies using different methodologies.
The Political and Health Policy Landscape
Despite its high prevalence and media coverage, PMDD remains relatively unknown, both to the layperson and within medical and healthcare institutions. The 1996 ‘Global Burden of Disease’ report by the World Bank and World Health Organisation (WHO), in collaboration with Harvard School of Public Health, highlighted the disease burden of a large variety of both physical and psychological disorders. This report did not mention PMDD or PMS ─ neither did the 2001 WHO World Health devoted to mental health conditions. Given PMDD’s significant impact on a woman’s quality of life, it is surprising that PMDD was only recognised and included in the 11th revision (ICD-11) of the WHO’s International Classification of Diseases and Health Problems in June 2019. Before this inclusion, PMDD had not been recognised as a legitimate medical condition.
Current and Possible Treatments
Treatment studies have focused on suppressing ovulation through the administration of gonadotropin-releasing analogues (GnRHa) or transdermal oestrogen. A bilateral oophorectomy, meaning the removal of the ovaries, albeit an extreme measure, is a possible treatment option. However, these require intensive care and are not appropriate treatment methods. Consequentially, SSRIs are the first-line pharmacological approach used. Additional medications may be used in treatment, such as oral contraceptives. These may include oestrogen, progesterone and/or testosterone hormones. Psychological interventions, such as cognitive behavioural therapy (CBT), are important to consider especially if experiencing anxiety and/or depressive symptoms. Lifestyle changes are also important, such as exercise, a healthy diet, and mindful practices such as yoga, meditation, and aromatherapy. Please consult a healthcare professional to discuss treatment options that are best suited to your needs.
A Call for More Funding
PMDD is a serious and under-recognised condition. Whilst the disability-adjusted life years lost are of the same scale as major recognised affective mood disorders, PMDD is often ignored in large epidemiological studies. Given that most women experience PMDD symptoms for 7 days per month throughout their reproductive years, the burden of illness is extremely high. We must tackle this women’s health issue with more urgency, aim to increase the quality of life and reduce the social, economic, and familial burden of women suffering from this disorder. Unfortunately, the lack of funding and research is not uncommon in Women’s Health. Despite 1 in 3 women in the UK experiencing a gynaecological problem, less than 2.5% of publicly funded research is entirely dedicated to reproductive health. Contrastingly, where erectile dysfunction affects 19% of men, in comparison to the 90% of women who experience PMS, five times more research exists for the former. There is a clear discrepancy in allocated funds, expertise, and public health attention between health issues affecting men and those affecting women, therefore we need to devote our resources to advancing the health of women now, more than ever.
Please visit the following links for more information and support:
The International Association for Premenstrual Disorders: https://iapmd.org/
John Hopkins Medicine: https://www.hopkinsmedicine.org/health/conditions-and-diseases/premenstrual-dysphoric-disorder-pmdd
HerLife HerHealth patient leaflet: https://pcwhf.co.uk/wpcontent/uploads/2020/05/HLHH_Premenstrual-Disorders_Resource.pdf