According to Jean Endicott, Ph.D, director of the Premenstrual Evaluation Unit at Columbia Presbyterian Medical Centre: “Women should never again be told they ‘just have to live’ with their symptoms. PMDD is treatable. Recognising and treating this condition is a huge advancement for women’s health.”
It is a widely known fact that the prevalence of depression and anxiety disorders is higher in women than in men, throughout the entire life-cycle, and it is also known that the risk increases for women during the period of fertility and during menopause. What has recently been discovered though, is that there is a link between what is known in layman’s terms as PMS or Premenstrual Syndrome and the affective or depressive disorders.
The term premenstrual syndrome is one that to this day remains vague, and is used mainly by gynaecologists, internists, family practitioners and also the lay community. PMS is characterised by the appearance of a group of distressing emotional and physical symptoms that begin up to two weeks before the onset of menses and disappear within the first five days of the follicular phase.
As early as 1847, PMS was described by Baron Ernest Freiherr von Feuchtersleben, in the first “textbook” of medical psychology to be published in Germany, as: “The monthly activity of the ovaries which marks the advent of puberty in women has a notable effect upon the mind and body: wherefore it may become an important cause of mental and physical derangement…’ and in 1931, Professor Frank described a condition that he named as ‘premenstrual tension’ when reporting on a group of women who; “complain of a feeling of indescribable tension from ten to seven days preceding menstruation which in most instances, continues until the time that menstruation occurs.”
During the course of various studies, more than 150 emotional and physical symptoms have been documented as appearing in the week before menstrual bleeding. These symptoms include:
v Emotional or mood-related symptoms like: irritability, depression, hostility, aggression, tension and sadness
v Cognitive symptoms like: confusion, poor concentration, loss of self-control and clumsiness or poor co-ordination
v Behaviour related symptoms like: arguing, decreased interest in activities that are usually enjoyed, including sex, overeating and social withdrawal
v Somatic or physical symptoms like: appetite changes, weight gain, bloating, puffiness of face, abdomen or fingers, food cravings, fatigue, headaches, hot flashes, acne or other skin rashes, constipation or diarrhoea, muscle or joint stiffness, backache, abdominal pain/cramps, exacerbation of epilepsy, migraines and asthma, insomnia and breast tenderness.
It is estimated that between 25 and 80% of women suffer from premenstrual syndrome, but that approximately 3 to 8% of women suffer from a more severe form of PMS, known as Premenstrual Dysphoric Disorder (PMDD). PMDD is described by the psychiatric community as a menstrually related mood disorder. It is a serious, debilitating condition that prevents millions of women worldwide from functioning normally. It is estimated that PMDD leads to significant lost work/ productivity and family problems. The peak period during which the most distressing symptoms occur appears to be a woman’s late-20s to mid-30s.
Biological, psychological and social theories have been proposed to try and explain the cause of PMS, but to date no single hypothesis has been unanimously supported. A number of factors have been suggested, including oestrogen excess, progesterone deficiency and abnormal levels of the neurotransmitter serotonin. However there are a few factors that place women at an increased risk. These are:
Ÿ Family history of PMS
Ÿ The onset of symptoms after puberty or soon after stopping hormonal contraception
Ÿ History of mood changes induced by hormonal contraceptives
Ÿ History of post-natal depression
Ÿ History of non-reproductive related clinical depression
The main difference between PMS and PMDD is that to have PMS you need to experience only one symptom and it doesn’t necessarily have to be a mood-related symptom. To be diagnosed with PMDD, you need to have 5 of the 11 specified symptoms and mood symptoms are required. These symptoms must also markedly interfere with work, school or usual social activities and relationships.
According to the DSM-IV the other diagnostic criteria for PMDD are that the symptoms must appear during the time between ovulation and menstruation and remit with the onset of menstruation or shortly thereafter, and must be prospectively confirmed for at least two menstrual cycles, with some type of daily symptom measure, like a diary.
For women who suspect that they may be suffering from PMS, it is advisable to keep a diary or daily record of their mood, behaviour and any physical changes, so that they can discuss it with their doctors and ensure they receive the appropriate treatment. This diary then assists with the completion of a menstrual chart, which is now considered, along with the presence of a number of symptoms, to be the best diagnostic tool.
As the exact cause of the disorder is unknown, there is no single generally recommended and accepted treatment, but the good news though is that PMDD is treatable. Over the years, at least 50 treatment options have been suggested to be effective. These range from lifestyle therapies to hormonal and surgical interventions. Stress management, relaxation techniques, exercise and dietary changes (such as encouraging women to reduce their intake of caffeine, nicotine, salt and alcohol during their menstrual week) often help women cope with mild cases of PMS. Several clinical trials have demonstrated the effectivity of a number of anti-depressants in the treatment of PMDD. Prozac is the most widely studied antidepressant for PMDD and since 1991, seven independent studies have shown Prozac’s efficacy in alleviating emotional and physical symptoms of PMDD, and so Prozac is the first prescription medication to be licensed for the treatment of PMDD.
It is recommended that it is taken as a 20mg dose, as this seemed to show far fewer side effects. Studies have also been conducted into the difference between taking Prozac as a continuous treatment i.e. 20mg every day or as an intermittent treatment, i.e. taking 20mg every day for two weeks prior to menstruation. It was found that both types are equally effective. For some this may sound a little unusual, as it is thought that Prozac takes at least 10 days to a month to start working optimally, but according to Pretoria psychiatrist and DASG advisory board member, Dr Annemarie Potgieter: “It is thought that in the case of PMDD, the Prozac may be working on a different mechanism, and that this is why intermittent treatment is also proving to be effective.". She also stated that this intermittent treatment then raises the very important issue of diagnosis, and at the moment, until professionals know a lot more about PMDD, it will probably be a safer option for Prozac to be prescribed as a daily 20mg dose.
Although Prozac has already been approved and registered for the treatment of PMDD in the UK, it is still in the process of registration in South Africa and in the US.