What's new in PMS?

What is always new on the subject of premenstrual symptomatology is what name we call it, even though the condition itself probably has not changed since it was first described by the ancients. It has now been 17 years since the American Psychiatric Association (APA) included "Late Luteal Phase Dysphoric Disorder" (LLPDD) in the Appendix to the Diagnostic and Statistical Manual, Edition III-R. Although that inclusion sparked considerable controversy, especially among feminists, it did serve to help launch high-quality research into the area of premenstrual symptoms.

Although descriptive, the LLPDD moniker was cumbersome and lasted only until the next edition of the Diagnostic and Statistical Manual, which appeared in 1994. In that edition, the name was changed to premenstrual dysphoric disorder (PMDD). Still appearing in the Appendix, PMDD was noted for the first time as an example of a "Depressive Condition NOS," which gave it an ICD Code (ICD-9: 311). The new name also gave it some clout with the FDA, which approved fluoxetine and then sertraline for the treatment of this condition.

Gynecologists continued to use the term premenstrual syndrome (PMS), which already had an ICD Code (ICD-9: 625.4). The FDA has steadfastly refused to consider treatments for PMS, although the majority of women with premenstrual symptomatology undoubtedly have PMS rather than PMDD.

For reasons that have not been clearly elucidated, some women who use oral contraceptives, even monophasic pills, experience recurrent monthly symptoms that are strikingly similar to PMS. Although the American College of Obstetricians and Gynecologists' criterion specifically excludes those women, in clinical practice they are often diagnosed and successfully treated with strategies developed for patients with PMS and PMDD.

Premenstrual symptoms (irritability, mood lability, depression, anxiety, etc.) usually begin when women are in their 20s. Care-seeking for these symptoms typically begins when women are in their 30s. Once symptoms are established, they ease during pregnancy but tend to remain until the menopause.³

Impairment from severe premenstrual symptoms is similar to the degree of impairment seen in women with major depression, especially in the realms of social function.⁴ Work productivity, for example, may be unimpaired but overshadowed by conflicts with co-workers. Similar conflicts with children or partners often cause women to seek care for the first time.

Making the diagnosis A broad range of medical and psychiatric conditions get worse immediately prior to menstruation, and unfortunately the premenstrual exacerbation (PME) of other disorders has not been prominent in the medical or lay literature. Both ACOG and APA criteria mandate the prospective use of a daily symptom diary-not because women don't know they are having premenstrual symptoms, but because they are less likely to recognize lower-grade symptoms that occur during the follicular phase.

In one research study dedicated to the management of premenstrual symptoms, about 40% of women who initially identified themselves as having PMS or PMDD were diagnosed with mood, anxiety disorders, or both.⁵ The need to rule out PME of other conditions, especially psychiatric conditions, is a safety issue. Women with depressive conditions have long been known to have an increased incidence of psychiatric admissions and suicide attempts during the last few days before onset of menses and the first few days of menstrual bleeding.⁶

In clinical practice, for example, women with dysthymia (long-standing, low-grade depressive symptoms) commonly present with "premenstrual" symptoms. Review of the daily symptom diary will show low-level symptoms throughout the month with marked worsening premenstrually. Over time patients appear to accommodate to follicular phase symptoms, but notice and seek care for the premenstrual worsening.