The number of women suffering premenstrual dysphoric disorder is higher than you might think, and rates peak after age 35.
As many as one in four perimenopausal women may experience severe and highly distressing premenstrual syndrome.
Premenstrual dysphoric disorder or PMDD, a severe form of PMS, “should be taken more seriously”, consultant gynaecologist Professor Nick Panay told the Australasian Menopause Society Congress in Queenstown this month.
The prevalence of severe PMS “may be higher than you expect” and occurred particularly in the 35 to 45 age group, said Professor Panay, president of the International Menopause Society.
“Why over 35? Probably because that’s when ovarian reserve starts to fall and when you start to experience the more exaggerated fluctuations in hormone levels.”
Professor Panay said a UK women’s health survey found that moderate PMS affected 24% of women, while another study found that PMDD occurred in 5-8% of women.
And a 2014 South Korean study in the Journal of Menopausal Medicine found that 23% of perimenopausal women had PMDD, the reproductive medicine specialist and a professor of practice at the Imperial College in London said.
“Quite a large proportion of women that suffer with this condition still haven’t come forward to talk about it with their healthcare providers.”
Professor Panay said a 2021 survey by the International Association for Premenstrual Disorders in showed that 86% of women with PMDD had considered suicide and 30% reported at least one suicide attempt.
“So we really need to take this condition very seriously and manage it as effectively as possible and coordinate our management with mental health teams,” he said.
Severe PMS could be misdiagnosed as mental health conditions, Professor Panay said.
“I’ve seen so many patients that have been labelled with bipolar disorder where the cyclicity of symptoms has been missed.”
Symptoms associated with the cyclic change of hormone levels could be very distressing to women, “either physically, biologically or cognitively”.
“And this has a severe impairment on their quality of life and wellbeing.
“If there are symptoms of suicidality, then we may need to start the cycle suppression sooner rather than later.”
PMS was considered to meet the criteria of PMDD when women had five or more of the following symptoms during most menstrual cycles for at least a year: depressed mood, anger or irritability, trouble concentrating, lack of interest in activities once enjoyed, moodiness, increased appetite, insomnia or the need for more sleep, feeling overwhelmed or out of control, and other physical symptoms such as belly bloating, breast tenderness and headache.
“The symptoms have to lead to some sort of functional impairment, either in their personal, social or professional life, and they must not be an exaggeration or an exacerbation of a pre-existing condition,” he said.
Professor Panay said documenting symptoms as they occurred was the best way of making a diagnosis and was more accurate than retrospective recall, and said period apps were useful for patients to record symptoms.
First-line treatments for PMDD included diet and exercise changes, combined new-generation pills taken either cyclically or continuously, and low-dose SSRIs, he said.
Then possible second-line treatment options were hormone therapy in the form of estradiol patches, plus oral or vaginal progesterone such as utrogestan 100mg or a Mirena.
GnRH analogues were third-line treatments, and fourth-line treatment options were total abdominal hysterectomy and bilateral oophorectomy plus HRT, including testosterone, Professor Panay said.
Cognitive behavioural therapy could be helpful, he said, and modulating levels of serotonin with SSRIs helped improve psychological PMS symptoms.
“In the perimenopause, I definitely favour hormone therapy rather than SSRIs /SNRIs but as a short-term treatment of symptoms, a sticking plaster if you like, I don’t see any problem in starting with those.”
Professor Panay suggested women with symptoms consider reducing the hormone-free interval when taking the combined oral contraceptive pill. “The seven days of placebo, or avoiding the pill, allow for ovarian cycle activity to resurge and therefore PMS symptoms to resurge.”
He also suggested women avoid pills with “old-fashioned progestins” such as levonorgestrel because they could lead to progestogenic and androgenic side effects.
A Cochrane review with more than 1900 participants showed that the contraceptive pills containing drospirenone, such as Yasmin and Yaz, were the most effective for treating PMDD, Professor Panay said.
As for complementary therapies, Professor Panay said there was some evidence that vitamin B6, calcium, isoflavones and St Johns’ Wort could be helpful in reducing PMS symptoms.
The most effective alternative remedy according to research was the herb agnus castus, according to a meta-analysis of seven randomised controlled trials, he said.
Evening primrose oil was also commonly used for PMS, he added, but “it only really works if you have it with a slug of gin”.
Professor Panay said there were variants of PMS such as premenstrual exacerbation of pre-existing psychopathologies or medical conditions such as epilepsy, migraine and asthma.
“I’m sure you see that in your practices as well,” he told the audience.
It was also possible to have premenstrual disorders without menstruation, he said.
“One of the questions I’m asked is ‘should we just do a hysterectomy?’ Well, if you just did that in a patient but left the ovaries, then you can experience premenstrual symptoms without menstruation.”
Professor Panay said research at the University of Illinois has shown that prior emotional and physical abuse could make patients more vulnerable to premenstrual symptoms and PMDD.
And some women may be genetically predisposed to more severe PMS symptoms.
“Working out the aetiology of this condition has been like doing a difficult jigsaw puzzle because there are so many theories as to what causes it,” he said.
“But when you check hormone levels overall, there don’t appear to be any significant differences between sufferers and non-sufferers, but what we do think is that there is probably a genetic vulnerability of those women that do suffer with PMS to changing hormone levels and the impact on serotonin levels.
“As estrogen levels fall towards menstruation that can lead to an increase in depressive symptoms, but also women who are vulnerable to the effects of the metabolites of progesterone like allopregnanolone through stimulation of the GABA receptors can have a depressive effect as progesterone rise levels rise in the luteal phase of the cycle.”
Professor Panay said worsening PMS symptoms could be a sign of imminent menopause.
“As ovarian reserve reduces, potentially you get these hormonal fluctuations, you get less control from the hypothalamic pituitary ovarian axis and potentially, presenting with these premenstrual type symptoms before menstruation stops completely.
“And if you want to test that, then the best time to do a blood test to look at FSH levels would be day two to day three of the menstruation.”
