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Dx P.M.D.D. Treatments:

P.M.D.D.: Premenstrual Dysphoric Disorder

The Merck Manual Home Edition

In premenstrual dysphoric disorder, premenstrual symptoms are so severe that they interfere with work, social activities, or relationships. Interest in daily activities is greatly reduced, and some women may even become suicidal. Symptoms end when or shortly after menstrual periods start.

For women who have premenstrual dysphoric disorder, agonadotropin-releasing hormone (GnRH) agonist (such as leuprolide or goserelin —see see Drugs Commonly Used to Treat Endometriosis), given by injection, may help relieve symptoms. GnRH agonists are a synthetic form of a hormone produced by the body. They control the rapid fluctuations in hormone levels that occur before menstrual periods and that contribute to symptoms. GnRH agonists cause the ovaries to produce less estrogen and progesterone. Thus, if symptoms persist despite other treatments, these drugs can be used with estrogen plus a progestin, taken in a low dose by mouth or a patch.
[Editor] We suggest you refer to the Webpage on PMS -- treatment Danocrine. Many physicians (not Merck, N.H.S. Choices, Medscape or most doctors) believe this is a hormonal condition that will respond to hormonal medications, such as Danocrine and the mixed androgen injections.
Merck Manual Home Edition continues to state
"Premenstrual syndrome (PMS) is a group of physical and psychologic symptoms that start several days before and usually end a few hours after a menstrual period begins.

PMS includes any combination of the following: becoming irritable, anxious, moody, or depressed or having headaches or sore, swollen breasts. Doctors base the diagnosis on symptoms, which are usually tracked in a monthly calendar.

Consuming less sugar, salt, and caffeine and exercising may help relieve symptoms, as does taking certain supplements, pain relievers, birth control pills (sometimes), or antidepressants.

Because so many symptoms, such as a bad mood, irritability, bloating, and breast tenderness, have been ascribed to PMS, defining and identifying PMS can be difficult. About 20 to 50% of women of childbearing age have PMS. About 5% have a severe form of PMS called premenstrual dysphoric disorder. PMS may occur partly because estrogen and progesterone levels fluctuate during the menstrual cycle. Some women are more sensitive to these fluctuations. Some women may have a genetic make-up that makes them more susceptible to PMS. Also, serotonin levels tend to be lower in women with PMS. Serotonin is a substance that helps nerve cells communicate (a neurotransmitter) and is thought to help regulate mood.

The fluctuations in estrogen and progesterone may affect other hormones, such as aldosterone, which helps regulate salt and water balance. Excess aldosterone can cause fluid retention and bloating.

The type and intensity of symptoms vary from woman to woman and from month to month in the same woman. The various physical and psychologic symptoms of PMS can temporarily upset a woman's life.

Symptoms may begin a few hours up to about 10 days before a menstrual period, and they often disappear completely a few hours after the period begins. Women who are approaching menopause may have symptoms that persist through and after the menstrual period. Symptoms may become more severe during stress or during the years before menopause (called perimenopause—see Perimenopause). The symptoms of PMS may be followed each month by a painful period (cramps, or dysmenorrhea), particularly in adolescents.

Other disorders may worsen while PMS symptoms are occurring. They include the following:
*Seizure disorders, with more seizures than usual
*Connective tissue disorders, such as systemic lupus erythematosus (lupus) or rheumatoid arthritis, with flare-ups
*Respiratory disorders, such as allergies and congestion of the nose and airways
*Mood disorders, such as depression
*Mood disorders can cause similar symptoms, and those symptoms may worsen just before a menstrual period, even in women who do not have PMS or premenstrual dysphoric disorder.

Physical Symptoms That Can Occur in Premenstrual Syndrome:

Physical Symptoms Psychological Symptoms
Awareness of heartbeats (palpitations) Changes in appetite and cravings for certain foods Cramps, heaviness, or pressure in the lower abdomen Agitation Anxiety Confusion
Breast fullness and pain Backache Constipation Crying spells Depression Difficulty concentrating
Bloating Easy bruising Dizziness, including vertigo
Headaches Hot flashes Pins-and-needles sensations in the hands and feet Emotional hypersensitivity Irritability Forgetfulness or memory loss
Insomnia, including difficulty falling or staying asleep at night Lack of energy Nausea and vomiting Nervousness Short temper Social withdrawal
Weight gain Swelling of hands and feet Fainting Mood swings
Joint and muscle pain Skin problems, such as acne and localized scratch dermatitis

The diagnosis is based on symptoms. To identify PMS, doctors suggest a woman to keep a daily record of her symptoms. This record helps the woman be aware of changes in her body and moods and helps doctors identify any regular symptoms and determine what treatment is best.

Premenstrual dysphoric disorder cannot be diagnosed until a woman has recorded her symptoms for at least two menstrual cycles.

If women have symptoms of depression, they may be given standardized tests for depression or be referred to a mental health care practitioner. However, doctors can usually distinguish PMS or premenstrual dysphoric disorder from mood disorders based on factors such as the timing of symptoms. If the symptoms disappear soon after the menstrual period begins, they are probably caused by PMS or premenstrual dysphoric disorder.

Taking birth control pills sometimes relieves symptoms but may make them worse.

Women can do the following to help relieve symptoms:
*Get enough rest and sleep.
*Exercise regularly, which may help lessen bloating as well as irritability, anxiety, and insomnia.
*Use stress reduction techniques (meditation or relaxation exercises). Avoid stressful activities.
*Consume more protein and calcium and less sugar and caffeine (including that in chocolate).
*Consume less salt, which often reduces fluid retention and relieves bloating.
*Take certain supplements: vitamin B complex (especially vitamin B6), calcium (1000 milligrams a day), vitamin D, and magnesium.
*Women should talk to their doctor before they take supplements, especially vitamin B6, which may be harmful if taken in high doses. Nerve damage is possible with as little as 200 milligrams a day.

Doctors may prescribe the diuretic spironolactone (which helps the kidneys eliminate salt and water from the body). This drug helps reduce fluid retention.

Taking nonsteroidal anti-inflammatory drugs (NSAIDs—Nonsteroidal Anti-Inflammatory Drugs) may help relieve headaches, pain due to abdominal cramps, and joint pain. Taking birth control pills that contain estrogen and a progestin (combination oral contraceptives) reduces pain, breast tenderness, and changes in appetite in some women but worsens these symptoms in a few. (Progestins are a synthetic form of the female hormone progesterone, produced by the body). Taking oral contraceptives that contain only a progestin usually does not help but may reduce menstrual bleeding. Oral contraceptives that result in shorter menstrual periods or that increase the interval between periods to as much as 3 months may help some women.

Women who have more severe PMS symptoms or premenstrual dysphoric disorder may benefit from taking antidepressants such as fluoxetine, paroxetine, or sertraline (see Drugs Used to Treat Depression). These drugs are used to prevent symptoms, and to be effective, they should be taken before symptoms begin. Taking these drugs after symptoms begin usually does not relieve symptoms as well as taking them before symptoms begin. These drugs are most effective in reducing irritability, depression, and some other symptoms of PMS. Doctors may require a woman to continue keeping a record of her symptoms so that they can judge the effectiveness of treatment.

Medications Used in Treatment:
1. SSRIs: Zoloft®/sertraline, Paxil®CR/paroxetine er, Sarafem®/fluoxetine
2. Estrogen/Progestin Combinations: Yaz®/drospirenone, ethinyl estradiol; see list
3. Androgens: Danocrine®/danazol, testosterone, nandrolone, oxandrolone, stanozolol
4. Aldosterone Antagonist: Aldactone®/spirolactone
5. IUD: Mirvena®

*[Editor]"Two treatment modalities distinguish themselves as highly effective: suppression of ovulation and specific serotonin re-uptake inhibitor (SSRI) antidepressants. Suppression of ovulation is effective for a wide range of PMS, while SSRIs are effective for PMDD... The SSRIs are also efficacious when administered intermittently--only during the luteal phase of the menstrual cycle."

*[Editor] Deeny in a double-blind study published data that convincingly showed major improvement in Pre-Menstrual Syndrome symptoms with the use of danazol 100mg two to four times daily. These beneficial effects were noted even in menstruation continued.

Suggested Links:
N.H.S. Choices

*[Editor] Although spirolactone has been used in the treatment of PMS, PMDD, the other atypical diuretic, acetazolamide, has been reported to reduce symptoms even in women resistant to mood disorder/ anxiety treatment. While progesterone has been pushed as an over-the-counter treatment, and it has its scientific support, the Editor often chooses PMS hormonal treatment when the above treatments and SSRIs are not found to be beneficial.

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