Understanding premenstrual dysphoric disorder

[00:00:00] Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be "The Informed Patient" with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. Premenstrual dysphoric disorder is a disabling form of premenstrual syndrome that affects women of reproductive age, and it can range from severe mood swings to suicide attempts. Today I'm talking about how this is diagnosed and the challenges of treatment with Dr. Luba Leontieva and Dr. Nevena Radonjic. Both are from Upstate's department of psychiatry and behavioral sciences. Welcome to "The Informed Patient," both of you.

[00:00:40] Nevena Radonjic, MD, PhD: Thank you.

[00:00:41] Luba Leontieva, MD, PhD: Thank you.

[00:00:42] Host Amber Smith: Now, what percentage of women have PMS, and what portion of that number have PMDD?

[00:00:50] Nevena Radonjic, MD, PhD: Amber, it's a great question to start this conversation. A majority of women do have premenstrual syndrome, and this can really vary in presentation from one woman to another. And we think that it's usually around 80 to 95% of women that are going to have PMS.

From that number, only 1.3 to 7.7 percentage of women are diagnosed with PMDD. PMDD, Premenstrual Dysphoric Disorder, is a fairly novel psychiatric diagnosis that has been included in DSM-5 (Diagnostic & Statistical Manual of Mental Illnesses, from the American Psychiatric Association) only in 2014. And for these reasons we have, we are still learning how to identify the past, how to treat and how to help other providers recognize the disease.

[00:01:39] Host Amber Smith: Does it primarily affect younger women?

[00:01:43] Luba Leontieva, MD, PhD: Not necessarily. It affects women in reproductive age.

[00:01:49] Host Amber Smith: I see. Is it equally spread among races and geographic locations?

[00:01:56] Luba Leontieva, MD, PhD: So, research in this area is still developing. It's seen less in black women, 2.9% prevalence, and more in white women, 4.4% prevalence. The lifetime prevalence is also lowest in black women, 3.37%. And in white women, 5.29%. That's what research shows. But it could be that black women are underreporting the changes that occur in premenstrual dysphoric disorder. Interestingly enough, Asian women is the lowest lifetime prevalence, 3.23%.

[00:02:38] Host Amber Smith: Can we go over the symptoms? What are the typical symptoms that you see?

[00:02:44] Nevena Radonjic, MD, PhD: This diagnosis is really unique in many different ways. First is when it actually occurs, so there is temporal correlation or time relation to your period. So, just to remind our listeners, period, we consider to start on first day of menstruation. And around the 14 days of period is usually the ovulation. And then after that we have the part of the period we call the luteal phase. And in this phase, which is usually 10 days before the next period, is when women are going to start experiencing different symptoms that can be either affective or cognitive behavioral symptoms.

In order for the diagnosis of PMDD to be made, one person has to have at least five symptoms, and it has to be in both of these categories - mood and cognitive behavioral symptoms. What are the most usual mood symptoms? Emotional lability, such as sudden sadness, tearfulness, or sensitivity to rejection. Then irritability, anger, or increased interpersonal conflicts. Depressed mood, hopelessness or self-deprecating thoughts. Or just being more anxious or keyed up, or feeling like being on edge.

These are the moods and anxiety symptoms or what we call affective symptoms. In other category, we have cognitive behavioral symptoms such as decreased interest in usual activities, difficulty focusing, lethargy, low energy, change in appetite, overeating or food cravings, hypersomnia or insomnia, so we see changes in sleep, feeling overwhelmed or out of control, and having various physical symptoms that can present as a reaction to period, such as breast tenderness, swelling, headache, joint or muscle pain, bloating and weight gain. So just to sum up, we need to have five symptoms, five or more, and it has to be present in both affective and cognitive behavioral categories.

[00:04:51] Host Amber Smith: So Dr. Radnonjic, is this medical or psychiatric?

[00:04:58] Nevena Radonjic, MD, PhD: That's another great question, Amber.

I think we are, in our field, stepping away from diagnosis being either / or, um, and we are now seeing, or we at least on our end, conceptualize the diagnosis that are psychiatric to be medical as well, or we don't see any more behavioral health to be removed from medical diagnosis. So it is, though, most commonly diagnosed by psychiatrists, then family providers and OB Gyns (obstetrician gynecologists), our colleagues who are seeing patients or women for different reasons, can also diagnose the patient with PMDD.

[00:05:36] Host Amber Smith: So if the majority of women have some symptoms of PMS, what determines which of those women might go on to develop the premenstrual dysphoric disorder?

[00:05:49] Nevena Radonjic, MD, PhD: It's really the impact on functioning. In the field of psychiatry, it's always the impact on functioning and how much it affects person's wellbeing. But I think the key here is this temporal correlation, what we see that is in specific period of the month. The resolution once when period starts. And, I think that these are going to be the key factors. Dr. Leontieva, what do you think?

[00:06:19] Luba Leontieva, MD, PhD: Yes, and to add to this, there is a certain conditions in women that predispose to PMDD, such as a family history of this condition, anxiety and depression that increase stress, of course. And for the premenstrual syndrome, again, depression, stress, and proneness to stress, peculiar eating habits such as craving for certain food.

[00:06:49] Host Amber Smith: So, do we know what causes PMDD or why one woman gets it and the others do not? I know you just listed some of the risk factors, but what's happening biologically that determines how that's going to play out in a woman?

[00:07:05] Nevena Radonjic, MD, PhD: It's a combination of things. We think there is genetic predisposition. But the key question here is, we see the hormonal fluctuations. So why one woman is going to have PMDD, versus one only having PMS?

What we think the key or the answer lies is in the sensitivity of the brain to hormonal fluctuations. So, it's not really the absolute levels of the hormones. Those studies have been done and measured. So there is no difference in absolute level of hormones, estrogen or progesterone that are levels are that are being measured during the period. However, in some women, there is going to be increased vulnerability, how the brain tolerates the changes in ratios that happens normal during the month. And these women are often also more at risk for postpartum depression or for other affective disorders that can be seen in normal reproductive life cycle.

[00:08:06] Host Amber Smith: So you mentioned this is often diagnosed by a psychiatrist. Do primary care providers also diagnose this, or is it easy for them to recognize?

[00:08:17] Luba Leontieva, MD, PhD: Mostly the diagnosis comes from psychiatrists. For primary care, some primary care providers probably are more attuned to this and can diagnose, too. And as Dr. Radonjic mentioned already, a gynecologist and obstetricians can diagnose.

[00:08:36] Host Amber Smith: Does PMDD go away as a woman ages?

[00:08:41] Luba Leontieva, MD, PhD: This disappears when the periods stop, basically in menopause. But it can get worse before in premenopausal women.

[00:08:54] Host Amber Smith: What about during pregnancy?

[00:08:56] Nevena Radonjic, MD, PhD: So the hormone levels in pregnancy are rising, and they're just going to continuously rise until the delivery. So the next, the pregnancy itself, it's not characterized by cyclical changes. So in a way, there is a steady state that is just increasing of the hormones. However, after the delivery, this can be a period of vulnerability for onset of symptoms.

[00:09:21] Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking with Dr. Luba Leontieva and Dr. Nevena Radonjic. Both are from Upstate's department of psychiatry and behavioral sciences, and we're talking about PMDD.

Would you please tell us about the case you wrote about for the journal, Cureus that involved a 19-year-old?

[00:09:45] Luba Leontieva, MD, PhD: Yes, sure. So we have the 19-year-old female who came with severe anger problems, mood swings, and a suicide attempt that was very ego-dystonic for her, which means that she was shocked by the fact that she overdose on pills. It was very impulsive. She was very remorseful. And she recognized that this is not who she is and not what she wanted to do.

So as we treated the young woman, we discovered that she has the intense anger and intense mood swings around periods. And that's qualified for, with a lot of other symptoms that were listed before, it qualified her for this diagnosis.

[00:10:39] Host Amber Smith: It sounds like this can be, for someone who's afflicted, this can make you feel like you're out of your mind, it sounds like.

[00:10:46] Luba Leontieva, MD, PhD: That's exactly how this young woman thought she is, and her family also noticed that her mood swings became so intense that she basically couldn't control herself. She was throwing things, she had intense anger outbursts. She was very sensitive to what others are telling her, which culminated in her impulsively overdosing.

[00:11:10] Host Amber Smith: Now, what role, if any, did her use of birth control pills have?

[00:11:16] Nevena Radonjic, MD, PhD: So birth controls can actually be very helpful for the treatment of PMDD. I think for this patient justcoincided the, that there was a use of one and another. However, what we know from clinical studies is that some birth controls are more favorable, and they are decreasing the fluctuations in the level of hormones that are happening, which for which patient usually has vulnerability. So as such, it can actually help as a second line treatment for PMDD.

[00:11:51] Host Amber Smith: Well, I'd like to talk to you about treatment. What did you recommend for this particular person, and what do you recommend in general for people who are newly diagnosed? How is this treated?

[00:12:01] Nevena Radonjic, MD, PhD: We usually recommend as a first line treatment selective serotonin re-uptake inhibitors, or what would be in general population known as antidepressant. So this medication can be given in very unique way if patient only has this disorder, PMDD, which is only to be taken 10 days before getting the period.

We often see in clinical practice that women who have history of anxiety or depressive disorders, they have what we call a premenstrual worsening of already existing mood and anxiety disorder. And that is going to be what we see probably the most often in clinical practice. The women come and they say, "well, I'm doing worse," but even after the period starts, they don't have complete resolution of symptoms. So we know that we are actually seeing premenstrual worsening versus pure PMDD. And for those patients, they are continuously on antidepressants, and we try to titrate the dose, which means adjust the dose until the symptoms are well controlled. That's No. 1.

No. 2 is going to be use of hormonal contraceptives. The one that contains drospirenone with a combination of synthetic estrogen have been FDA-approved for treatment of PMDD. And of course, we always recommend behavioral modifications and alternative lifestyle. Dr. Leontieva can tell us more about that.

[00:13:33] Host Amber Smith: Let me ask if I can, before we get into that,do you see this, in women that you're treating, do they have underlying emotional issues to start with, and the treatment that you're giving for PMDD may also help that, or is it complicated by that?

[00:13:50] Nevena Radonjic, MD, PhD: So if I understood the question is, do we see that for women who have -- you termed it emotional vulnerability or what we call affective symptoms -- do we also see the changes? Yes, we can see that there is reaction to changes in hormonal status when it comes to symptoms, and yes, I think once when we are aware that the symptoms are actually getting worse before the period, we can focus a little bit more on tightening the treatment options and collaborating with other team members to make sure that we are doing everything possible to help the patient.

[00:14:31] Host Amber Smith: So, Dr. Leontieva, let's talk about the lifestyle modifications. Are there things that women can do to help reduce the symptoms?

[00:14:40] Luba Leontieva, MD, PhD: Yes, there is some things that women can do. So, first we're going to talk about diet modifications. So, complex carbohydrates or proteins that are slow burning in nature, it's a slow burning fuel, another name of it, is believed to be increasing the substance in our body called tryptophan. And tryptophan is a precursor to serotonin, which helps with PMDD. And serotonin reuptake inhibitors, the medication that Dr. Radonjic talked about just recently increase the serotonin. So what are those complex carbohydrates? It's whole grains, oats, lentils, peas, quinoa, brown rice, and fruits and vegetables, such as carrots, for example.

The second one is, there is some studies show that vitamin B6 -- 50 to a 100 milligram a day -- can help ease the PMDD symptoms. Another supplement is called chaste berry. Another name of it, scientific name, is vitex agnos castus. So this supplement helps to stimulate progesterone and has some dopaminergic effect, and dopamine helps with the mood swings and depression.

And of course, stress management such as relaxation, meditation, deep breathing, and yoga can help to ease the anxiety.

[00:16:08] Host Amber Smith: In terms of avoiding certain activities or food, we can recommend avoiding stimulating caffeinated beverages before bed, so, like, after 3 o'clock, TV screens, other devices, phones before bed as well, so the sleep is more full and better, not taking long naps during the day and try to stop smoking, or go into smoking cessation. Before we wrap up, I wanted to ask your advice for women who may believe they have some degree of PMDD. The young woman that you wrote about, she kept a symptom diary. Was that helpful?

[00:16:49] Nevena Radonjic, MD, PhD: Diaries are very helpful when it comes to PMDD. When we initially see the patient, we administer the diary that is retrospective, which basically we are asking for recollection. We are asking you, can you remember how you have been doing? What we learned is that although here sensitivity is high, specificity, which means is it really going to stand for what it shows is kind of lower. So the standard in the field is actually to administer prospectively from the moment patient sees us to give them the diary where they can follow affective and cognitive behavioral symptoms for two months. And they follow, daily, the symptoms, and they're also going to chart when they got their period, when they're ovulating and when there are fluctuations.

If now we see a patient after two months, they bring the diary, we review and we can see that there is a clear correlation between increase in the symptom severity and menstrual cycle, then we can proceed further to diagnose either with PMDD or premenstrual exacerbation of anxiety or mood disorders. So that's huge. I always encourage all of our patients, as I'm seeing mostly women, to keep the period diary. It's going to give us not only important information about mood symptoms in earlier stages of life, but also in later when women are going to be closer to their perimenopausal period and can also have mood symptoms.

[00:18:32] Host Amber Smith: Are there additional strategies that you think work better for teens?

[00:18:36] Nevena Radonjic, MD, PhD: I'm always going to go with psychoeducation. I think understanding and explaining clearly what they're experiencing is going to provide any patient, the sense of agency and ability to be in better control of their symptoms and disease management. So I think there is a lot of learning or teaching the patient about what they're experiencing, helping them utilize all of the behavioral modifications Dr. Leontieva very nicely suggested and outlined, keeping in mind, for some patients only understanding that they're in that period of month is already going to give them huge relief because they understand why they're feeling this certain way, although they're still not feeling great, but the fact that you know that this is happening for a certain reason versus out of blue is so important in how patients are perceiving their wellbeing and how they're going to act on that.

[00:19:41] Host Amber Smith: So I know, I think I understand this goes away or gets tremendously better at menopause, but are there lingering issues for women that have had this for years and then reach menopause? Or do we know yet?

[00:19:55] Luba Leontieva, MD, PhD: I think it's hard to predict, but of course there is lingering issue, if somebody has been struggling with intense mood swings throughout the life, it damage the relationship. It breaks certain relationship with a family members and friends, spouses, it has this connotation of somebody's very moody. So, yes, it is, it's similar to untreated ADHD, attention deficit hyperactivity disorder. There is things that linger with individuals who have ADHD.

[00:20:29] Host Amber Smith: This has been a lot of important information. I appreciate both of you making time to share it.

[00:20:34] Nevena Radonjic, MD, PhD: Thank you for this opportunity.

[00:20:36] Luba Leontieva, MD, PhD: Thank you very much.

[00:20:37] Host Amber Smith:

My guests have been Dr. Luba Leontieva and Dr. Nevena Radonjic. Both are from Upstate's, department of psychiatry and behavioral sciences. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/informed. If you enjoyed this episode, please tell a friend to listen too. And you can rate and review "The Informed Patient" podcast on Spotify, Apple podcasts, YouTube, or wherever you tune in. This is your host, Amber Smith, thanking you for listening.