Premenstrual Dysphoric Disorder (PMDD): Assessment & Management
Clinical diagnosis and evidence-based treatment of PMDD in general practice: DSM-5 diagnostic criteria, symptom tracking, SSRIs, and hormonal therapies.
Pathophysiology: Abnormal Neurosteroid Sensitivity
Current neurobiological research confirms that women with PMDD do not have abnormal peripheral hormone levels. Oestrogen and progesterone concentrations are identical to asymptomatic controls.
Instead, PMDD represents an abnormal cellular and neural sensitivity to normal physiological fluctuations in reproductive neurosteroids—specifically allopregnanolone, a metabolite of progesterone that modulates GABA-A receptors in the brain's emotional regulation networks (amygdala and prefrontal cortex).
DSM-5 Diagnostic Criteria & Prospective Daily Tracking
Under the DSM-5, a definitive diagnosis of PMDD requires at least five symptoms present in the final week before menses, improving within a few days after onset, and becoming minimal or absent in the week post-menses:
- Core Mood Symptoms (at least one required): Marked affective lability (sudden sadness, crying spells); marked irritability, anger, or interpersonal conflict; markedly depressed mood, hopelessness, or self-deprecating thoughts; marked anxiety, tension, or feelings of being 'on edge'.
- Additional Symptoms: Decreased interest in usual activities; subjective concentration difficulties; lethargy and fatigue; marked change in appetite or food cravings; hypersomnia or insomnia; feeling overwhelmed or out of control; physical symptoms (breast tenderness, abdominal bloating, joint pain).
- Mandatory Prospective Charting: Confirmation requires daily symptom tracking across at least two consecutive menstrual cycles using a validated instrument such as the Daily Record of Severity of Problems (DRSP) to rule out premenstrual exacerbation of underlying major depression or bipolar disorder.
Evidence-Based Treatment Pathways
Management utilizes a stepped, multimodal approach tailored to symptom severity:
- First-Line Pharmacotherapy — SSRIs: Selective Serotonin Reuptake Inhibitors (e.g. Sertraline, Fluoxetine, Escitalopram) demonstrate rapid clinical efficacy in PMDD, often working within hours to days rather than the weeks required in major depression. SSRIs can be prescribed as continuous daily therapy or luteal-phase-only dosing (taken from ovulation / day 14 until the onset of menses).
- Hormonal Suppression of Ovulation: Combined oral contraceptive pills containing drospirenone (e.g. Yaz — drospirenone 3 mg / ethinylestradiol 20 mcg taken on a 24/4 or continuous active regimen) suppress the hypothalamic-pituitary-ovarian axis and prevent cyclic hormone fluctuations.
- Psychological & Lifestyle Interventions: Trauma-informed Cognitive Behavioural Therapy (CBT), sleep hygiene optimisation, reduction of alcohol and caffeine during the luteal phase, and stress reduction frameworks.