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Vol. 25, no 5, 2000 Journal of Psychiatry & Neuroscience 459 Chronobiology and Mood Disorders Symposium Premenstrual syndrome and premenstrualdysphoric disorder: guidelines for management Departments of Psychiatry and Behavioural Neurosciences, and of Obstetrics and Gynecology, McMaster University, andFather Sean OÕSullivan Research Centre, St. JosephÕs Hospital, Hamilton, Ont. Correspondence to: Dr. Meir Steiner, St. JosephÕs Hospital, 50 Charlton Ave. East, Hamilton ON L8N 4A8; fax 905 521-6098;mst@fhs.mcmaster.ca Medical subject headings: clinical protocols; diagnosis, differential; premenstrual syndrome; serotonin; serotonin uptake inhibitors J Psychiatry Neurosci Diagnosticand Statistical Manual of Mental Disorders , 4th edition, recognizes the fact that some women have extreme-ly distressing emotional and behavioural symptoms premenstrually. PMDD can be differentiated from pre-menstrual syndrome (PMS), which presents with milder physical symptoms, headache, and more minor Manuel diagnostique et statistique des troubles mentaux , 4eŽdition, reconna”t que certaines femmes ont,avant les menstruations, des sympt™mes Ž 460 Revue de psychiatrie et de neuroscience Vol. 25, no5, 2000 s au TDPM dans le systme nerveux central et dautres organes cibles. Le systcations du style de vie et la gestion du stress, autres traitements sans antidpresseur ou interventions plussemblent constituer le traitement le plus efficace. Les res chez des femmes atteintes de TDPM ont d clairement que les ISRS sont trmenstruel seulement) au moyen des ISRS est tout aussi efficace chez ces femmes et peut ainsi offrir int Epidemiologic surveys have estimated that as many as75% of women of reproductive age experience somesymptoms attributed to the premenstrual phase of themenstrual cycle.1More than 100 physical and psycholog-ical symptoms have been reported to occur premenstru-ally.Most women are able to manage these symptomsthrough lifestyle changes and conservative therapies.Premenstrual symptoms are often classified under thegeneric term Òpremenstrual syndromeÓ (PMS), which islisted in the International Statistical Classification of Diseasesand Related Health Problems disorders of the genitourinary system. The symptoms (PMDD) have Diagnostic and Statistical Manual of MentalDisorders (DSM-III-R and DSM-IV).11,12Women who meetthe diagnostic criteria for PMDD do not usually respondto conservative and conventional interventions and oftenseek the expertise of a health professional. Etiology or surgical meno- all mood and behavioural symptomslished reciprocity between fluctuations in ovarian Steiner Premenstrual syndrome and premenstrual dysphoric disorder Journal of Psychiatry & Neuroscience 461 Taken together, most research indicates that womenwith PMDD may be behaviourally or biochemicallysub- or supersensitive to biological challenges of theserotonergic system. It is not yet clear whether thesewomen present with a trait or state marker of PMDD. Screening and diagnosis 2)another psychiatric or medical illness only; 3) PMS or ofPMS, nor is there a requirement for prospective confir- Table 1: Criteria for premenstrual dysphoric disorder (PMDD, modified from the Diagnostic and Statistical Manual of Mental Disorders, 4th editionASymptoms must occur during the week before menses and remita few days after onset of menses.Five of the following symptoms must be present and at least onemust be (1), (2), (3), or (4). 1Depressed mood or dysphoria2Anxiety or tension3Affective lability4Irritability5Decreased interest in usual activities6Concentration difficulties7Marked lack of energy8Marked change in appetite, overeating, or food cravings9Hypersomnia or insomnia10Feeling overwhelmed11Other physical symptoms, e.g., breast tenderness, bloatingBSymptoms must interfere with work, school, usual activities orrelationshipsCSymptoms must not merely be an exacerbation of anotherdisorderDCriteria A, B, and C must be confirmed by prospective dailyratings for at least 2 consecutive symptomatic menstrual cycles throughout the menstrual cycle but worsen premen-strually. Some women have continuous symptoms (asin dysthymia) or cyclical symptoms that do not matchthe phases of their menstrual cycle (as in cyclothymia).Women who do not meet the criteria for any diagnosismay subjectively sense disruptive symptoms as a resultof psychosocial stressors and likely still benefit fromcharting and conservative interventions. Treatment fective for this disorder.Mefenamic acid given pre- Steiner Revue de psychiatrie et de neuroscience Vol. 25, no5, 2000 Table 3: Low-risk pharmacological interventions supported by the evidenceSupplementDosage Vitamin B6100 mg daily Calcium1000 to 1200 mg dailyMagnesium ion200 mg daily or 360 mg daily (14 days beforemenses)Vitamin E400 IU daily Table 2: Conservative interventions to treat PMS or PMDDChartingDaily charting of symptoms DietReduction or elimination, especially in the lutealphase, of salt, chocolate, caffeine and alcohol;small, frequent meals high in complexcarbohydrate; vitamins and minerals inmoderationExerciseModerate, regular, aerobic exerciseStress reductionStress management courses or counselling, ifnecessary, or bothRelaxationRelaxation courses or audiotapesRelationshipAssertiveness course or marital counselling, ifnecessary, or bothSelf-help groupsIf availableEducationSelf-help books Premenstrual syndrome and premenstrual dysphoric disorder Journal of Psychiatry & Neuroscience 463 The pharmacological approaches to PMDD and or ovariectomy in the complete relief of severe premen- SSRIs and reproduction This side Table 4: Pharmacological interventions to treat PMS and PMDD that are supported by evidenceDrug classDrugDosage AntidepressantsFluoxetine20 mg/d, every day or during luteal phase only Sertraline50150 mg/d, every day or during luteal phase onlyParoxetine1030 mg/d, every day or during luteal phase onlyCitalopram520 mg/d, every day or during luteal phase onlyClomipramine2575 mg/d, every day or during luteal phase onlyAnxiolyticsAlprazolam0.251.0 mg/tid, 614 days before mensesBuspirone25 mg/d, 12 days before mensesOvulation suppressants(GnRH agonists)Buserelin400900 mg/day (intranasal)Leuprolide3.757.5 mg/mo (intramuscular injection)Danazol200400 mg/d, intermittent substituting another agent or aug- Prognosis and outcome To date, no single intervention has proven to be equal-ly effective in treating all luteal symptoms remit significantly or the difference Steiner Revue de psychiatrie et de neuroscience Vol. 25, no5, 2000 Fig. 1: Algorithm for diagnosing and treating premenstrual syndrome and premenstrual dysphoric disorder ProfileDifferentialTreatmentWoman of reproductive age presents with premenstrual complaintsReview charting for timing with relation to menstrual cycle most troublesome symptomsPremenstrual mood and physicalsymptoms severe enough tointerfere with functioning Treat underlying Premenstrual exacerbation/or psychiatric disorderConservative therapies (Table 2)Low risk therapies (Table 3)Symptom specific therapies (Table 4) Predominantly premenstrual physical symptoms symptoms NOT associated Mood or physical symptomswith premenstrual worsening Situational disorder, vocational or marital stress PMS PMDD (Table 1) Evidence-based therapies (Table 4) Conservative therapies (Table 2) Rule out major psychiatric disorders Chart prospectively for 2 months Line 2Assessment Premenstrual syndrome and premenstrual dysphoric disorder Journal of Psychiatry & Neuroscience 465 cannot predict efficacy, and more consideration is nowbeing given to psychiatric history as well as to familypsychiatric history, especially to mood disorders in thefamilies of women with PMDD.There are 3 major concerns regarding the prognosis insevere PMS or PMDD: 1) the average age of onset isaround 26 years, 2) there is evidence that symptomsgradually worsen over time, and 3) there is evidencethat symptoms recur when treatment is halted.105,106these reasons, therapeutic goals must be set to ensuremaximal safety and efficacy for the patient. Diagnosis and treatment algorithm (Fig. 1) up the spectrum of evidence-based therapies as Conclusion Most women of reproductive age experience premen-strual symptoms that can be physical or affective innature. Approximately 5% of these women experiencesevere premenstrual symptoms that markedly influ-ence work, social activities or relationships. Prospectivecharting of premenstrual symptoms for at least 2 men-strual cycles is required to facilitate an accurate diagno-sis of this condition. While many women meet criteriafor PMS or PMDD, others have premenstrual worsen-ing of a pre-existing condition, or a continuous or inter-mittent condition not related to the menstrual cycle.Treatment of women with PMS or PMDD shouldbegin with conservative and low-risk interventions, fol-lowed by prescribed pharmacological interventions.Low-dose SSRIs have demonstrated excellent efficacywith minimal side effects, and there is increasing evi-dence that intermittent treatment is as efficacious ascontinuous daily treatment. Second-line therapy con-sists of modification of the menstrual cycle and shouldbe considered only after all other treatment optionshave failed. References 1.Johnson SR, McChesney C, Bean JA. Epidemiology of premen- . J Reprod Med 2.Budeiri DJ, Li Wan Po A, Dornan JC. Clinical trials of treatments . Br J Obstet Gynaecol 3.World Health Organization . International Statistical Classi- 4.Rivera-Tovar AD, Frank E. 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Neurodevelopment of children exposed in utero to N Engl J Med 102.Pastuszak A, Schick-Boschetto B, Zuber C, Feldkamp M, JAMA 103.Kulin NA, Pastuszak A, Sage SR, Schick-Boschetto B, Spivey G, JAMA 104.Goldstein D, Sundell K. A review of the safety of selective sero- Hum Psychopharmacol 105.Eriksson E. Serotonin reuptake inhibitors for the treatment of pre- Int Clin Psychopharmacol 106.Endicott J, Amsterdam J, Eriksson E, Frank E, Freeman E, J Womens Health Gender Based Med 107.Steiner M, Born L. Advances in the diagnosis and treatment of Cent Nerv SystDrugs 2000; 13:286-304. Steiner Revue de psychiatrie et de neuroscience Vol. 25, no5, 2000 CANADIAN COLLEGE OFNEUROPSYCHOPHARMACOLOGYCOLLGE CANADIEN DENEUROPSYCHOPHARMACOLOGIE CCNP Medal This Award was established to honour individuals for a meritorious career in, and outstanding contribution to, neuropsy-chopharmacology in Canada as evidenced by their activities in education, administration and/or patient care. Achievement inresearch is not a necessary criterion for this Award.The Award, which does not have to be awarded each year, consists of a bronze medal engraved with the name of the recipient. Nomination for 2001 CCNP Medal 1.Six copies of a two-page summary prepared by the sponsor describing the nominee2.Six copies of the nominee3.Six copies of a brief biographical sketch of the candidate prepared by the sponsor.Edmonton AB T6G 2B7 Deadline for receipt of initial nomination and short supporting letter is November 30, 2000.