Premenstrual Dysphoric Disorder (PMDD) and Premenstrual Syndrome (PMS)

Introduction

Premenstrual Syndrome (PMS) and Premenstrual Dysphoric Disorder (PMDD) are important topics for the MCCQE1 exam, particularly in the context of Canadian women's health. Understanding these conditions is crucial for providing comprehensive care in the Canadian healthcare system.

Definitions and Epidemiology

Premenstrual Syndrome (PMS)

PMS is a collection of physical and emotional symptoms that occur in the luteal phase of the menstrual cycle and resolve with the onset of menses.

Premenstrual Dysphoric Disorder (PMDD)

PMDD is a more severe form of PMS, characterized by significant mood disturbances that interfere with daily functioning.

Clinical Presentation

Diagnostic Criteria

PMS Diagnostic Criteria

1. Symptoms occur during the luteal phase of the menstrual cycle
2. Symptoms resolve within a few days of menses onset
3. Symptoms are present in most menstrual cycles
4. Symptoms interfere with daily activities

PMDD Diagnostic Criteria (DSM-5)

1. At least five symptoms present in the week before menses
2. Symptoms improve within a few days after menses onset
3. Symptoms are minimal or absent in the week post-menses
4. Symptoms cause significant functional impairment
5. Symptoms are not attributable to another medical condition or substance use

Pathophysiology

The exact pathophysiology of PMS and PMDD is not fully understood, but several factors are thought to contribute:

1. Hormonal fluctuations
2. Neurotransmitter imbalances (particularly serotonin)
3. Genetic predisposition
4. Environmental factors

Management

Canadian Guidelines

The Society of Obstetricians and Gynaecologists of Canada (SOGC) provides the following recommendations for managing PMS and PMDD:

1. Diagnosis should be based on prospective symptom charting for at least two menstrual cycles
2. SSRIs are the first-line pharmacological treatment for PMDD
3. Combined oral contraceptives containing drospirenone may be beneficial for some women with PMS
4. Cognitive Behavioral Therapy should be considered as a non-pharmacological treatment option

Sample Question

# Sample Question

A 28-year-old woman presents to her family physician with complaints of severe mood swings, irritability, and difficulty concentrating for the past six months. These symptoms occur about a week before her menstrual period and resolve a few days after the onset of menses. She reports that these symptoms are significantly affecting her work and relationships. Which of the following is the most appropriate next step in management?

- [ ] A. Prescribe oral contraceptives
- [ ] B. Recommend over-the-counter NSAIDs
- [ ] C. Start selective serotonin reuptake inhibitor (SSRI) therapy
- [ ] D. Suggest calcium and vitamin D supplementation
- [ ] E. Refer to a psychiatrist for further evaluation

Explanation

The correct answer is:

• C. Start selective serotonin reuptake inhibitor (SSRI) therapy

This patient's presentation is consistent with Premenstrual Dysphoric Disorder (PMDD). The symptoms are severe, occur in the luteal phase, resolve with menses, and significantly impact her daily functioning. According to Canadian guidelines (SOGC), SSRIs are the first-line pharmacological treatment for PMDD.

A. Oral contraceptives can be helpful for PMS but are not the first-line treatment for PMDD. B. NSAIDs may help with physical symptoms but do not address the mood symptoms characteristic of PMDD. D. While calcium and vitamin D supplementation may be beneficial, it is not the most appropriate first-line treatment for PMDD. E. While mental health referral may be considered, starting SSRI therapy is the most appropriate initial step in primary care.

References

1. Reid, R. L., & Soares, C. N. (2018). Premenstrual Dysphoric Disorder: Contemporary Diagnosis and Management. Journal of Obstetrics and Gynaecology Canada, 40(2), 215-223. https://doi.org/10.1016/j.jogc.2017.05.018 (opens in a new tab)

2. Society of Obstetricians and Gynaecologists of Canada. (2017). Managing Menstruation: A Canadian Consensus Guideline. Journal of Obstetrics and Gynaecology Canada, 39(7), e1-e33. https://doi.org/10.1016/j.jogc.2017.04.016 (opens in a new tab)

3. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

4. Yonkers, K. A., & Simoni, M. K. (2018). Premenstrual disorders. American Journal of Obstetrics and Gynecology, 218(1), 68-74. https://doi.org/10.1016/j.ajog.2017.05.045 (opens in a new tab)

5. Health Canada. (2021). Natural Health Products Ingredients Database. https://www.canada.ca/en/health-canada/services/drugs-health-products/natural-non-prescription/applications-submissions/product-licensing/natural-health-products-ingredients-database.html (opens in a new tab)