History, Evolution, and Diagnosis of PMDD in the Ob/Gyn Office.
The symposium, entitled "New Horizons in the Management of Mood Disorders in Women of Reproductive Age: PMDD & Depression During Pregnancy," was moderated by Frank Ling, MD, Professor and Chair, Department of Obstetrics and Gynecology at the University of Tennessee College of Medicine, Memphis.
Premenstrual syndrome (PMS) and the related psychiatric disorder premenstrual dysphoric disorder (PMDD) "present a challenge, even to the most dedicated practitioner," Dr Ling said. Ob/gyn specialists must often identify and diagnose these conditions, then guide women onto the most appropriate management track.
History and Evolution of PMS/PMDD
The symptoms of what was called premenstrual tension syndrome--significant mood and behavior changes associated with the menstrual cycle--were first described in the medical literature in the 1930s, in a group of 15 patients, Dr Ling noted. However, not much attention was given to the condition at that time. The diagnosis became more common in the 1950s, when the term "premenstrual syndrome" was adopted. The syndrome became more clearly defined--and more frequently identified-in the early 1980s, when the National Institute of Mental Health convened a workshop on the issue.
Later, PMS was included in the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition (DSM-III-R) under the heading late luteal phase dysphoric disorder. In the early 1990s, Dr Ling reported, when the DSM-IV was published, the term for the disorder had been revised to PMDD, which was classified as "a depressive disorder not otherwise specified."
"It's important to recognize that the severe form of what we ob/gyns call PMS is what psychiatrists are now calling PMDD, with mood being the primary focus," Dr Ling noted.
Presentations of PMS/PMDD
Some patients present convinced they have PMS, some are completely unaware that their symptoms are related to PMS, others have been diagnosed correctly but have been inadequately treated, and still others have been misdiagnosed as having PMS. Still, according to Dr Ling, many women with PMS are both correctly diagnosed and adequately treated.
In making the diagnosis of PMS/PMDD, the following medical disorders should be considered: anemia, autoimmune disorders, hypothyroidism, diabetes, seizure disorders, and chronic fatigue syndrome. In addition, psychiatric diagnoses other than PMDD should be ruled out, including dysthymia (a chronic, low-grade constellation of depressive symptoms) and premenstrual exacerbations or worsening of such psychiatric conditions.
By definition, Dr Ling said, PMS is a collection of mood, behavior, and physical changes that 1) have a regular cyclic relationship to the luteal phase of the menstrual cycle; 2) are present in most but not all cycles; 3) remit by the end of the menstrual flow; and 4) remain in remission for at least 1 week each cycle. He noted that while 80% to 90% of women have some degree of symptoms that occur in this cyclic pattern, "only about 5% of women have symptoms that significantly affect school, work, or other responsibilities."
The cycle of symptoms varies among women. Symptoms may occur throughout the luteal phase or be limited to part of the luteal phase. Regardless of the pattern, Dr Ling said, "the constant in all patients with PMS is the approximately 1-week symptom-free interval after the menstrual flow and prior to ovulation."
A variety of rating forms and calendars are available for documenting the PMS symptom pattern, including the Calendar of Premenstrual Experiences, the Daily Rating Form, the Menstrual Distress Questionnaire, the Premenstrual Assessment Form, and the Premenstrual Record of Impact and Severity of Menstruation.
However, Dr Ling advised that ob/gyn colleagues consider a simple alternative--an empty calendar. For a patient whose history suggests a PMS diagnosis, Dr Ling provides a blank calendar and asks her to choose the three symptoms that concern her most, to assign a letter to each (for example, I for irritability or D for depression), and to chart the daily occurrence of those symptoms, along with the severity (ranked from 0 = absent to 3 = most severe). The starring date of each menstrual period is marked with an X.
"At the follow-up visit, it's easy for both of us to see if there is a pattern that fulfills the diagnostic criteria for PMS/PMDD," he said.
PMS or PMDD?
For the cycle-related symptoms to qualify for the more strict, psychiatric diagnosis of PMDD, as defined by the DSM-IV, patients must have at least five recognized symptoms, with at least one of those being a core symptom, that begin at least 1 week prior to the onset of the menstrual period and remit at the start of the flow. These core symptoms are depressed mood or dysphoria, anxiety or depression, affective lability, or irritability. Other qualifying--although not core--symptoms include decreased interest in usual activities, difficulty concentrating, marked lack of energy, hypersomnia or insomnia, changes in appetite, or physical symptoms such as breast tenderness, bloating, headache, or joint or muscle pain.
Further, the DSM-IV specifies that these symptoms must interfere with work, school, or other usual activities or relationships; must be not merely an exacerbation of another disorder; and must be confirmed by at least two cycles' worth of prospective daily ratings.
For a PMS diagnosis, the criteria are far less exacting, Dr Ling noted, requiring only one or more of the following symptoms: mild psychologic discomfort, bloating and weight gain, breast tenderness, swelling of hands and feet, aches and pains, poor concentration, sleep disturbance, or change in appetite. Other symptoms may also indicate PMS, but to qualify for the PMS diagnosis, one of these symptoms must be present.
The International Classification of Diseases, Tenth Revision (ICD-10) specifies that the symptoms must occur only in the luteal phase, peak shortly before the menses, and cease with the menstrual flow or soon thereafter, Dr Ling added.
Although spending the extra time required to properly evaluate and manage patients with PMS may not seem cost-effective, Dr Ling reminded his colleagues that "if you spend more than 50% of your face-to-face encounter in counseling, you can bill according to time by utilizing the ICD-10 Evaluation and Management codes. Document the amount of time spent and the proportion allotted to topics such as diet and stress management, for example. As a result, offices can provide care for these difficult clinical situations and still remain cost-effective.