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Miss O.B. is a 22 year old recent college graduate who saw me in the office because of problems with her periods.
Starting a couple of weeks before her menstrual flow, she becomes increasingly depressed, anxious, and feels tense. She has episodes of angry outbursts, can’t sleep and has trouble concentrating. She feels totally out of control and just wants to be left alone. One or two days each month, she can’t get out of bed to go to work, first because she feels terrible and doesn’t want to get up, and also because she’s afraid someone will cross her and she’ll explode. She also notes breast tenderness, some headaches, and bloating, but they don’t bother her as much as the other symptoms. Once she gets her period, all of the symptoms go away and she feels fine for about two weeks. Then the next cycle of terrible symptoms develops.
O.B. is presenting with stereotypical symptoms of Premenstrual Dysphoric Disorder or PMDD. The symptoms of PMDD are similar or indistinguishable from the symptoms of PMS, but the severity and duration of symptoms is worse with PMDD. With PMDD, the symptoms occur during the two weeks preceeding the menstrual flow, rather than the 5 days associated with PMS. PMS causes some identifiable impairment in the patient’s functioning, but PMDD markedly interferes with work, school, or the usual sucial activities and relationships with others.
The clinical features of PMDD include:
• Essential features
o Markedly depressed mood
o Anxiety
o Tension
o Frequent mood swings
o Persistent anger or irritability
• Other features
o Decreased interest in activities
o Difficulty concentrating
o Lack of energy
o Change in appetite or sleep
o Feeling out of control
• Physical symptoms
o Breast tenderness
o Headaches
o Joint and muscle pain
o Bloating
o Weight gain
In evaluating patients presenting like this, it is very important to explore how they feel at other times of the menstrual cycle. About a third of women presenting with PMS symptoms will have some underlying mood disorder, such as depression or anxiety. With PMDD, the likelihood of concomittant psychiatric disorder is probably higher. Thyroid disease is one of a number of medical problems that can present initially as PMS or PMDD.
In the case of O.B., she did not have any other symptoms to suggest an underlying medical or mood disorder, so I started her treatment based on the primary diagnosis of PMDD. I counseled her as to the nature of the problem, and then recommended a strong, low-dose birth control pill, Portia. She had never taken birth control pills and was a little bit afraid of them, so I needed to persuade her to try them for a 6-month trial. Keep in mind that some of the newer, lower dose birth control pills do a fine job of preventing pregnancy, but a terrible job of suppressing ovulation. In O.B.’s case, she didn’t need the contraceptive benefit, but the success of birth control pills in regulating her symptoms would hinge on their ability to down-regulate ovarian function. For that reason, I needed a strong low dose pill that would reliably suppress ovulation.
I arranged to see her again in 3 months to evaluate the impact of the birth control pills on her symptoms.
• If her symptoms were completely resolved, then I would continue with the birth control pills alone.
• If her symptoms were improved but not resolved, I would add an SSRI, probably Zoloft.
• If her symptoms were unchanged, then I would move her to continuous birth control pills (non-stop, without a break for any periods), and also start Zoloft.
• If her symptoms were were, then I would move her to continuous birth control pills, and refer her to a psychiatrist for further evaluation and management.
The reasons for this approach are straightforward. Should her symptoms be completely resolved with BCPs, then there’s no need for any further intervention. Just keep going with the BCPs. But if she is improved but still has some symptoms, then I would add an SSRI to the therapeutic mix. We know that SSRI’s alone can be effective in regulating many of these period-related mood changes, and I’m not shy about prescribing it. But if she doesn’t need it, then I’ll stick with BCPs alone.
If there has been no change in her symptoms, then I’m concerned that the BCPs, taken in the usual way, are not being effective in suppressing ovulation and other ovarian function, so I change the dosing to the most effective pattern we have…continuous birth control pills. I’ll also start an SSRI, because she has demonstrated that she’s not going to respond to the simple expedient of BCPs. Best to add the other proven medication to help this problem. The reason for a psychiatric consultation in the event she is worsening is the increasing likelihood that she has a serious underlying psychiatric disorder that I’m not qualified by experience or training to take care of.
