Journal of Psychosocial Nursing and Mental Health Services

Psychopharmacology 

Premenstrual Exacerbations: Achieving Stability All Month, Every Month

Laura G. Leahy, DrNP, APRN, PMH-CNS/FNP, BC

Abstract

Premenstrual syndrome, premenstrual dysphoric disorder, or premenstrual exacerbation of a psychiatric condition may disrupt 10 years of a woman's life over the course of her reproductive lifespan. As health care practitioners, nurses see women who experience these premenstrual symptom exacerbations in all treatment settings. Premenstrual exacerbation of psychiatric illness is a common phenomenon, and it is treatable; however, research is limited and evidence-based guidelines for treatment are sparse. The current article offers insights and an algorithm, extrapolated from the existing literature, into a lesser-known treatment strategy, semi-intermittent dosing, which will provide symptom stability all month, every month. [Journal of Psychosocial Nursing and Mental Health Services, 55(4), 9–13.]

Abstract

Premenstrual syndrome, premenstrual dysphoric disorder, or premenstrual exacerbation of a psychiatric condition may disrupt 10 years of a woman's life over the course of her reproductive lifespan. As health care practitioners, nurses see women who experience these premenstrual symptom exacerbations in all treatment settings. Premenstrual exacerbation of psychiatric illness is a common phenomenon, and it is treatable; however, research is limited and evidence-based guidelines for treatment are sparse. The current article offers insights and an algorithm, extrapolated from the existing literature, into a lesser-known treatment strategy, semi-intermittent dosing, which will provide symptom stability all month, every month. [Journal of Psychosocial Nursing and Mental Health Services, 55(4), 9–13.]

Exploring psychotherapeutic issues and agents in clinical practice

With the average female experiencing menarche close to the age of 12 and menopause around the age of 52, premenstrual symptoms, occurring just 1 week per month, can disrupt a woman's quality of life for 10 years over the course of the reproductive lifecycle. Treating women with comorbid psychiatric illness and premenstrual exacerbations presents a unique challenge to the prescribing practitioner. The hormonal fluctuations during a woman's menstrual cycle alone can contribute to symptoms of anxiety, depressed mood, anger, irritability, fatigue, sleep disruption, lack of focus, social withdrawal, food cravings, and a host of physical complaints. During the week or two prior to menstrual onset, women diagnosed with a psychiatric illness may also experience a worsening of their condition, even if stabilized on medications. As the symptoms of premenstrual exacerbation mimic those of various psychiatric illnesses, it can be difficult for practitioners to differentiate the root cause of the symptom presentation. For this reason, it is important for practitioners treating women with psychiatric illness to thoroughly explore abrupt symptom changes and their timing in relation to a woman's menses (Leahy, 2016).

What Is Premenstrual Exacerbation?

Various terms are used to describe the constellation of physical and emotional symptoms experienced by women prior to their menses. Stöppler (2014) defines premenstrual syndrome (PMS) as a complex health concern consisting of various physical, mental, and behavioral symptoms occurring during the 2 weeks prior to the onset of a woman's period and resolving within the first 2 days of menstrual flow. The American College of Obstetricians and Gynecologists (ACOG; 2000) offers diagnostic criteria for PMS, which can be found in Table 1. Htay, Ahmed, and Aung (2016) define premenstrual dysphoric disorder (PMDD) as the deterioration of functioning, characterized by depressed or labile mood, anxiety, irritability, anger, and other symptoms causing serious distress and occurring during the 2 weeks prior to the onset of menses and subsiding shortly thereafter. The American Psychiatric Association (APA; 2013) offers diagnostic criteria for PMDD in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which can be found in Table 2.


American College of Obstetricians and Gynecologists (2000) Diagnostic Criteria for Premenstrual Syndrome

Table 1:

American College of Obstetricians and Gynecologists (2000) Diagnostic Criteria for Premenstrual Syndrome


DSM-5 Diagnostic Criteria for Premenstrual Dysphoric Disorder (APA, 2013)

Table 2:

DSM-5 Diagnostic Criteria for Premenstrual Dysphoric Disorder (APA, 2013)

Premenstrual exacerbation is defined by Hsiao, Hsiao, and Liu (2004) as the premenstrual worsening of a pre-existing psychiatric disorder. In 2002, Hsiao, Liu, Chen, and Hsieh described premenstrual exacerbation as the aggravation of any DSM-based symptoms for women with the corresponding DSM diagnosis. For example, magnification of psychic/somatic anxiety for patients with generalized anxiety disorder, increased depression for those with a depressive disorder, increased incidence of panic for patients diagnosed with panic disorder, and a worsening of positive or disorganized symptoms in patients diagnosed with psychotic disorders.

Although only 3% to 8% of menstruating reproductive-aged women meet the DSM-5 (APA, 2013) criteria for PMDD, it is estimated that 85% of those women experience premenstrual exacerbation (Pearlstein & Steiner, 2008). In a study of approximately 300 women diagnosed with bipolar disorder, Dias et al. (2011) found that approximately 60% of the women who charted their menses prospectively reported premenstrual exacerbation of their mood symptoms. Similarly, studies have shown more than 50% correlation between premenstrual exacerbation, depressive disorders, and anxiety disorders (Hsiao et al., 2004). Thus, for the majority of women diagnosed with a psychiatric illness, premenstrual exacerbation appears to exacerbate the symptoms and disrupt quality of life.

How Can We Treat Comorbid Psychiatric Illness and Premenstrual Exacerbation?

Unfortunately, the literature regarding treatment for premenstrual exacerbation is sparse, leaving little in terms of evidence-based practice guidelines. The published studies are small, outdated in terms of current standards, and often offer inconclusive results. Yet, these women continue to experience and seek treatments to relieve their physical, emotional, and behavioral symptoms. Nonpharmacological treatments, which have shown some efficacy for premenstrual exacerbation, include acupuncture, relaxation, light therapy, and cognitive-behavioral therapy.

In treating PMS and PMDD, pharmacotherapies have demonstrated greater evidence to support their use. Various classes of medications have been studied: hormonal agents (e.g., oral contraceptives), diuretics to relieve fluid retention, nonsteroidal anti-inflammatory drugs to relieve cramping and physical symptoms, and psychotropic agents (i.e., anxiolytic, antidepressant, and mood stabilizing agents). A meta-analysis of 3,000 women found that the all available selective serotonin reuptake inhibitor (SSRI) antidepressant agents were effective in treating PMS and PMDD when taken continuously as opposed to being taken only during the luteal phase of the menstrual cycle (i.e., intermittent dosing) (Shah et al., 2008). Yet, the treatment of premenstrual exacerbation and comorbid psychiatric illness remains relatively unresearched; thus, treatments for these comorbid conditions must be extrapolated from the treatments for PMS and PMDD.

Semi-Intermittent Dosing

A little known and sparsely researched strategy to treat premenstrual exacerbation of an underlying psychiatric condition is called semi-intermittent dosing. This method involves the “bumping up” of the medication used to treat the psychiatric condition during the luteal phase of the woman's menstrual cycle and then resuming the usual dosage upon the onset of menses (Steiner et al., 2006). The Figure offers a treatment algorithm used in the current author's practice to treat women with comorbid psychiatric illness and premenstrual exacerbation.


Algorithm to treat comorbid premenstrual exacerbation of psychiatric illness. Printed with permission from L.G. Leahy. Copyright © Leahy 2014.

Figure.

Algorithm to treat comorbid premenstrual exacerbation of psychiatric illness. Printed with permission from L.G. Leahy. Copyright © Leahy 2014.

Using the algorithm in the Figure as a guide, a hypothetical case is presented to illustrate the principles of semi-intermittent dosing in the treatment of premenstrual exacerbation of major depressive disorder and panic disorder. None of the information contained in the case pertains to an actual patient in the author's practice.

Case Example

Barbara is a 26-year-old woman who presents with depressed mood, irritability, decreased concentration, fatigue, delayed sleep onset, self-injurious behavior (i.e., cutting), daily crying episodes, and feelings of worthlessness. She describes these symptoms as occurring most days over the past 2 to 3 months and cannot identify any significant changes or stressors that have contributed to the symptoms. The symptoms are causing tension in the relationship with her boyfriend and poor grades in her graduate school classes. She reports no chronic medical conditions and no allergies to medications. She is currently prescribed YAZ® (drospirenone 3 mg/ethinyl estradiol 20 mcg × 24 days then inert tabs × 4 days) as a form of birth control. She has a family history of depression on her mother's side and alcoholism on her father's side. She denies any suicide attempts. She is diagnosed with major depressive disorder, single episode, moderate severity. A decision is made to start the SSRI antidepressant Zoloft® (sertraline). Over the course of 1 month, the dose is titrated up to 100 mg daily and Barbara reports feeling approximately 75% relief of her symptoms.

By the second month of treatment, Barbara comes to her appointment and says, “I feel great, except for the week before my period!” Further exploration reveals increased irritability, cravings for sweet and salty foods, feeling exhausted, insomnia, and crying for 5 to 7 days prior to menses and ending at the onset of bleeding. The symptoms are consistent with premenstrual exacerbation of major depressive disorder. As Barbara is currently prescribed sertraline 100 mg daily, the recommendation is made to increase the dose to 150 mg daily for the 5 to 7 days before her period and then return to the 100-mg dose upon the start of bleeding. It is also recommended that Barbara prospectively track her symptoms and their severity over her next few cycles using a free PMDD Symptom Tracker (access http://nap-mdd.org/tracking-symptoms) or free menstrual cycle tracking application (app) (i.e., CLUE, access http://hel-loclue.com/index.html).

When Barbara arrives for her appointment, she reviews her symptom tracking record and reports that her symptoms are less intense but still occur approximately 3 days prior to her menstrual onset. Her dose of sertraline is increased to 200 mg daily for the 5 days prior to her menses with a return to 100 mg daily at the onset of her cycle. Barbara continues to prospectively track her symptoms and reports at her 6-month appointment, “I feel normal! All month, every month!”

Case Review and Conclusion

Although Barbara's case was straightforward regarding her depressive symptoms and premenstrual exacerbation, it is curious that the oral contraceptive she was taking did not alleviate the emotional and behavioral symptoms premenstrually. Research suggests that YAZ may be helpful in decreasing food cravings, decreasing appetite, reducing bloating and weight gain, and relieving acne (Freeman, 2002), all of which may have a beneficial effect on the emotional symptoms of premenstrual exacerbation. Unfortunately, in Barbara's case, the emotional symptoms continued and, because the oral contraceptive did not contribute to any adverse events, it was continued along with the SSRI antidepressant agent.

The current case example illustrates the need to take a thorough menstrual symptom history when treating female patients of reproductive age. It is also important to request that patients track their symptoms prospectively across multiple menstrual cycles to gain a better understanding of the onset, severity, and cessation of premenstrual symptom exacerbation in patients with psychiatric comorbidities.

PMS, PMDD, and premenstrual exacerbation are all treatable conditions. Partnering with female patients to understand their unique symptom profiles is imperative to facilitating the best therapy to improve their quality of life all month, every month, despite the disruption of the menstrual cycle.

References

  • American College of Obstetricians and Gynecologists. (2000). Premenstrual syndrome (Practice Bulletin No. 15). Washington, DC: Author.
  • American Psychiatric Association. (2013). Premenstrual dysphoric disorder: Diagnostic criteria. In Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
  • Dias, R.S., Lafer, B., Russo, C., Del Debbio, A., Nierenberg, A.A., Sachs, G.S. & Joffe, H. (2011). Longitudinal follow-up of bipolar disorder in women with premenstrual exacerbation: Findings from STEP-BD. American Journal of Psychiatry, 168, 386–394. doi:10.1176/appi.ajp.2010.09121816 [CrossRef]
  • Freeman, E.W. (2002). Evaluation of a unique oral contraceptive (Yasmin) in the management of premenstrual dysphoric disorder. European Journal of Contraceptive and Reproductive Health Care, 7(Suppl. 3), 27–34.
  • Hsiao, M.C., Hsiao, C.C. & Liu, C.Y. (2004). Premenstrual symptoms and premenstrual exacerbation in patients with psychiatric disorders. Psychiatry and Clinical Neurosciences, 58, 186–190. doi:10.1111/j.1440-1819.2003.01215.x [CrossRef]
  • Hsiao, M.C., Liu, C.Y., Chen, K.C. & Hsieh, T.T. (2002). Characteristics of women seeking treatment for premenstrual syndrome in Taiwan. Acta Psychiatrica Scandinavica, 106, 150–155. doi:10.1034/j.1600-0447.2002.01265.x [CrossRef]
  • Htay, T.T., Ahmed, I. & Aung, K. (2016). Premenstrual dysphoric disorder. Retrieved from http://emedicine.medscape.com/article/293257-overview
  • Leahy, L.G. (2016). Are you missing important changes in your women patients? Retrieved from http://psychnews.psychiatryonline.org/doi/full/10.1176/appi.pn.2016.pp9b2
  • Pearlstein, T. & Steiner, M. (2008). Premenstrual dysphoric disorder: Burden of illness and treatment update. Journal of Psychiatry and Neuroscience, 33, 291–301.
  • Shah, N.R., Jones, J.B., Aperi, J., Shemtov, R., Karne, A. & Borenstein, J. (2008). Selective serotonin reuptake inhibitors for premenstrual syndrome and premenstrual dysphoric disorder: A meta-analysis. Obstetrics and Gynecology, 111, 1175–1182. doi:10.1097/AOG.0b013e31816fd73b [CrossRef]
  • Steiner, M., Pearlstein, T., Cohen, L.S., Endicott, J., Kornstein, S.G., Roberts, C. & Yonkers, K. (2006). Expert guidelines for the treatment of severe PMS, PMDD, and comorbidities: The role of SSRIs. Journal of Womens Health, 15, 57–69. doi:10.1089/jwh.2006.15.57 [CrossRef]
  • Stöppler, M. (2014). PMDD: A severe form of PMS. Retrieved from http://www.emedicinehealth.com/premenstrual_syndrome_pms/article_em.html

American College of Obstetricians and Gynecologists (2000) Diagnostic Criteria for Premenstrual Syndrome

Patient reports at least one of each of the following affective and somatic symptoms during the 5 days before menses. Symptoms must appear in three consecutive menstrual cycles: Affective: Depression, angry outbursts, irritability, anxiety, confusion, social withdrawal Somatic: Breast tenderness, abdominal bloating, headache, swelling of extremities Symptoms must also meet the following criteria:

Be relieved within 4 days of the onset of menses, without recurrence until at least cycle day 13

Be present in the absence of any pharmacological therapy, hormone ingestion, or drug or alcohol use

Be causing identifiable dysfunction in social or economic performance

Occur reproducibly during two cycles of prospective recording

DSM-5 Diagnostic Criteria for Premenstrual Dysphoric Disorder (APA, 2013)

In most menstrual cycles during the past year, five (or more) of the following symptoms were present for most of the time during the last week of the luteal phase, began to remit within a few days after the onset of the follicular phase, and were absent in the week post-menses, with at least one of the symptoms being 1, 2, 3, or 4:

Markedly depressed mood, feelings of hopelessness, or self-deprecating thoughts

Marked anxiety, tension, feelings of being “keyed up” or “on the edge”

Marked affective lability (e.g., feeling suddenly sad or tearful or increased sensitivity to rejection)

Persistent and marked anger or irritability or increased interpersonal conflicts

Decreased interest in usual activities (e.g., work, school, friends, hobbies)

Subjective sense of difficulty in concentrating

Lethargy, easy fatigability, or marked lack of energy

Marked change in appetite, overeating, or specific food cravings

Hypersomnia or insomnia

A subjective sense of being overwhelmed or out of control

Other physical symptoms, such as breast tenderness or swelling, headaches, joint or muscle pain, a sensation of “bloating,” weight gain

The symptoms are associated with clinically significant distress or markedly interfere with work or school or usual social activities and relationships with others (e.g., avoidance of social activities, decreased productivity and efficiency at work or school).

The disturbance is not merely an exacerbation of the symptoms of another disorder, such as major depressive disorder, panic disorder, dysthymic disorder, or a personality disorder (although, it may be superimposed on any of these disorders).

Criteria A, B, and C must be confirmed by prospective daily ratings during at least two consecutive somatic cycles. (A provisional diagnosis may be made prior to this confirmation.)

The symptoms are not attributable to the physiological effects of a substance (e.g., drug of abuse, medication, other treatment) or another medical condition (e.g., hyperthyroidism).

Authors

Dr. Leahy is Family Psychiatric Advanced Practice Nurse and Master Clinician in Psychopharmacology, APNSolutions, LLC, Sewell, New Jersey.

The author has disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Laura G. Leahy, DrNP, APRN, PMH-CNS/FNP, BC, Family Psychiatric Advanced Practice Nurse and Master Clinician in Psychopharmacology, APNSolutions, LLC, 123 Egg Harbor Road, Suite 703, Sewell, NJ 08080; e-mail: lgleahy@apnsolutions.com.

10.3928/02793695-20170330-02

Sign up to receive

Journal E-contents