Q&A: Menstrual mood disorders and their mental health effects

Symptoms of menstrual mood disorders, including premenstrual syndrome and premenstrual dysphoric disorder, range from physical to emotional, and researchers have estimated that they occur in up to 80% of women in the United States.

Healio spoke with Thalia Robakis, MD, PhD, associate professor of psychiatry at Icahn School of Medicine and co-director of the Women's Mental Health Program at Mount Sinai, about the mental health effects of these disorders on women and how clinicians should treat them. by Kate Burba

Question: What are the symptoms of premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD)?

Answer: PMS includes physical symptoms that occur in the days prior to the onset of menses. Typical symptoms of PMS could include breast tenderness, cramping, water retention or a bloating sensation and headaches.

PMDD includes mental/emotional symptoms that occur prior to menses and remit when menstruation starts. Typical symptoms of PMDD could include irritability, emotional lability, anxiety and depressed mood, as well as disturbances in sleep, appetite, energy and focus. To be classified as such, the disturbances must be severe enough to interfere significantly with relationships, work or social activities.

PMS varies a lot cross-culturally and it depends a bit on how it is assessed (meaning which symptoms clinicians ask about). Mild PMS is common, but severe PMS is less common.

The prevalence of clinically significant PMS has been estimated at 13% to 18%, and PMDD prevalence at 3% to 8%.

Q: What is the role of reproductive hormones in PMS/PMDD? Do they cause mental health issues or exacerbate an existing issue?

A: Our best understanding is that women with PMDD are more sensitive to abrupt changes in levels of gonadal steroids. There is a peak in estrogen right around ovulation and then a peak in both estrogen and progesterone in the luteal phase, which then abruptly drops off at the onset of menstruation. It seems that women with PMDD don’t respond well to the rapid increase and decrease in gonadal steroids that happens right before menstruation starts. A few women also have some symptoms around ovulation.

On a molecular level, we know that cells isolated from women with PMDD show different cellular responses to applied estrogen than cells isolated from women without PMDD. Actual serum concentrations of hormones are not different between women with and without PMDD.

Q: Are some women more likely to develop PMS/PMDD than others? Are PMS/PMDD related to other reproductive or metabolic conditions?

A: PMDD, like other psychiatric disorders, has high comorbidity with many other types of psychiatric disorders. Someone with depression, bipolar disorder or anxiety is more likely than people without any of those to also have PMDD. There are also plenty of women who have isolated PMDD without other psychiatric disorders.

Q: How are PMS/PMDD diagnosed?

A: The gold standard for diagnosing PMDD includes prospective charting of mood for at least three consecutive menstrual cycles. In practice, I usually diagnose it by clinical interview. Generally, if a woman has a certain number of psychiatric/emotional symptoms that last for most of the week before her period and she is clear that this happens every cycle and it is sufficiently severe as to disrupt her normal functioning, I would go ahead and diagnose PMDD.

Q: How are these patients treated?

A: There are generally two options for the treatment of PMDD. One is to erase the hormonal cycling by using a hormonal contraceptive, typically an oral pill, and ideally one that provides a constant level of hormone at all times (ie, a monophasic, extended-cycle or continuous pill rather than a biphasic or triphasic). Combination drospirenone/ethinyl estradiol (Yaz, Bayer) has been specifically studied for PMDD, but the drospirenone is somewhat riskier for blood clots than other types of oral contraceptive. The choice of pill is one that should be discussed carefully with the prescribing physician.

The other option is to use antidepressants to treat the symptoms. This is very effective and often better tolerated than oral contraceptives. In many cases of PMDD, the antidepressants can be used only in the 1 to 2 weeks when symptoms are present (luteal-phase dosing) rather than all the time.

There is some published evidence for vitamin B6 in PMS treatment, and I have seen positive response for PMDD as well, although I don’t believe there are any published data for B6 in PMDD. Some people also prescribe calcium and/or vitamin D, although I haven’t myself seen benefit from this.

Q: Are other mental health issues among women for example, postpartum depression or depressive symptoms during the menopause transition similar to PMS/PMDD in pathophysiology? Might a woman be more likely to develop issues during pregnancy or menopause if she has PMS/PMDD?

A: Yes. Several studies have turned up in correlation between PMDD and increased risk for postpartum depression. I think the connection with perimenopausal depression is less clear. It’s been reported that women with perimenopausal depression are also more symptomatic premenstrual, but I don’t think PMDD has been prospectively investigated as a risk factor for perimenopausal depression vs. just being more active in women during the menopausal transition. Prior history of depression is definitely a risk factor for depression in perimenopause.

Q: Do men experience any analogous endocrine-related mental health issues? Does identifying PMS/PMDD or depressive symptoms during menopause medicalize normal female biology?

A: Hormonal regulation of mood is present in everyone, but men don’t go through the types of predictable, regular transitions in circulating levels of sex steroids that women do, so the effects are less obvious because they are more constant. If you provide exogenous sex steroids or hormone blockers to men (eg testosterone for libido, athletic purposes or estrogen for gender transition) or to male experimental animals, you can definitely observe effects on mood regulation.

Some common symptoms of menopause like insomnia, problems with focus and loss of libido can overlap with symptoms of depression. But symptoms like hopelessness, loss of interest or pleasure in life or thoughts of suicide are not normal components of the menopausal transition and should absolutely be treated. Once the menopausal transition is complete, the prevalence of depression drops again, so there is a light at the other side of the tunnel.

Disclosure: Robakis reports no relevant financial disclosures.

Symptoms of menstrual mood disorders, including premenstrual syndrome and premenstrual dysphoric disorder, range from physical to emotional, and researchers have estimated that they occur in up to 80% of women in the United States.

Healio spoke with Thalia Robakis, MD, PhD, associate professor of psychiatry at Icahn School of Medicine and co-director of the Women's Mental Health Program at Mount Sinai, about the mental health effects of these disorders on women and how clinicians should treat them. by Kate Burba

Question: What are the symptoms of premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD)?

Answer: PMS includes physical symptoms that occur in the days prior to the onset of menses. Typical symptoms of PMS could include breast tenderness, cramping, water retention or a bloating sensation and headaches.

PMDD includes mental/emotional symptoms that occur prior to menses and remit when menstruation starts. Typical symptoms of PMDD could include irritability, emotional lability, anxiety and depressed mood, as well as disturbances in sleep, appetite, energy and focus. To be classified as such, the disturbances must be severe enough to interfere significantly with relationships, work or social activities.

PMS varies a lot cross-culturally and it depends a bit on how it is assessed (meaning which symptoms clinicians ask about). Mild PMS is common, but severe PMS is less common.

The prevalence of clinically significant PMS has been estimated at 13% to 18%, and PMDD prevalence at 3% to 8%.

Q: What is the role of reproductive hormones in PMS/PMDD? Do they cause mental health issues or exacerbate an existing issue?

A: Our best understanding is that women with PMDD are more sensitive to abrupt changes in levels of gonadal steroids. There is a peak in estrogen right around ovulation and then a peak in both estrogen and progesterone in the luteal phase, which then abruptly drops off at the onset of menstruation. It seems that women with PMDD don’t respond well to the rapid increase and decrease in gonadal steroids that happens right before menstruation starts. A few women also have some symptoms around ovulation.

On a molecular level, we know that cells isolated from women with PMDD show different cellular responses to applied estrogen than cells isolated from women without PMDD. Actual serum concentrations of hormones are not different between women with and without PMDD.

Q: Are some women more likely to develop PMS/PMDD than others? Are PMS/PMDD related to other reproductive or metabolic conditions?

A: PMDD, like other psychiatric disorders, has high comorbidity with many other types of psychiatric disorders. Someone with depression, bipolar disorder or anxiety is more likely than people without any of those to also have PMDD. There are also plenty of women who have isolated PMDD without other psychiatric disorders.

Q: How are PMS/PMDD diagnosed?

A: The gold standard for diagnosing PMDD includes prospective charting of mood for at least three consecutive menstrual cycles. In practice, I usually diagnose it by clinical interview. Generally, if a woman has a certain number of psychiatric/emotional symptoms that last for most of the week before her period and she is clear that this happens every cycle and it is sufficiently severe as to disrupt her normal functioning, I would go ahead and diagnose PMDD.

Q: How are these patients treated?

A: There are generally two options for the treatment of PMDD. One is to erase the hormonal cycling by using a hormonal contraceptive, typically an oral pill, and ideally one that provides a constant level of hormone at all times (ie, a monophasic, extended-cycle or continuous pill rather than a biphasic or triphasic). Combination drospirenone/ethinyl estradiol (Yaz, Bayer) has been specifically studied for PMDD, but the drospirenone is somewhat riskier for blood clots than other types of oral contraceptive. The choice of pill is one that should be discussed carefully with the prescribing physician.

The other option is to use antidepressants to treat the symptoms. This is very effective and often better tolerated than oral contraceptives. In many cases of PMDD, the antidepressants can be used only in the 1 to 2 weeks when symptoms are present (luteal-phase dosing) rather than all the time.

There is some published evidence for vitamin B6 in PMS treatment, and I have seen positive response for PMDD as well, although I don’t believe there are any published data for B6 in PMDD. Some people also prescribe calcium and/or vitamin D, although I haven’t myself seen benefit from this.

Q: Are other mental health issues among women for example, postpartum depression or depressive symptoms during the menopause transition similar to PMS/PMDD in pathophysiology? Might a woman be more likely to develop issues during pregnancy or menopause if she has PMS/PMDD?

A: Yes. Several studies have turned up in correlation between PMDD and increased risk for postpartum depression. I think the connection with perimenopausal depression is less clear. It’s been reported that women with perimenopausal depression are also more symptomatic premenstrual, but I don’t think PMDD has been prospectively investigated as a risk factor for perimenopausal depression vs. just being more active in women during the menopausal transition. Prior history of depression is definitely a risk factor for depression in perimenopause.

Q: Do men experience any analogous endocrine-related mental health issues? Does identifying PMS/PMDD or depressive symptoms during menopause medicalize normal female biology?

A: Hormonal regulation of mood is present in everyone, but men don’t go through the types of predictable, regular transitions in circulating levels of sex steroids that women do, so the effects are less obvious because they are more constant. If you provide exogenous sex steroids or hormone blockers to men (eg testosterone for libido, athletic purposes or estrogen for gender transition) or to male experimental animals, you can definitely observe effects on mood regulation.

Some common symptoms of menopause like insomnia, problems with focus and loss of libido can overlap with symptoms of depression. But symptoms like hopelessness, loss of interest or pleasure in life or thoughts of suicide are not normal components of the menopausal transition and should absolutely be treated. Once the menopausal transition is complete, the prevalence of depression drops again, so there is a light at the other side of the tunnel.

Disclosure: Robakis reports no relevant financial disclosures.