Premenstrual Syndromes : PMS and PMDD - Rutuja :: The site ...

Universal acceptance of a diagnostic entity is needed
for unified coding and for regulatory purposes. It
has financial ramifications for service delivery and
reimbursement as well as for prescriptions and their
reimbursements.
The lack of clear, acceptable definitions inhibits the
development of drugs and other treatments. Regulatory
agencies, like the US Food and Drug Administration
(FDA) and the European Union’s European Medicines
Agency (EMEA) require clear clinical indication for
pivotal clinical trials and clear projected outcome measures.
In the USA, the indication of PMDD is acceptable
mainly because it is included in the influential DSM-IV
and follows its descriptive principles; PMS, though, is
still not acceptable despite the weight of the ACOG.
The implied dichotomy between the physical symptoms
of PMS and the mental symptoms of PMDD is
arbitrary. The association between physical and mental
symptoms is still unclear, especially when any of them is
severe enough to cause dysfunction and/or distress. The
repeated and widely presumed reference to PMDD as a
severe form of PMS is not supported by data, either. It
also assumes a continuum of basically the same manifestation
of an entity along a severity gradation and attributes
lesser severity to perception of physical and other
non-dysphoric symptoms.
A major unsolved issue is the definition of PMDD as
a diagnostic entity, independent of PMS. This may well be
correct but so far data to the contrary are no less convincing.
Most catamenial disorders (Table 2.4) are characterized
as an episode whose phenomena and etiology
are similar to generally occurring disorders, but the timing
of the episode is entrained to the menstrual cycle – mostly
due to hormonal fluctuations. Therefore, the menstrually
related changes trigger the occurrence of the specific
episode but do not influence the basic etiology and pathophysiology
or the vulnerability to the parent disorder.
Only a few physical symptoms of PMS or catamenial disorders
(e.g. breast tenderness) may be attributed to the
influence of estrogen or progesterone per se.
Review of the literature (for example, Refs 28–33)
demonstrates that PMDD may be a catamenial disorder
like any other catamenial disorder. The phenomena
are similar to other depressions and anxiety disorders
and there is a statistical association with them. In some
cases treatment interventions and responses are similar.
A vulnerability–trigger conceptualization 33–35 of
etiology and pathophysiology of PMS/PMDD suggests
that some women are vulnerable to develop specific
phenotypes of dysphoric disorders. Vulnerability implies
a symptomatic threshold in response to hormonal or
situational triggers. In many people symptoms appear
even without a currently known trigger and the course
of illness depends on currently unknown mechanisms.
DIAGNOSIS OF PMS/PMDD 13
Table 2.4 Is PMDD conceptually similar to the
following catamenial episodes?
● Epilepsy ● Genital herpes
● Migraine headache ● Asthma
● Other headaches ● Pneumothorax
● Meningioma symptoms ● Pulmonary
endometriosis
● Kleine–Levin syndrome ● Rheumatoid arthritis
(hypersomnia) ● Diabetes mellitus
● Myoclonus ● Porphyria
● Neuralgia paresthetica ● Platelets disorders
● Paraparesis ● Cholelithiasis
● Autoimmune diseases ● Urticaria and
(SLE, MS) anaphylaxis
● Suicidal behavior ● Glaucoma
● Sleep disorders ● Pain
Therefore, the main difference between DSM-IV affective
and anxiety disorders and subtypes of PMS/PMDD
would be the added vulnerability to menstrually related
triggers and probably also an intact or strong normalization
process that prevents the episode from extending
for a long time beyond the expiration of the menstrually
related transitory stimulus.
According to this conceptualization, the distinction
between PMDD (or PMS) and premenstrual exacerbation
(PME) of other mental or physical disorders may
not be substantial, especially when the exacerbations
are limited to or occur mostly during the premenstrual
period. Biologically, PMS and PME may represent stages
on a continuum of vulnerability–(threshold)–stimulus
interactions.
Even if PMDD is viewed as a separate entity, it presents
a plethora of unsolved issues.
Despite the acceptance of the PMDD entity by the US
FDA and despite several FDA-approved medications
for that indication, the definitions of PMDD are far from
being perfect. The main weakness of that diagnostic
entity is the requirement of endorsing five of the 11
listed symptoms. The reason for the choice of a specific
numerical threshold is unclear and it is not necessarily
clinically relevant. A significant proportion of women
report severe impairment but of only three or four
symptoms. 15 They seek and certainly warrant treatment
no less than the 5% of women who report the highly
specific and restrictive five symptoms. Even though a
multitude of premenstrual dysphoric symptoms 29 have