Contraceptive options for women with premenstrual dysphoric disorder: current insights and a narrative review

Figures & data

Table 1 Diagnostic and Statistical Manual of Mental Disorders, fifth edition, requirements for the diagnosis of PMDD

A. In the majority of menstrual cycles, at least five symptoms must be present in the final week before the onset of menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week post menses.

B. One (or more) of the following symptoms must be present:

1. Marked affective lability (eg, mood swings; feeling suddenly sad or tearful, or increased sensitivity to rejection).

2. Marked irritability or anger or increased interpersonal conflicts.

3. Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts.

4. Marked anxiety, tension, and/or feelings of being keyed up or on edge.

C. One (or more) of the following symptoms must additionally be present, to reach a total of five symptoms when combined with symptoms from Criterion B above.

1. Decreased interest in usual activities (eg, work, school, friends, hobbies).

2. Subjective difficulty in concentration.

3. Lethargy, easy fatigability, or marked lack of energy.

4. Marked change in appetite, overeating, or specific food cravings.

5. Hypersomnia or insomnia.

6. A sense of being overwhelmed or out of control.

7. Physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of “bloating,” or weight gain. school, usual social activities, or relationships with

D. The symptoms are associated with clinically significant distress or interference with work, others (eg, avoidance of social activities; decreased productivity and efficiency at work, school, or home).

E. The disturbance is not merely an exacerbation of the symptoms of another disorder, such as major depressive disorder, panic disorder, persistent depressive disorder (dysthymia), or a personality disorder (although it may co-occur with any of these disorders).

F. Criterion A should be confirmed by prospective daily ratings during at least two symptomatic cycles. (Note: The diagnosis may be made provisionally prior to this confirmation.)

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

Note: The symptoms in Criteria A–C must have been met for most menstrual cycles that occurred in the preceding year. Data from American Psychiatric Association.⁷

Abbreviation: PMDD, premenstrual dysphoric disorder.

Table 2 The Premenstrual Symptom Screening Tool

Do you experience some or any of the following premenstrual symptoms which start before your period and stop within a few days of bleeding? Please mark an X in the appropriate box.
Symptom	Not at all	Mild	Moderate	Severe
1. Anger/irritability
2. Anxiety/tension
3. Tearful/increased sensitivity to rejection
4. Depressed mood/hopelessness
5. Decreased interest in work activities
6. Decreased interest in home activities
7. Decreased interest in social activities
8. Difficulty concentrating
9. Fatigue/lack of energy
10. Overeating/food cravings
11. Insomnia
12. Hypersomnia (needing more sleep)
13. Feeling overwhelmed or out of control
14. Physical symptoms: breast tenderness, headaches, joint/muscle pain, bloating, weight gain
Have your symptoms interfered with:
A. Work efficiency or productivity
B. Relationships with coworkers
C. Relationships with the family
D. Social life activities
E. Home responsibilities

Notes: Scoring: the following criteria must be present for a diagnosis of moderate-to-severe PMS: 1) At least one of 1, 2, 3, and 4 is moderate to severe. 2) In addition, at least four of 1–14 are moderate to severe. 3) At least one of A, B, C, D, and E is moderate to severe. The following criteria must be present for a diagnosis of PMDD: 1) At least one of 1, 2, 3, and 4 is severe. 2) In addition, at least four of 1–14 are moderate to severe. 3) At least one of A, B, C, D, and E is severe. Data from Steiner et al.⁸

Abbreviations: PMS, premenstrual syndrome; PMDD, premenstrual dysphoric disorder.

Table 3 Symptoms described by women suffering PMS or PMDD

Physical	Behavioral	Mood
Swelling	Sleep disturbances	Irritability
Breast tenderness	Appetite changes	Mood swings
General aches	Poor concentration	Anxiety
Headache	Decreased interest	Depression
Weight gain	Social withdrawal	Loss of self-control
Feeling bloated

Note: Data from Freedman.¹⁶

Abbreviations: PMS, premenstrual syndrome; PMDD, premenstrual dysphoric disorder.

Table 4 Different types of CHCs

1. Dose of EE: The CHCs currently available are based on doses of between 15 µg and 50 µg of EE

2. Type and dose of progestogen: progestogens used for contraception can be derived from the following three sources

2.1. 17 OH progesterone

2.2. 19 Nortestosterone

2.3. Spironolactone

3. Regimen of administration: To date, treatments are based on 21 days of intake of the active ingredient and a hormone-free interval of 7 days or other patterns such as 22+6, 24+4, or 26+2, as well as extended and continuous regimens

4. Route of administration. CHCs can be administered orally, transdermally, vaginally, or by IM or SC injection

Abbreviations: CHCs, combined hormonal contraceptives; EE, ethinyl estradiol; IM, intramuscular; SC, subcutaneous.

American Psychiatric AssociationDiagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)ArlingtonAmerican Psychiatric Association2013

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FreedmanEWPremenstrual syndrome and premenstrual dysphoric disorder: definitions and diagnosisPsychoneuroendocrinology200328252712892988

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