Don’t Miss the Diagnosis of Premenstrual Dysphoric Disorder

Jennifer Middleton, MD, MPH
Posted on December 4, 2023

The American College of Obstetrics and Gynecology (ACOG) published a guideline this month on “Management of Premenstrual Disorders,” which reviewed the diagnosis and treatment of both premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD). Unlike PMS, the symptoms of PMDD are “severe enough to interfere with the ability to function, comparable with other mental disorders, such as a major depressive episode or generalized anxiety disorder.” PMDD’s inclusion in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was not without controversy, and many of the millions of people who experience its symptoms every month continue to face delays in diagnosis and unempathetic treatment by physicians.

The diagnosis of both PMS and PMDD require that symptoms only “occur during the luteal phase and resolve shortly after the onset of menstruation.” In addition to gathering specific symptoms, their timing during the menstrual cycle, and their effect on patients’ functions in their history taking, family physicians may also find the Daily Record of Severity of Problems for Diagnosis of Premenstrual Dysphoric Disorder (DRSP) a helpful tool. Patients prospectively track their symptoms over at least two cycles; [a] cutoff value of 50 provides a positive predictive value of 63.4% and a negative predictive value of 90% for either PMS or PMDD. A positive screen, especially in patients describing significant distress with their symptoms, can then prompt use of PMDD’s DSM-5 criteria to clarify the diagnosis. In their new guideline, ACOG stresses that PMDD is a “diagnosis of exclusion” and encourages physicians to rule out other possible etiologies. Treatment options with at least moderate evidence include selective serotonin reuptake inhibitors (SSRIs) and cognitive behavioral therapy.

To receive these treatments, though, patients experiencing PMDD first need to receive a diagnosis. A recent qualitative study of people in the United States with PMDD identified several barriers to PMDD diagnosis and treatment. Many participants initially assumed that their symptoms were normal or typical for menstruating people and, therefore, did not seek medical care. Over one-quarter of participants were initially misdiagnosed with another psychiatric disorder before being diagnosed with PMDD. Most participants reported having their symptoms dismissed or invalidated by physicians (both male and female), with some physicians expressing doubt that PMDD was “real.” Some participants "saw up to 10 different providers before receiving a diagnosis.” The authors conclude that “[p]articipant experiences demonstrated that much of the diagnostic and treatment processes were burdened on the patient, and that successful navigation within the healthcare system was dependent on high levels of self-advocacy.”

Family physicians are well suited to provide supportive, empathetic care to those with PMDD. Recognizing our biases and educating ourselves on the best evidence and recommendations are musts if we are to provide the care that our patients experiencing PMDD need and deserve. You can start with this AFP article on “Premenstrual Syndrome and Premenstrual Dysphoric Disorder,” found in the AFP By Topic on Menstrual Disorders. The ACOG guideline referenced previously provides further detail, including the quality of evidence behind each recommendation. Finally, promoting neutral, nonstigmatizing language around menstruation can create a society where menstrual concerns are shared freely and treated compassionately.