Book Review

Premenstrual Dysphorias: Myths and Realities

N Engl J Med 1994; 331:1318November 10, 1994

Article

Premenstrual Dysphorias: Myths and Realities
Edited by Judith H. Gold and Sally K. Severino. 262 pp. Washington, D.C., American Psychiatric Press, 1994. $32. ISBN: 0-88048-666-X

This resource book brings us up to date on the facts about premenstrual dysphoria while showing how these facts are embedded in a sociocultural context that is fraught with psychological meaning and mythology and much in need of continued study and clarification. Premenstrual dysphoric disorder, or premenstrual dysphoria, is the currently accepted term for a controversial condition related to premenstrual syndrome and late-luteal-phase dysphoric disorder that has been added to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders.

To meet the diagnostic criteria for premenstrual dysphoric disorder, a woman needs to demonstrate, by keeping daily records of two menstrual cycles, that during the last week of the luteal phase in most menstrual cycles, she has at least five physical or emotional symptoms that markedly interfere with her work and social life. Of the five, one must be associated with a mood disorder, such as severe affective lability, increased anger or irritability, or depression. These symptoms must be present premenstrually (in the luteal phase), but absent in the week after the onset of menses (the follicular phase); they cannot be always present, nor can they reflect exacerbations of other conditions. Premenstrual dysphoric disorder lacks a biologic marker, its cause is unknown, and its natural history and epidemiology have yet to be described. It is a set of symptoms derived from sociocultural and personal psychological experiences for which medical advice is sought and a diagnosis is made.

Women given this new diagnosis may be easier to treat than the majority of women who have symptoms consistent with premenstrual syndrome but who do not meet the strict diagnostic criteria. Most women being seen for premenstrual syndrome have a complicated and inconsistent pattern of symptoms. Premenstrual syndrome and premenstrual dysphoric disorder can be distinguished by examining the daily records a woman has kept of her menstrual cycles. On the basis of history alone, many women associate personal, familial, and work problems with the onset of their menses. The symptoms need to be taken seriously and may reflect a profound life disturbance. They may also require extended evaluation. Women who report having premenstrual syndrome but do not meet the strict criteria for premenstrual dysphoric disorder are particularly likely to have another psychiatric disorder, such as dysthymic disorder, phobia, obsessive-compulsive disorder, or alcohol- or substance-abuse disorder. They can be well served by referral to a psychiatrist for treatment of their primary psychiatric problems. A trend toward progressive worsening of problems over several menstrual cycles in prospective records can be a precursor of a major mental disorder and another reason for a psychiatric referral.

There have been numerous treatments for premenstrual syndrome, and the better studies are well summarized in the chapter in Premenstrual Dysphorias by Rivera-Tovar and colleagues. The effectiveness of treatments for those who meet the criteria for premenstrual dysphoric disorder raises interesting questions about this diagnosis. A placebo response is frequent and substantial. Though a hormonally correlated disorder, premenstrual syndrome is not consistently helped by treatment with progesterone. Ovulation suppressors such as danazol may work but have excessive side effects; the extreme of oophorectomy has been used. Psychotherapies have not been well studied but do not appear especially promising as the only form of treatment. Many somatic treatments (such as those involving alprazolam, bromocriptine, buspirone, light therapy, metolazone, naltrexone, and spironolactone) are superior to placebo when administered cyclically. Of particular interest is why alprazolam works, and why dependence and dose escalation do not seem to occur when it is given in a daily dose of 0.25 to 4.0 mg only in the symptomatic phase.

This book is particularly appropriate for gynecologists, primary care physicians who see many women with premenstrual problems, and psychiatrists. It is an excellent resource full of carefully documented and current studies. With its balanced presentation of controversies, this book goes far to combat the stigma that has been associated with premenstrual syndrome.

Roberta J. Apfel, M.D., M.P.H.
Harvard Medical School, Boston, MA 02115