Powerless

Is dysphoric disorder a new disease?

Not entirely new. Dysphoric disorder has sort of been separated from premenstrual syndrome – PMS. It is associated with a very severe course of PMS, which does not meet the criteria of this definition. PMS is thought to affect 15-20 percent of all women, dysphoric disorder, or PMDD, is a much rarer disease – nearly 1 percent of women suffer from it, but that does not mean that it should be underestimated.

If we associate PMS with an angry and sore woman before menstruation, how bad must it be if she suffers from dysphoric disorder?

To imagine the situation of a woman with PMDD, you could say it is PMS times a hundred. The symptoms last longer, most women experience low mood, pain, mental afflictions: social aversion, anxiety, a drastic decrease in libido – sometimes even sexual aversion – extreme irritation, and even photophobia.

In addition, the symptoms in this disorder are much more intense than in premenstrual syndrome. Patients with dysphoric disorder often seek help from doctors of various specialties. Many women coming to me have already visited gynaecology and obstetrics specialists, who do not work in this field, or even psychiatrists. In our community of specialists, dysphoric disorder is not fully known, and it is often underestimated or left undiagnosed.

What do these patients tell you?

That they feel powerless. They report repeated ailments and complain about the mental component overlapping with depression, decreased self-esteem. Such a patient should always be treated with a great deal of patience. The visit never lasts as standard, but longer, because the details of the medical interview are so important.

If we believe or strongly suspect that a woman suffers from dysphoric disorder, we begin therapy. It is often combined: hormonal and drugs used by psychiatrists, most often antidepressants from the SSRI group.

But does this disease have an organic background?

Research is ambiguous here, no one has analysed the substances secreted by the female brain in real time. It is hard even to imagine how to measure such neurotransmitters. Dysphoric disorder is believed to be related to the metabolism of progesterone during the second phase of the menstrual cycle.

Progesterone is a hormone that is produced by the corpus luteum after ovulation in healthy, regularly menstruating women. It is also produced in a minimal concentration by the adrenal glands throughout the cycle.

It is likely that some women transform progesterone metabolites in the central nervous system differently from the majority of the population. That is, intermediates that are made from progesterone in the brain lead to an increase in mental responses, stimulate pathways that are normally stimulated in people with depression, such as GABA-nergic and those related to serotonin secretion.

And these women are often diagnosed with depression, but, which is very characteristic of PMDD, they usually function normally in the first phase of the cycle. Then comes the post-ovulation period, and the cyclical drama begins. The cyclicality of these changes, combined with the menstrual cycle, is an essential element in making this diagnosis.

Do symptoms worsen as progesterone levels rise?

It varies a lot. Most often, with the approaching period, the symptoms worsen, but there are women who feel terrible almost from the very beginning of the second phase of the cycle.

Does the treatment involve reducing progesterone production?

On the basis of the theory, it would seem that the easiest way to proceed would be to block ovulation, i.e. prevent the formation of progesterone, and that’s it. In fact, some women take gestagens, i.e. derivatives of progesterone that are not identical to it, but similar enough to compete with its receptors. And because gestagens are stronger, they attach themselves first and block most of the pathways that progesterone would normally work on.

It is a basic, cheap and safe therapy, but unfortunately it is usually ineffective in women with PMDD.

And then what?

We go a step further, that is, we try using two-component hormonal contraception to block ovulation and the entire cycle. This therapy is much more effective and is successfully used in half of PMDD cases.

What about other patients?

Observational studies have shown that treatment with antidepressants is equally effective – and often even used alongside hormone therapy. In addition, this form of therapy eliminates the effect, i.e. the aforementioned abnormal secretion of neurotransmitters in the brain. Today we use both very often. This two-way treatment increases the chance that the patient will function normally throughout the cycle. But there are still women for whom even combination therapy doesn’t work. The last resort that you can try are drugs from the group of GnRH analogues in the form of subcutaneous implants, which are used monthly. This is an emergency solution, but it may not be effective for all patients. Those for whom it doesn’t work are waiting for new drugs and forms of therapy.

Do you try to work with these women using behavioural therapy techniques?

Psychotherapy is an important component. Comprehensive assistance for a patient with dysphoric disorder should be based on the cooperation of three or four specialists: a gynaecologist, endocrinologist, psychiatrist, psychologist or psychotherapist, and it seems that a nutritionist can also play a large role.

Often, patients have food intolerances that they do not know about, which additionally overlap with their ailments. We know more and more about diet and its importance also in hormonal and mental health. I never rule it out and I try to eliminate dietary mistakes or look for allergies in patients. But also, to be clear, when it comes to dietetics, it is still not evidence-based medicine.

How important is genetics when it comes to dysphoric disorder?

Its symptoms usually appear in adolescent women and then potentially evolve – the physical component, i.e. painful menstruation with accompanying symptoms, and the mental component appear. Very rarely, dysphoric disorder is “acquired,” i.e. when the patient has had normal cycles for years and PMDD suddenly appears. This is why this disease is believed to be likely related to genetics or environmental influences that can activate specific, yet unknown, genes.

What comes first? Mental or organic disorders?

PMDD is a disease on the border of gynaecological endocrinology and psychiatry. If we had talked 10 years ago, I would have probably said that mental issues come first, and hormonal secretion is only an additional source of the problem. Today, however, it is believed that the disturbances associated with progesterone metabolism are primary. More and more scientists are supporting the thesis that the mental sphere is a consequence of what is happening in the central nervous system.

This is also logical, actually. If you have felt terrible for half of every month since you were a teenager, you lose social relationships: with friends, your partner, professional relations, and this aggravates mental problems. The teenage period is a time of building friendships, bonds, first relationships and feelings. Depriving a woman of a healthy relationship for part of a month will affect her psyche in the future.

Does poor metabolism of progesterone affect other reproductive functions?

Research does not indicate this. A patient with PMDD is most often a woman who secretes progesterone, has ovulation, and has a properly built endometrium. Progesterone fulfils its function in the reproductive system and nothing prevents a woman from getting pregnant in such a situation.

How do you distinguish severe PMS from mild PMDD? Where is the border?

The border is fluid. There are specific forms that the patient must complete to identify such a syndrome. For example, Daily Record of Severity of Problems – DRSP. However, you should bear in mind that there is no completely unified evaluation system for these questionnaires. It doesn’t mean that a patient with nine points has PMDD, and one with seven no longer suffers from this disease. The cyclical nature of the changes also causes one cycle to be more severe and another to be milder.

A patient cannot be removed from treatment on the basis of the questionnaire. It is a matter of the doctor’s experience, their knowledge, the accuracy of the interview, and the degree of discomfort in a woman’s life.

In PMS, treatment is similar to PMDD. If it doesn’t work, maybe this is a separation criterion?

Treatment is similar but much more effective in women with PMS. In these patients, gestagens alone are a sufficient form of therapy in a significant percentage of women. Undoubtedly, the ineffectiveness of the therapy indicates that the problem is much more serious, and one should at least consider dysphoric disorder in differential diagnosis.

Interview with Artur Drobniak, MD, obstetrician-gynaecologist by Margit Kossobudzka

Illustration: Marta Frej

The text was published in „Wysokie Obcasy" on 13 February 2021