PANCE Blueprint Psychiatry (6%)

Patient will present as → a 26-year-old patient is complaining of depression and anxiety just prior to her menses. The symptoms have been going on for more than 1 year, but are now starting to interfere with her relationships and her productivity at work. One week prior to menses each month she experiences a depressed mood, a feeling of being on edge, increased irritability, difficulty sleeping, a feeling of being overwhelmed, and is easily fatigued. She charted her symptoms daily in a log and returned to the office two cycles later. The log is consistent with the history. Her physical examination and general laboratory profile showed no abnormalities.

Key Points:

• Repeated episodes of significant depression and related symptoms during the week before menstruation

DSM-5 Diagnostic Criteria

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.

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

• Marked affective lability (e.g., mood swings; feeling suddenly sad or tearful, or increased sensitivity to rejection).
• Marked irritability or anger or increased interpersonal conflicts.
• Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts.
• Marked anxiety, tension, and/or feelings of being keyed up or on edge.

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

• Decreased interest in usual activities (e.g., work, school, friends, hobbies).
• Subjective difficulty in concentration.
• Lethargy, easy fatigability, or marked lack of energy.
• Marked change in appetite; overeating; or specific food cravings.
• Hypersomnia or insomnia.
• A sense of being overwhelmed or out of control.
• Physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of “bloating,” or weight gain.

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

SSRIs (fluoxetine 10 mg, sertraline 50 mg qd, etc) are useful for the treatment of PMDD.

• These medications can be administered continuously during the menstrual cycle or only when the patients experience symptoms.
• Luteal phase or intermittent administration involves initiating medication at the time of ovulation and stopping it at the beginning of menses.
• SNRIs such as venlafaxine may also be effective in women with predominantly psychological symptoms.

Other useful agents are benzodiazepines (addictive) and the tricyclic antidepressant clomipramine (25 mg QD as starting dose).

Birth control, low-dose estrogen, and diuretics may also be beneficial.

Gonadotropin-releasing hormone (GnRH) - accelerated bone loss and vasomotor symptoms associated with long-term use of a GnRH agonist will require add-back therapy.

• Hormonal intervention with monthly intramuscular injections of leuprolide has been reported effective in some patients; however, it should be reserved only for patients unresponsive to first- and second-line agents.

Nutritional supplementation (vitamin B6 up to 100 mg/day, vitamin E up to 600 IU/day, calcium carbonate up to 1200 mg/day, and magnesium up to 500 mg/day) are also commonly used for symptom reduction in some patients with limited results.

Ovariectomy may be considered in severe refractory cases.