It is the experience of those gynecologists dealing with severe premenstrual syndrome (PMS) or premenstrual dysphoric disorder (PMDD) that long-standing ‘bipolar depression’ which has been diagnosed by psychiatrists often disappears when the cyclical premenstrual nature of the condition is treated by hormonal suppression of ovarian cycles. This treatment could be by transdermal estradiol, GnRH analogues or even a hysterectomy and bilateral salpingo-oophorectomy.
The purpose of this comment is to emphasize that this is not a rare misdiagnosis. It is one which leads to many years of inappropriate drug therapy without noticeable improvement. It is also the intention to clarify the ways in which the diagnosis of PMDD can be made and be distinguished from bipolar disease by certain characteristics in the history.
Depression is more common in women than in men and it particularly occurs at times of hormonal fluctuation. There is a triad of hormone-responsive mood disorders such as premenstrual depression, postnatal depression and climacteric depression which is best referred to as reproductive depression. These episodes of depression often occur in the same patient and would, in a depressed perimenopausal patient, be an important aspect in the diagnosis of a hormone-responsive depression. The typical life history of these women is that they will have the frequent teenage premenstrual mood swings and, when the hormone levels cease to fluctuate as in pregnancy, they experience a good mood for the duration of the pregnancy in spite of early problems of nausea or even late pregnancy obstetric complications. After birth, this may be followed by postnatal depression which may last for months or several years. As the periods recur, the cyclical PMS returns. This premenstrual depression becomes worse and less cyclical with age towards the menopausal transition, when the many menopausal symptoms are at their worst in the 2 or 3 years before the periods cease completely.
The long-term health of these women very much depends upon the initial diagnosis made by the psychiatrist or general practitioner and the treatment that they receive. It is a great regret that estrogens are rarely used for treatment of depression in women by psychiatrists, although there is adequate evidence from randomized trials showing that transdermal estradiol is effective in premenstrual depression, postnatal depression and premenopausal climacteric depression.
It is vital to appreciate that the diagnosis of hormone-responsive depression is made through the history and not through the measurement of hormone levels. It is commonplace for women to believe that their depression is ‘cyclical and hormonal’ but the medical attendant measures the hormone levels which are normal in the premenopausal range. As they would be. But this is not a valid reason for denying that there is a hormonal causation to the depression and not treating the patient appropriately.
The important items in the history that should clarify the diagnosis are as follows:
1. There is a history of mild or severe PMS as a teenager.
2. There is a relief of depressive symptoms during pregnancy.
3. Depression started or recurred postpartum as postnatal depression.
4. Premenstrual depression recurred when menstruation returned months after delivery.
5. Premenstrual depression became worse with age, blending into the menopausal transition and becoming less cyclical.
6. There is often co-existence of cyclical somatic symptoms such as menstrual migraine, bloating or mastalgia.
7. These patients usually have runs of 7–10 good days in each month.
8. These patients have recurrent episodes of depression related to periods but rarely have episodes of mania.
PMDD is frequently misdiagnosed. It can be overdiagnosed in women with normal mood changes, as an excuse for behavioral problems or in place of a depressive illness. In these cases, hormone therapy will not help. That it can be underdiagnosed and wrongly diagnosed as bipolar disorder is indisputable but there is little way of knowing the frequency of this error. These women suffer from their cyclical symptoms and the full range of psychiatric care, including antidepressants, mood-stabilizing drugs, hospitalization and ECT, without clear benefit but experiencing many side-effects from years of ineffective and inappropriate therapy. It is therefore vital to make a clear and accurate diagnosis of PMDD which, if severe, needs treatment by suppression of ovulation and suppression of the cyclical hormonal changes that produce these cyclical symptoms. They do not need the antidepressants, mood-stabilizing drugs or ECT used for bipolar disorder.
Consultant Gynecologist, London, UK