”Rage”—that’s how multiple women with Premenstrual Dysphoric Disorder describe their worst symptoms. PMDD manifests in the days or even weeks leading up to patients’ menstrual cycle, but is distinct from PMS in that the symptoms are so severe that it impairs patients’ ability to function.
PMDD, which affects less than 8 percent of women, doesn’t feel like the “slowness and sadness of depression,” said Chloe Caldwell, a 33-year-old writer who is working on a memoir about PMDD called The Red Zone: A Love Story. For her, she said, “It's more like a physical sensation...an altered reality; not seeing things clearly.”
Vivien K. Burt, a psychiatrist at UCLA, said there is one, relatively new treatment for the condition doctors agree is most effective: fluoxetine, colloquially known as the antidepressant Prozac, which is a selective serotonin reuptake inhibitor (SSRI). Fluoxetine was approved by the FDA to treat PMDD in 2000, but PMDD wasn’t included in the Diagnostic and Statistical Manual of Mental Disorders (DSM) until 2013.
Even now, not all patients with PMDD are aware of the condition or this means of treating it, nor are all the doctors that treat them. That’s in part because prescribing an SSRI for PMS falls under a relatively new and lesser-known field called reproductive psychiatry, focused on psychiatric conditions associated with hormonal challenges and reproductive events. But like other women’s health fields, and mental health issues, reproductive psychiatry has struggled to gain acceptance and integrate in mainstream medicine.
Burt founded the Women’s Life Center at UCLA back in 1993.The reproductive psychiatry center, staffed by a small group of medical providers, treat conditions like PMS and PMDD as well as postpartum depression and perimenopause. At Burt’s center, providers use a “symptoms rating chart” to diagnose PMDD versus PMS versus other conditions, like major depression, that are simply exacerbated during the menstrual cycle.
“We ask patients to complete charts on a daily basis, which record all of those symptoms,” she said. “We try to do that for at least a couple of months.” The team can then use the charts to see how the symptoms are linked to a patient’s menstrual cycle.
Even filling out those charts is extraordinarily helpful for patients. Once patients themselves begin to see that there may or may not be a regularity to their emotional complaints, they “then can decide that they're not going to pay bills on the pre menstrual days, or not get into a major discussion with a partner,” said Burt.
Only 59% of residency programs require any level of training in reproductive psychiatry.
Since Caldwell was diagnosed with PMDD, her doctor has recommended many ways to treat it, including, for example, attempting to balance her hormones by sticking to a “Whole 30” style diet from when she begins menstruating up until her period. Since she began taking Prozac, she said, the symptoms have “shrunk.” “So it'll be like half a day. Whereas before, I could have it for like six days.” Still, she does a variety of exercises to deal with it, like yoga and breathing exercises with her therapist, as well as planning around her PMDD when it comes to important discussions.
The American Psychiatric Association and the American Board of Psychiatry and Neurology—the body that certifies psychiatrists and neurologists as qualified to practice—have yet to recognize reproductive psychiatry as an official sub-specialty. In 2015, the National Task Force on Women’s Reproductive Mental Health, founded in 2013, surveyed psychiatric residency directors and found “that only 59% of residency programs require any level of training in reproductive psychiatry and that only 36% believe all residents need to be competent in the field.”
“This is part of a general lag in addressing the needs (medical and psychiatric) for women,” said Burt. “Only since the end of the 1990's has the dearth of research into gender-specific medical and mental health issues been given the attention that it needs.” But, she said, the medical community is now starting to better understand that medical needs can be “influenced by gender”—possibly because
Burt and other psychiatrists are working to give reproductive psychiatry the official recognition they believe the field deserves. Their efforts are working. The National Taskforce on Women’s Reproductive Mental Health is currently working to create a national, web-based curriculum that will increase access to education on reproductive psychiatry. Burt hopes that eventually these efforts will lead to an official reproductive psychiatry subspecialty. Once this happens, every psychiatry student in the country will be required “to recognize disorders associated with reproductive issues in women and...be able to treat them,” Burt said.
Caldwell, whose memoir talks about this treatment, hopes for the sake of others with PMDD that this happens soon. She said she was only able to figure out that she had PMDD and that Prozac was a possible solution because her therapist had PMDD herself and told her to ask her doctor for her prescription. “Otherwise, I think I would have been really screwed,” she said.
But now that Caldwell understands her condition and is receiving treatment, her outlook has changed. The upside, she said, is that she should do a lot of these things anyway. “What's good about it, like kind of a gift in a way, is it really does teach you to take care of yourself,” she said. Proper treatment for PMDD has allowed Caldwell to see her condition as a blessing, not a curse—and as the field of reproductive psychiatry grows, perhaps others PMDD sufferers can make this transition, too.
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