Premenstrual dysphoric disorder and its association with complex trauma disorder: Three cases

To the Editor

The cyclical manifestation of physical, emotional and behavioural symptoms in the luteal phase of the menstrual cycle is referred to as premenstrual syndrome (PMS). The more severe form is premenstrual dysphoric disorder (PMDD) and occurs in 2–5% of the female population (Dubey et al., 2017). PMDD has been reported as a precursor to major depression, and in many cases, they are concomitant, with a marked worsening of symptoms during the premenstrual period. An abnormal sensitivity to hormonal fluctuations has been described (Dubey et al., 2017), and several studies have reported increased rates of abuse and trauma history in women with PMDD (Golding et al., 2009; Soydas et al., 2014). Trauma is a broad term ranging from emotional neglect to physical and sexual abuse.

Ms A is a 36-year-old woman with a history of depression and anxiety. She was unable to recall much of her childhood but described experiencing several years of bullying. Ms A described cyclical premenstrual depressive episodes occurring 2 weeks prior to menstruation, with difficulty concentrating, low mood and irritability, and noted a sudden improvement after the commencement of menses.

Mrs B is a 30-year-old woman with a history of chronic depression. Mrs B experienced a number of traumatic events as a child, including multiple deaths, bullying and indirect experiences with sexual assault, and as a young adult personally experienced sexual abuse. Mrs B described fatigue, low mood and suicidal ideation in the week prior to menstruation.

Mrs C is a 42-year-old woman with long history of premenstrual mood symptoms commencing at menarche. Mrs C had difficulty with attachment to her parents during childhood and an unsupportive home environment. She described low mood, anger and a sense of feeling overwhelmed in the 48-hour period prior to menstruation.

All three women were diagnosed with PMDD in the context of complex trauma disorder. A biopsychosocial treatment model was used to support these women, including hormone treatment with the oral contraceptive pill Zoely (Zoely consists of 2.5 mg nomegestrol acetate and 1.5 mg oestradiol) and psychotherapy.

Mood changes occur commonly in the premenstrual period; however, practitioners are often unsure of the impact or how to best help their patients. Often selective serotonin reuptake inhibitors (SSRIs) and many oral contraceptives (OCPs) – particularly progestin-only preparations – can worsen symptoms, and the underlying trauma is left unaddressed. While not all women with PMDD have a history of trauma, there is clear evidence of increased rates in this population and it is essential clinicians take a thorough history asking specifically about early life traumatic experiences and incorporate therapeutic approaches to address the trauma experienced in these women.