Prepare for the PANCE® with this challenging clinical scenario involving a 25-year-old woman with intense mood swings and physical symptoms that appear 1–2 weeks before menstruation and resolve with onset of bleeding. What’s the most likely diagnosis?
A 25-year-old woman presents to the gynecology office with a year of mood swings, feelings of hopelessness, and anxiety that have negatively affected her personal and professional relationships. She also reports struggling with lethargy, easy fatigability, hypersomnia, and bloating. She has not experienced cold intolerance, weight gain, or dry skin. All these symptoms begin about one to two weeks before her period starts and improve significantly once bleeding begins. The patient takes no medications and reports no alcohol or other recreational substance use. Vital signs are within normal limits. A chaperoned examination is unremarkable.
Which of the following is the most likely diagnosis?
A. Premenstrual dysphoric disorder (PMDD)
B. Premenstrual syndrome (PMS)
C. Depression
D. Hypothyroidism
E. Substance misuse
Scroll down to find the answer!
The correct answer to today’s PANCE® Question is…
A. Premenstrual dysphoric disorder (PMDD)
Correct: See Main Explanation.
Incorrect Answer Explanations
B. Premenstrual syndrome (PMS)
Incorrect: Although PMS can present with cyclical mood swings, anxiety, and bloating, premenstrual dysphoric disorder (PMDD) is distinguished by affective symptoms that are severe enough to interfere with daily functioning.
C. Depression
Incorrect: Depression can have similar symptoms to premenstrual dysphoric disorder (PMDD). However, the symptoms of PMDD are cyclically related to the menstrual cycle and typically resolve with the onset of menses, unlike depression.
D. Hypothyroidism
Incorrect: Hypothyroidism can cause lethargy, easy fatigability, and mood swings; however, its symptoms are not cyclical. In addition, other symptoms would be expected, such as cold intolerance, weight gain, and/or dry skin. Symptoms of premenstrual dysphoric disorder (PMDD), the likely diagnosis, are cyclic and occur during the luteal phase of the menstrual cycle.
E. Substance misuse
Incorrect: Patients with substance misuse can present with similar symptoms, such as irritability and fatigue, and it should be ruled out during the workup for premenstrual dysphoric disorder (PMDD). However, this patient reports no alcohol or other recreational substance use, and the cyclical nature of her symptoms makes PMDD the most likely diagnosis.
Main Explanation
This patient has severe cyclical symptoms during the luteal phase of her menstrual cycle, including mood swings, feelings of hopelessness, anxiety, and interpersonal conflicts that can be disabling. These symptoms, along with lethargy, easy fatigability, hypersomnia, and bloating are consistent with the diagnosis of premenstrual dysphoric disorder (PMDD).
PMDD and premenstrual syndrome (PMS) share symptoms that begin during the luteal phase and resolve with the onset of menses. However, PMDD symptoms are predominantly affective, more severe, and sometimes disabling, profoundly affecting daily functioning.
Diagnostic criteria for PMDD, according to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), are detailed in the table below.
Major Takeaway
Premenstrual dysphoric disorder (PMDD) is a severe, sometimes disabling condition characterized by symptoms that start during the luteal phase and resolve with the onset of menses. Key features include marked affective lability, irritability, anger, increased interpersonal conflicts, depressed mood, feelings of hopelessness, self-deprecating thoughts, anxiety, tension, or feeling on-edge.
Want to learn more about this topic?
Watch this Osmosis video: Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD): Clinical sciences
References
- American College of Obstetrics and Gynecologists’ committee on clinical practice guidelines-gynecology. Management of premenstrual disorders: ACOG clinical practice guideline no 7. Obstet Gynecol. 2023;142(6):1516-1533. doi:10.1097/AOG.0000000000005426
- Gray SH. Menstrual disorders. Pediatr Rev. 2013;34(1):6-18. doi:10.1542/pir.34-1-6
- Bhatia SC, Bhatia SK. Diagnosis, and treatment of premenstrual dysphoric disorder. Am Fam Physician. 2002;66(7):1239-1248.
- Kliegman, RM, St Geme, JW, Blum, NJ, et al, eds. Nelson Textbook of Pediatrics. 21st ed. Elsevier; 2020.
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