Dr. John Studd
clinical gynaecologist

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Misdiagnosis of Severe PMS and Bipolar Disorder

13 October 2016

It is the experience of those gynecologists dealing with severe PMS or PMDD that longstanding “bipolar depression” that 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 oestradiol, GnRH analogues or even a hysterectomy and bilateral salpingo-oophorectomy.

This is not a rare misdiagnosis. It is one which leads to many years of inappropriate drug therapy without noticeable improvement. The diagnosis of PMDD can be made and it distinguished from bipolar disease by certain characteristics in the history.

Depression in women particularly occurs at times of hormonal fluctuation. As the triad of hormone responsive mood disorders such as premenstrual depression, premenstrual depression and climacteric depression often occur in the same patient these factors are an important part of the diagnosis. 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 post-natal 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 two or three 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 oestrogens are rarely used for treatment of depression in women by psychiatrists although there is adequate evidence from randomised trials showing that transdermal oestradiol is effective.

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 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 with the menopausal transition and becoming less cyclical
  6. There is often coexistence of cyclical somatic symptoms such as menstrual migraine, bloating or mastalgia
  7. These patients usually have runs of seven to ten good days per month
  8. These patients have recurrent episodes of depression but rarely have episodes of mania

Premenstrual syndrome is frequently misdiagnosed by psychiatrists. It can be over diagnosed in women with normal mood changes, as an excuse for behaviour problems or in place of a depressive illness. In these cases hormone therapy will not help. That it can be under diagnosed 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 effect of years of ineffective and inappropriate therapy.

Transdermal oestrogens are the best possible treatment of PMS and should be used by psychiatrists once they learn how to use this simple effective and safe therapy.