Do GPs know enough about this ‘debilitating’ disorder?

Women have reported going untreated for years with severe symptoms of premenstrual dysphoric disorder (PMDD), including suicidal ideation, severe depression and social isolation, but experts hope an increase in education and interest from GPs could open more options for patients.
 
Associate Professor Len Kliman, who has specialised in the treatment of PMDD for more than two decades, told newsGP this is an area that has been consistently under resourced and is ‘poorly understood’.
 
‘Because we don’t completely understand what causes PMDD, the treatment is so varied and because it’s underappreciated and often not part of the usual curriculum, people often don’t know a lot about it or the correct approach to it,’ he said.
 
Associate Professor Kliman urged that ‘GPs need to take this extremely seriously’, saying if GPs had more knowledge in this space, they would be ‘in the ideal situation to manage this’.
 
‘The advantage is that they often have frequent contact and interaction with their patients, which is really important with this condition,’ he said.
 
‘If they do that, I think they’d be an excellent treatment option for patients.’
 
However, there are issues around recognition by GPs for this disorder, Associate Professor Kliman explains.
 
‘A number of GPs who, quite understandably because they aren’t cognizant with the best treatment, will tell the patient to either just live with it, get used to it, or basically throw it back on the patient,’ he said.
 
‘But it’s a terrible disorder that often lasts for 14 days a month, so for half their life these women are someone that would prefer not to exist.’
 
He said the disorder affects virtually every part of a patient’s life and the duration of symptoms can vary ‘enormously’.
 
‘They really need help, they need to have some light at the end of the tunnel and so I actually tell my patients that I won’t stop treating you until I think you’re better,’ he said.
 
‘You need to try and get these women 90% to 100% better to have a major impact on their life, so being partially treated or a bit better is not good enough.’
 
GP and women’s health expert Associate Professor Magda Simonis told newsGP that GPs traditionally have focussed on premenstrual syndrome (PMS) rather than PMDD, which can be very unpredictable.
 
‘Now there’s a shift towards PMDD as a classification of a mood disorder which is quite severe and it’s only come into our overall awareness relatively recently,’ she said.
 
‘For some women, it’s not just the decline in estrogen, it’s the fluctuation in the levels that they’re sensitive to and how we respond to those hormonal fluctuations is a variable.
 
‘You really need to manage women on a person-to-person basis.’
 
Associate Professor Kliman said there are two main approaches to treatment.
 
‘You can use hormonal treatment to stop their period altogether, with a continuous pill, especially the more natural estrogen pills,’ he said.
 
‘There’s a study showing that improves the outlook for about 85% of women and you have to concentrate on estrogen rather than progesterone.’
 
The other arm of treatment is psychiatric medication, says Associate Professor Kliman.
 
‘There are a number of psychiatric drugs and antidepressant mood stabilizers that have been trialled in people with PMDD and have been found to be useful,’ he said.
 
As there is no blood test available for PMDD and ‘measuring hormone levels are a waste of time’ according to Associate Professor Kliman, GPs need to assess this in context of a patient’s overall health and that it must be a symptom-based diagnosis.
 
‘I send all the patients I see a questionnaire first, about what symptoms they have, how long they’ve had them for and what impact it has on their life, just to get an idea before I see them what condition they’re in,’ he said.
 
‘The common symptoms are depression, anxiety, anger, brain fog, avoidance behaviour, where they avoid socialising during the period where they feel unwell.
 
‘If someone comes in and says their symptom are severe depression and suicidal thoughts, then I think one symptom there is enough and you don’t need to have anything else.’
 
Associate Professor Kliman, who is based in Melbourne, speaks to around 10 interstate patients a week via telehealth and says women on average ‘put up with debilitating symptoms for seven years before they obtained help or even sought help’.
 
‘There are a lot of self-help groups that people turn to on social media but, as far as the medical community goes, there are not a lot of people who deal with it,’ he said.
 
‘I don’t think it’s a lack of interest, it is a lack of education and being aware of what resources are available.
 
‘The GPs that refer me patients will often, in the letter, say “look, I don’t know a lot about this disorder, and I’m seeking your help” and when I write back to them, I try and put some ideas about what the best approach to the disorder might be overall, not just this particular patient.’
 
Associate Professor Simonis said that another contributing factor in treatment delay is that women often don’t recognize that what they’re going through is unordinary.
 
‘Because, like a lot of things that women experience, it’s a case that women learn to tolerate not feeling well, which can be from generations of handed down misinformation around what’s normal and what’s not,’ she said,
 
‘The fact that a good proportion of women will experience something that impacts their life so negatively doesn’t make it a normal thing that we should put up with.’
 
PMDD can often present differently, and GPs might not always think to relate symptoms to a woman’s reproductive cycle first up, Associate Professor Simonis said.
 
‘Some cycles are worse than others, so it can fluctuate, but if you have consistent symptoms over three, six or more cycles, you’re looking at a condition that is worth investigating further and treating,’ she said.
 
‘A lot of this will revolve around a contraceptive talk and when you first teach young women about options, so it’s important to understand what their cycles are like and whether or not there’s any mood disturbance.’
 
Associate Professor Simonis said GPs need to approach this ‘as a spectrum all the way from PMS, PMDD, perimenopause and menopause’.
 
‘Then we can place them around what’s happened to the hormones for a woman across their life cycle,’ she said.
 
‘These conditions require a series of consultations over time, with reviews and with someone who understands and knows them, and that’s where the GP is well placed.’
 
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