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Diagnose (Avtrykk): PMDD – Premenstruell Dysphoric Disorder – Speilvendt
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Diagnose (Avtrykk): PMDD – Premenstruell Dysphoric Disorder


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Premenstruell dysforisk forstyrrelse

Det antas at majoriteten av mennesker med en menstruasjonssyklus opplever fysiske, psykiske eller atferdsmessige plager som oppstår mellom eggløsning og begynnelsen av menstruasjonen  (Yonkers et al., 2008). Den humørsyke kvinnen som spiser sjokolade i store kvanta, gråter i dusjen og glefser mot kjæresten har blitt humoristisk portrettert flere ganger opp gjennom populærkulturens historie. 

Dette velkjente fenomenet, også kalt premenstruelt syndrom (PMS), kan knyttes til de hormonelle svingningene som holder menstruasjonssyklusen i gang. PMS i seg selv er ingen sykdom, men for 3-8 % av de som menstruerer bærer denne perioden av syklusen med seg såpass mye fysisk og psykisk lidelse at det går ut over sosiale, familiære og jobbrelaterte forhold (Halbreich et al., 2003). Vi kaller dette for premenstruell dysforisk forstyrrelse (PMDD); en alvorlig og veldig plagsom form for PMS. 

PMDD er klassifisert både som en somatisk (endokrin/hormonforstyrrelse) og psykisk sykdom (i DSM). Symptomene på PMDD følger menstruasjonssyklus og oppstår ofte uken før menstruasjon og avtar noen dager etter. Symptomene inkluderer vanlige PMS-symptomer som oppblåsthet, brystsmerter, kramper, akne, økt appetitt og emosjonell labilitet, samt mer alvorlige og påfallende stemningsforandringer. Blant disse er det ofte observert en markant økning i irritabilitet og sinne, noe som fører til konflikt, en forhøyet avvisningssensitivitet, dårlig selvbilde og søvnforstyrrelser. Mange kan også oppleve sterke angst- og depresjonssymptomer, samt panikkanfall, selv om symptomer som tilsvarer en diagnose ikke er tilstede under andre deler av syklusen (Feingold et al., 2000). Mennesker med PMDD har en markant forhøyet selvmordsrisiko sammenlignet med den øvrige befolkningen, og det er estimert at om lag 70 % av denne pasientgruppen sliter med selvmordstanker, både som en direkte konsekvens av hormonelle forandringer og som resultat av lidelsestrykket denne sykdommen medbringer (Pilver et al., 2013).  

Diagnostisering og sykdomsforløp
For at en PMDD-diagnose kan settes, må symptomene være tilstede i majoriteten av pasientens menstruasjonssykluser, og kun være tilstede under pasientens lutealfase (perioden mellom eggløsning og menstruasjon). Dersom symptomene strekker seg utover denne fasen, skal andre diagnoser vurderes. Dette er fordi PMDD er knyttet til de hormonelle forandringene i forkant av menstruasjon (Yonkers et al., 2008). 

Mot slutten av lutealfasen, omtrent 10-14 dager etter eggløsning, går progesteronnivået i kroppen kraftig ned. Dette fører til at slimhinnen i livmorveggen støtes ut. Det er dette som kalles for menstruasjon. Fra menstruasjonens begynnelse øker progesteronnivåene igjen, og progesteronets metabolitter påvirker GABA-reseptorene i hjernen. Disse er knyttet til nedregulering av angstresponser. En hypotese er at personer med PMDD responderer dårlig på den raske nedgangen i progesteron i uken før menstruasjon, altså mot slutten av lutealfasen, noe som fører til de kraftige premenstruelle symptomene (Hantsoo et al., 2020). 

PMDD feildiagnostiseres ofte som bipolar type 2. En mulig forklaring på dette kan være at mange klinikere har dårlig kjennskap til PMDD-diagnosen, og at de to lidelsene har mange fellestrekk. Den sentrale forskjellen ligger i at de depressive periodene hos de med PMDD kun forekommer i perioden mellom eggløsning og menstruasjon, og at de dermed også er lettere å forutse. Konsekvensen av feildiagnostiseringen er at personer med PMDD ikke får den behandlingen og hjelpen de egentlig har krav på riktig hjelp. For eksempel vet man at medisinene som brukes i behandlingen av bipolar lidelse har svært liten effekt på PMDD-symptomer. (Studd, 2012). 

Behandling

PMDD kan lindres med hormonell prevensjon som flater ut kroppens naturlige syklus. Antidepressiva i form av selektive serotoninreopptakshemmere (SSRI) har også vist å være effektfullt for en betydelig andel pasienter. Medisinering med SSRI har rask effekt på PMDD (i motsetning til ordinær depresjon) og man trenger bare behandling i dagene rundt menstruasjon (FHI, 2021). Psykoterapi har vist å ha liten effekt, og anbefales ikke som behandlingsform alene, da symptomene er så nært knyttet opp mot somatiske forhold. For noen kan likevel kognitiv terapi bidra med verktøy til å håndtere angst- og depresjonssymptomer. Hva som fungerer og ikke, vil variere fra individ til individ, og en betydelig andel vil oppleve at ingen av disse behandlingsmetodene bidrar til god nok lindring. Da vil en hysterektomi, eventuelt hormoner som induserer overgangsalder, kunne fungere som et siste behandlingsalternativ. Dette er fordi PMDD kun oppstår hos individer med aktiv menstruasjonssyklus. 

Premenstruell dysforisk forstyrrelse innebærer ofte stor grad av lidelse. Sterke følelser av depresjon, angst, og emosjonell usikkerhet rundt menstruasjon kan føles umulig å stå i. Noen beskriver at tiden før menstruasjon er preget av en følelse av å miste seg selv helt. Andre sammenligner det med en lysbryter som skrur seg av og gjør alt mørkt (Ro, 2019). Personer med PMDD har økt risiko for å falle ut av arbeidslivet og sine sosiale nettverk (Rapkin, 2013). Derfor er det viktig med tidlig og riktig diagnostisering. Bevisstgjøring rundt egen syklus og symptomer er viktig fordi det gjør en i stand til å tilrettelegge hverdagen rundt gode og dårlige perioder. Det kan også være hjelpsomt å vite at det man gjennomgår har en klar medisinsk årsak. 

Kilder:
Halbreich, U., Borenstein, J., Pearlstein, T., & Kahn, L. S. (2003). The prevalence, impairment, impact, and burden of premenstrual dysphoric disorder (PMS/PMDD). Psychoneuroendocrinology, 28 Suppl 3, 1–23. https://doi.org/10.1016/s0306-4530(03)00098-2 

Yonkers, K. A., O’Brien, P. M., & Eriksson, E. (2008). Premenstrual syndrome. Lancet (London, England), 371(9619), 1200–1210. https://doi.org/10.1016/S0140-6736(08)60527-9 

Feingold KR., Anawalt, B., Boyce, A. et al., Premenstrual Dysphoric Disorder (Formerly Premenstrual Syndrome) [Updated 2017 Jan 23]. South Dartmouth (MA): MDText.com, Inc.; 2000-. Table 1, Diagnostic Criteria for Premenstrual Dysphoric Disorder (PMDD) Available from: https://www.ncbi.nlm.nih.gov/books/NBK279045/table/premenstrual-syndrom.table1diag/ 

Pilver, C. E., Libby, D. J., & Hoff, R. A. (2013). Premenstrual dysphoric disorder as a correlate of suicidal ideation, plans, and attempts among a nationally representative sample. Social psychiatry and psychiatric epidemiology, 48(3), 437–446. https://doi.org/10.1007/s00127-012-0548-z 

Hantsoo, L., & Epperson, C. N. (2020). Allopregnanolone in premenstrual dysphoric disorder (PMDD): Evidence for dysregulated sensitivity to GABA-A receptor modulating neuroactive steroids across the menstrual cycle. Neurobiology of stress, 12, 100213. https://doi.org/10.1016/j.ynstr.2020.100213 

Rapkin, A. J., & Lewis, E. I. (2013). Treatment of Premenstrual Dysphoric Disorder. Women’s Health, 537–556. https://doi.org/10.2217/WHE.13.62 

Studd, J. (2012). Severe premenstrual syndrome and bipolar disorder: a tragic confusion. Menopause international, 18(2), 82–86. https://doi.org/10.1258/mi.2012.012018

Ro, Christine (16.12.2019). The overlooked condition that can trigger extreme behavior. BBC, BBC future. https://www.bbc.com/future/article/20191213-pmdd-a-little-understood-and-often-misdiagnosed-condition 

Norsk Helseinformatikk (FHI) (2021), Premenstruelt syndrom (PMS og PMDD)
https://nhi.no/kroppen-var/kropp/premenstruelt-syndrom/?page=4


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