Overlooked consequences of undiagnosed Premenstrual Dysphoric Disorder in Pakistani women

Madam, Premenstrual Dysphoric Disorder (PMDD) is a depressive disorder which comprises psychological and somatic symptoms brought on by sensitivity to fluctuations in the levels of female sex hormones throughout the menstrual cycle.1 Symptoms of PMDD present at the luteal phase of the menstrual cycle and usually resolve at the end of menstruation.1 These include but are not limited to affective lability and an increase in anxiety, anger and depressive episodes. Women with PMDD may also experience certain physical symptoms that deviate from normal physiological mechanisms such as lethargy, hypersomnia or insomnia and changes in appetite.1 Women worldwide struggle with self-harm and suicidal ideation; however, new studies suggest a possible correlation between these mental health issues and the prevalence of menstrual disorders like PMDD. A 2021 meta-analysis conducted by Divya Prasad et al. indicated that PMDD increases the likelihood of suicide attempt by almost sevenfold and of ideation by fourfold.2 The findings of this study raise grave concerns in countries such as Pakistan where discussions and studies related to both menstrual disorders and mental health are limited. A study on PMDD incidence in Pakistan's general population found no research on the topic. However, a cross-sectional study in three Karachi universities revealed that only 19% of female students were aware of PMDD, highlighting the country's lack of awareness and the taboo associated with menstruation in Pakistan's conservative society.3 Cultural perspectives often overlook PMDD symptoms due to the belief that women experience moodiness and sensitivity during menstruation. This generalization disregards hormonal pathology and views PMDD as a natural physiological phenomenon. This issue affects Pakistani women and physicians, as women may be influenced by this ideology, not considering their symptoms significant enough to warrant treatment. The Pakistani community can benefit from investigating the prevalence of PMDD in rural and urban areas to identify differential factors affecting symptoms and exacerbation. Studies have shown that higher perceived stress is linked to increased perimenstrual symptoms in women with PMDD.4 Future studies should measure the knowledge gap in physicians regarding PMDD's diagnostic criteria to prevent misdiagnosis. Recent findings highlight a single gene polymorphism in the ESR1 gene and contradictory neurobiological effects of Allopregnanolone on GABA-A receptors in women experiencing PMDD.5 This validates the symptoms experienced by women, protecting them from biased dismissals and societal stereotypes. These advancements could reduce healthcare gender disparity and foster confidence in seeking suitable treatment. Continued...