Premenstrual syndrome (PMS) is characterised by repetitive, cyclical, physical, and behavioural symptoms occurring in the luteal phase of the normal menstrual cycle. Symptoms may extend into the first few days of menses. The symptoms cannot be an exacerbation of another disorder, and they must interfere with some aspects of the woman's life.
Premenstrual dysphoric disorder (PMDD) is a more severe variant of PMS. In addition to physical symptoms, at least one affective symptom such as anger, irritability, and/or internal tension occurs during the second half of the menstrual cycle, and sometimes in the first few days of menses. Symptoms must remit post-menses, and not represent an exacerbation of another psychiatric disorder.
PMS and PMDD are diagnoses of exclusion, confirmed by a prospective symptom diary that verifies their repetitive, cyclical nature. Physical examination and limited laboratory testing are typically normal.
Treatment options include lifestyle modification, behavioural therapy, pharmacological interventions, and, in severe refractory cases, surgical removal of the ovaries.
Premenstrual symptoms are experienced by up to 80% of women. Women who experience minor, transient symptoms that do not cause personal, interpersonal, or functional impairment are experiencing premenstrual symptoms rather than having a diagnosis of premenstrual syndrome (PMS) or premenstrual dysphoric disorder (PMDD). These may include physical symptoms such as abdominal bloating (most common), breast tenderness, headache, or minor mood changes. In a 2019 internet-based survey of 42,879 Dutch women, 85% reported dysmenorrhoea, 77% psychological complaints, and 71% tiredness, leading to disruption of daily life in 38%.
PMS is characterised by repetitive, cyclical, physical, and behavioural symptoms occurring in the luteal phase of the normal menstrual cycle (the time between ovulation and onset of menstruation). The criteria for PMS were outlined by the International Society for Premenstrual Disorders in 2011. They recognise over 150 different psychological, physical, and behavioural symptoms that may be associated with PMS. Symptoms must not be present at other times through the cycle, must also cause significant impairment, and must not represent an exacerbation of another disorder, and at least one symptom-free week must be present. PMS is not classified as a mental illness in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). The American College of Obstetricians and Gynecologists defines PMS as the cyclic recurrence of symptoms that occur in the luteal phase of the menstrual cycle, are variable in intensity and effect on daily life, and cease shortly after the onset of menstruation.
PMDD, the more severe form of the disorder, is classified in the DSM-5-TR as a mental illness. The criteria for PMDD require that the woman experience at least 5 of 11 cognitive-affective, behavioural, and physical symptoms during the final week of the luteal phase that resolve with or near the onset of menses. Symptoms must also remit post-menses, and not represent an exacerbation of another psychiatric disorder.
History and exam
Key diagnostic factors
- presence of risk factors
- abdominal bloating
- breast tenderness
- depressed mood, irritability, and internal tension
- labile mood
- adverse effect on life
Other diagnostic factors
- increased appetite
- forgetfulness and difficulty concentrating
- other subjective symptoms
- insomnia or hypersomnia
- gastrointestinal upset
- heart palpitations
- hot flushes
- post-pubescent and premenopausal women
- family history
- mood disorders
- cigarette smoking
- white women
- sexual abuse and/or trauma
- alcohol consumption
1st investigations to order
- prospective symptom diary
Investigations to consider
- thyroid function tests
- follicle-stimulating hormone levels
- depression screening
moderate to severe PMS or PMDD
- Thyroid disease
- Generalised anxiety disorder
- Management of premenstrual syndrome
- Fourth consensus of the International Society for Premenstrual Disorders (ISPMD): auditable standards for diagnosis and management of premenstrual disorder
Premenstrual syndromeMore Patient leaflets
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