Clinical descriptions of premenstrual symptoms have been reported in the medical literature since the time of Hippocrates. Emotional and physical symptoms occurring along a continuum of severity are common during the luteal phase of the menstrual cycle. Premenstrual syndrome (PMS) is a complex of mild to moderate emotional and/or physical symptoms, which typically do not interfere with patients’ usual level of functioning. Up to 75% of reproductive-aged women have reported premenstrual symptoms at some time during their lives. Premenstrual dysphoric disorder (PMDD) is a severe form of premenstrual syndrome, which affects 3-8% of reproductive-aged women. The hallmark of premenstrual syndrome at all levels of severity is the exclusive occurrence of symptoms during the luteal phase of the menstrual cycle with remission typically within 3 days of menses onset.

A diagnosis of premenstrual syndrome (PMS) requires at least one physical or emotional symptom from the International Classification of Diseases — 10th edition (ICD-I 0). Premenstrual dysphoric disorder, premenstrual dysphoric disorder, is a more severe condition in which there is a marked mood change (depression, mood swings, irritability or anxiety) as well as the presence of other physical and somatic symptoms. Prospective symptom rating for at least two menstrual cycles and disruption in social and/or occupational functioning are required to fulfill the “research” criteria for this diagnosis found in the Appendix of the Diagnostic and Statistical Manual — 4th edition-Text Revision (DSM-IV-TR) and listed in Table Premenstrual dysphoric disorder criteria. The presence of the diagnosis of premenstrual dysphoric disorder in the DSM classification has been met with significant controversy. The controversy centered on the fact that only women could be affected by this diagnosis and that it could potentially lead to gender discrimination. After a period of discussion and debate, it was determined that the diagnostic criteria for premenstrual dysphoric disorder would remain as “research” criteria to improve understanding of the etiology and to identify the best treatment options.

Risk Factors

Family history of mood disorder, history of severe mood swings or negative reactions to oral contraceptives, obesity, poor diet, and lack of exercise are among the factors that increase a woman’s susceptibility to the development of PMS/ PMDD. A history of sexual or physical abuse also appears to put women at greater risk for premenstrual syndrome (PMS).

Table Premenstrual dysphoric disorder criteria*

A. In most menstrual cycles during the past year, five (or more) of the following symptoms were present for most of the time during the last week of the luteal phase, began to remit within a few days after the onset of the follicular phase, and were absent in the week postmenses, with at least one of the symptoms being either (1), (2), (3), or (4):

1. Markedly depressed mood, feelings of hopelessness, or self-deprecating thoughts

2. Marked anxiety, tension, feelings of being “keyed up,” or “on edge”

3. Marked affective lability (e.g., feeling suddenly sad or tearful or increased sensitivity to rejection)

4. Persistent and marked anger or irritability or increased interpersonal conflicts

5. Decreased interest in usual activities (e.g., work, school, friends, hobbies)

6. Subjective sense of difficulty in concentrating

7. Lethargy, easy fatigabilily, or marked lack of energy

8. Marked change in appetite, overeating, or specific food cravings

9. Hypersomnia or insomnia

10. A subjective sense of being overwhelmed or out of control

11. Other physical symptoms, such as breast tenderness or swelling, headaches, joint or muscle pain, a sensation of “bloating,” weight gain

Note: In nonmenstruating females (e.g., those who have had a hysterectomy), the timing of luteal and follicular phases may require measurement of circulating reproductive hormones.

B. The disturbance markedly interferes with work or school or with usual social activities and relationships with others (e.g., avoidance of social activities, decreased productivity and efficiency at work or school).

C. The disturbance is not merely an exacerbation of the symptoms of another disorder, such as major depressive disorder, panic disorder, dysthymic disorder, or a personality disorder (although it may be superimposed on any of these disorders).

D. Criteria A, B, and C must be confirmed by prospective daily ratings during at least two consecutive symptomatic cycles. (The diagnosis may be made provisionally prior to this confirmation.)

*DSM-IV-TR research criteria

Clinical Symptoms and History

Premenstrual syndrome is characterized by mood swings, depressed mood, irritability and/or anxiety, which may be accompanied by physical symptoms. These symptoms occur exclusively during the luteal phase of the menstrual cycle. Common physical symptoms observed in premenstrual syndrome are breast tenderness, abdominal bloating, headache, and joint and muscle aches. The diagnosis of premenstrual dysphoric disorder requires marked mood disturbance (depression, irritability, mood swings) as well as the presence of other emotional and/or physical symptoms. Additionally, a significant reduction in social and/or occupational functioning is required for the diagnosis of premenstrual dysphoric disorder. The functional impairment tends to be in social as opposed to occupational domains. Prospective daily recording of the presence and severity of symptoms for at least two menstrual cycles is used to confirm the diagnosis of premenstrual dysphoric disorder. Specific diagnostic criteria for premenstrual dysphoric disorder are shown in Table Premenstrual dysphoric disorder criteria.

Differential Diagnosis of PMS

Etiology of PMS

Treatment of PMS

PMS: Pharmacologic Interventions

PMS: Key Points

Spironolactone

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