INTRODUCTION — The premenstrual syndrome (PMS) is characterized by the presence of both physical and behavioral (including affective) symptoms that occur repetitively in the second half of the menstrual cycle and interfere with some aspects of the woman's life. The American Psychiatric Association (APA) defines premenstrual dysphoric disorder (PMDD) as a severe form of PMS in which symptoms of anger, irritability, and internal tension are prominent. (See 'Evaluation' below.)
This topic will review the clinical manifestations and diagnosis of PMS and PMDD. The epidemiology, pathogenesis, and treatment of this disorder are discussed separately. (See "Epidemiology and pathogenesis of premenstrual syndrome and premenstrual dysphoric disorder" and "Treatment of premenstrual syndrome and premenstrual dysphoric disorder".)
DEFINITIONS — Most women of reproductive age experience one or more mild emotional or physical symptoms for one to two days before the onset of menses (figure 1). These symptoms (such as breast soreness and bloating) are mild, do not cause severe distress or functional impairment, and are not considered to represent premenstrual syndrome (PMS) .
In contrast, clinically significant PMS is defined by the American College of Obstetricians and Gynecologists (ACOG) as at least one symptom associated with "economic or social dysfunction" that occurs during the five days before the onset of menses and is present in at least three consecutive menstrual cycles (figure 1). Symptoms may be affective (eg, angry outbursts, depression) or physical (eg, breast pain and bloating) (table 1). (See 'Evaluation' below.)
Premenstrual dysphoric disorder (PMDD) is the most severe form and is described below. (See 'PMDD' below.)
CLINICAL MANIFESTATIONS — Women with premenstrual syndrome (PMS) experience a wide variety of cyclic and recurrent physical, emotional, behavioral, and cognitive symptoms that begin in the luteal phase (second half) of the menstrual cycle and resolve shortly after the onset of menses (the follicular phase) (figure 1). However, the core symptoms include affective symptoms, such as depression, irritability, and anxiety, and somatic symptoms, such as breast pain, bloating and swelling, and headache (table 1). The core feature is the recurrent onset of symptoms during the end of the luteal phase of the menstrual cycle with a symptom-free period shortly after menses has begun, typically when the menstrual flow has ended .
Timing of symptoms — For most women, the types of symptoms are fairly consistent across cycles and last for an average of six days per month . Analysis of prospective symptom surveys in women with premenstrual dysphoric disorder (PMDD) suggest that mood and physical symptoms are typically most severe (and accompanied by functional impairment) in the four days before through the first two to three days of menses . (See 'PMDD' below.)
Most common symptoms — More than 150 physical, behavioral, emotional, and cognitive symptoms have been ascribed to PMS in the literature. However, the number of symptoms seen in the vast majority of patients is much more limited [4-7]. By definition, affective symptoms predominate in women with PMDD, although most women with this condition also have physical symptoms (table 1) . (See 'DSM-5 criteria' below.)
●The most common affective or behavioral symptom of PMS is mood swings. Other frequent nonphysical behavioral symptoms include irritability, anxiety/tension, sad or depressed mood, increased appetite/food cravings, sensitivity to rejection, and diminished interest in activities .
●The most common physical manifestations of PMS are abdominal bloating and an extreme sense of fatigue. Other common symptoms include breast tenderness, headaches, hot flashes, and dizziness . Hot flashes in women who are neither postpartum nor peri-or postmenopausal are highly suggestive of PMS or PMDD. These flushes also occur cyclically premenstrually and have been shown to be physiologically similar to menopausal hot flashes .
Impact on quality of life — Moderate to severe PMS symptoms have been associated with reductions in health-related quality of life [9,10], as well as a decrease in work productivity, increase in work absenteeism, and an increase in visits to ambulatory healthcare providers [11,12].
Suicide risk — Some work suggests that women with PMDD, especially those with more severe symptoms, have an elevated risk of suicidal ideation and attempts [13,14]. Clinicians may want to ask patients if mood symptoms "ever become so severe that she (the patient) thinks she would be better off if she were not around or not alive." Any positive response should trigger referral to a mental health professional.
Natural history — PMS symptoms begin any time after menarche, but usually by one's early 20s, and typically continue throughout reproductive life (if untreated) . Some women experience more severe symptoms in the late reproductive years , and women with premenstrual disorders appear to be at higher risk for developing mood disorders during the menopausal transition . PMS resolves completely after menopause and transiently during pregnancy or during any disruption of ovulatory cycles [15,18]. (See "Epidemiology and pathogenesis of premenstrual syndrome and premenstrual dysphoric disorder", section on 'Epidemiology' and "Clinical manifestations and diagnosis of menopause", section on 'Depression'.)
Physical exam — There are no specific abnormalities on physical exam in women with PMS/PMDD.
Laboratory findings — There are no specific biochemical abnormalities associated with the disorder. Daily serum concentrations of gonadotropins and sex steroids are no different in women with PMS than women without PMS [19,20]. (See "Epidemiology and pathogenesis of premenstrual syndrome and premenstrual dysphoric disorder", section on 'Ovarian steroids'.)
General approach — The assessment of patients with possible premenstrual syndrome (PMS) or premenstrual dysphoric disorder (PMDD) should include the following:
●A detailed menstrual history, because the relationship between symptoms and cycle phase must be confirmed.
If the patient's cycles are regular (25- to 35-day intermenstrual interval), detailed information about her symptoms should then be obtained (type, pattern of onset and offset, severity, presence of functional impairment, and confirmation that symptoms are recurrent).
Women with PMS/PMDD may also experience irregular menstrual cycles (<25 or >35 days) particularly during the menopausal transition. In this setting, symptoms may be more difficult to track because of cycle variability. Biochemical testing is not required in women with irregular cycles during the transition but should be performed in younger women to determine the etiology of the irregular menstrual cycles. We suggest measuring serum human chorionic gonadotropin (hCG), thyroid-stimulating hormone (TSH), prolactin, and follicle-stimulating hormone (FSH). (See "Evaluation and management of secondary amenorrhea", section on 'Initial evaluation'.)
●Evaluation of medications, including hormonal treatment – Women taking oral contraceptives (OCs) should be asked if their premenstrual symptoms were present before the OC was started, or if the symptoms first began after initiation of the OC (eg, exogenous hormone-induced rather than true PMS or PMDD). Of note, OCs are sometimes used to treat premenstrual disorders, although data on their efficacy are conflicting. (See "Treatment of premenstrual syndrome and premenstrual dysphoric disorder", section on 'General principles'.)
●Consideration of endocrine disorders that can cause similar symptoms, such as hyper- or hypothyroidism (see 'Thyroid disorders' below) and cortisol excess (eg, if symptoms are severe and refractory to standard treatment and/or are present throughout the entire menstrual cycle).
●Laboratory testing should be limited. We suggest a serum TSH to rule out hyper- and hypothyroidism, both of which can cause mood symptoms. (See 'Thyroid disorders' below.)
●If the patient's symptom history is consistent with PMS/PMDD and there is no evidence of other medical disorders, the patient should be asked to record symptoms prospectively for two months to confirm the diagnosis. (See 'Prospective monitoring with self-rating scale' below.)
●The existence of a chronic, mild mood disorder such as dysthymic disorder or major depressive disorder should be ruled out. Prospective symptom charting helps to determine if symptoms are present continuously or only during the premenstrual phase of the cycle. (See 'Mood and anxiety disorders' below.)
Prospective monitoring with self-rating scale — Because of the similarity of PMS and PMDD symptoms to those of other disorders, a valid and reliable prospective symptom inventory is required to confirm the diagnosis . Several tools are available, but the Daily Record of Severity of Problems (DRSP) form, which has been validated as a prospectively self-administered questionnaire, is the most commonly used . The DRSP consists of 17 common PMS symptoms, including 11 symptoms from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) PMDD diagnostic criteria. Patients rate each symptom on a six-point scale, from 1 (none at all) to 6 (extreme) (table 2).
DIAGNOSTIC CRITERIA — Once the detailed menstrual and symptom history have been taken, the prospective monitoring is complete (table 2), exam and laboratory data are completed (and normal), we make the diagnosis of premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) using the following criteria [2,23]:
PMS — We make a diagnosis of PMS if a woman has:
●One to four symptoms that may be physical, behavioral, or affective/psychological in nature, or
●≥5 symptoms that are physical or behavioral.
●If, on the other hand, a woman has ≥5 symptoms and one of them is an "affective symptom" (eg, mood swings, anger, irritability, sense of hopelessness or tension, anxiety or feeling on edge), it is more accurate to diagnose her with PMDD rather than PMS. (See 'Definitions' above.)
The American College of Obstetricians and Gynecologists (ACOG) define PMS as the presence of at least one symptom occurring in the luteal phase of the cycle, which leads to impairment in functioning. The International Society for Premenstrual Disorders (ISPMD) identified "core" criteria for clinically significant PMS to include at least one symptom that is either psychological or behavioral. The symptom(s) must impair functioning in some way and the symptom must remit at menses or shortly thereafter to constitute a symptom-free interval .
PMDD — The diagnosis of PMDD is made using the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria. (See 'DSM-5 criteria' below.)
Available diagnostic criteria — Many groups have published diagnostic criteria for premenstrual disorders including the World Health Organization (WHO), ACOG, Royal College of Obstetricians and Gynecologists (RCOG), ISPMD, and the American Psychiatric Association (APA; DSM-5), which has published criteria for the diagnosis of PMDD. Although the criteria for diagnosis of premenstrual disorders are variable, there is general agreement that the ACOG and RCOG adequately describe PMS, while the DSM criteria describe the more severe syndrome, PMDD . (See 'DSM-5 criteria' below.)
We currently use the APA DSM-5 system, which provides PMDD criteria. These criteria require:
●Prospective documentation of physical and behavioral symptoms (using diaries) being present for most of the preceding year .
●Five or more symptoms must have been present during the week prior to menses, resolving within a few days after menses starts.
●These criteria also specify that PMDD may be superimposed on other psychiatric disorders, provided it is not merely an exacerbation of those disorders.
DSM-5 criteria — One or more of the following symptoms must be present:
●Mood swings, sudden sadness, increased sensitivity to rejection
●Sense of hopelessness, depressed mood, self-critical thoughts
●Tension, anxiety, feeling on edge
One or more of the following symptoms must be present to reach a total of five symptoms overall:
●Change in appetite, food cravings, overeating
●Diminished interest in usual activities
●Easy fatigability, decreased energy
●Feeling overwhelmed or out of control
●Breast tenderness, bloating, weight gain, or joint/muscles aches
●Sleeping too much or not sleeping enough
Among these symptoms, premenstrual irritability is the most common symptom. Symptoms must have been present in most menstrual cycles that occurred the previous year, and the symptoms must be associated with significant distress or interference with usual activities (eg, work, school, social life). These criteria also specify that PMDD may be superimposed on other psychiatric disorders, provided it is not merely an exacerbation of those disorders.
Women without menstruation — The diagnosis of premenstrual disorders is more challenging, but still possible, in women with normal ovarian function and ovulation in the absence of menstruation. These women experience the typical cyclic symptoms of PMS/PMDD but cannot use menses as a reference point for their symptoms. Examples include:
●Women who have undergone hysterectomy (with ovarian conservation) or an endometrial ablation, which results in amenorrhea in approximately 35 to 40 percent.
●Women using a levonorgestrel intrauterine device (for contraception or heavy menstrual bleeding). Amenorrhea typically develops after six months of use, but ovulation persists in approximately 75 percent of women. (See "Abnormal uterine bleeding in nonpregnant reproductive-age patients: Management", section on 'Levonorgestrel intrauterine device' and "Hormonal contraception for suppression of menstruation", section on 'Levonorgestrel intrauterine device (LNG 52 mg)'.)
In this setting, prospective charting is essential to document a cyclic pattern of symptoms that recur approximately every 28 to 35 days, the normal range for intermenstrual intervals.
DIFFERENTIAL DIAGNOSIS — Premenstrual disorders should always be differentiated from premenstrual exacerbation of an underlying major psychiatric disorder; the menopausal transition ; thyroid disorders (hyper- or hypothyroidism); and mood disorders, such as major depressive disorder, minor depressive disorder, or dysthymic disorder.
Mood and anxiety disorders — There is substantial overlap between premenstrual dysphoric disorder (PMDD) and psychiatric disorders, particularly mood and anxiety disorders. In some instances, women with premenstrual disorders may have had an episode of a mood or anxiety disorder in the past that has resolved. Assigning a diagnosis of premenstrual syndrome (PMS)/PMDD is not difficult in this group but often requires that a patient keep a daily calendar that demonstrates luteal phase onset of symptoms with resolution of symptoms in the follicular phase of the cycle.
However, women who present with the complaint of PMS and experience significant symptoms in both the follicular and luteal phase are likely to have a mood disorder such as major, minor, or dysthymic disorder rather than PMDD . While symptoms may worsen during the luteal phase, treatment should be geared toward ameliorating symptoms of the ongoing mood or anxiety disorder, although in practice, both may be treated simultaneously. (See "Treatment of premenstrual syndrome and premenstrual dysphoric disorder".)
Menopausal transition — New mood and/or anxiety symptoms in a woman in her 40s or 50s are more likely to be due to the menopausal transition than to new-onset PMS. As noted above, PMS symptoms typically start at a younger age, most often by the early 20s. (See 'Natural history' above.)
It is estimated that up to 20 percent of women develop mood and/or anxiety disorders during the menopausal transition. But unlike PMS symptoms, which occur during ovulatory cycles, menopausal mood symptoms typically begin when menstrual cycles become irregular/anovulatory. (See "Clinical manifestations and diagnosis of menopause", section on 'Depression'.)
The diagnosis of the menopausal transition is a clinical diagnosis, based upon the menstrual history (onset of irregular cycles) with or without menopausal symptoms, such as hot flashes, and mood symptoms. Documentation of an elevated serum follicle-stimulating hormone (FSH) is not necessary to confirm the diagnosis. (See "Clinical manifestations and diagnosis of menopause", section on 'Diagnosis'.)
Thyroid disorders — Both hyper- and hypothyroidism are common in women. Hyperthyroidism, in particular, may present with mood symptoms. Both disorders can be distinguished from PMS based upon other typical features of thyroid disease on history, exam, and by a serum thyroid-stimulating hormone (TSH) that is either above or below the normal range (hypo- and hyperthyroidism, respectively). (See "Overview of the clinical manifestations of hyperthyroidism in adults" and "Diagnosis of hyperthyroidism" and "Clinical manifestations of hypothyroidism".)
Substance abuse — It has been suggested that women with PMS consume more alcohol than controls , independent of cycle phase, and that women with a family history of alcoholism experience more anxiety premenstrually . However, a firm link between alcoholism and PMS has never been established.
Other — A variety of medical disorders (eg, migraine; chronic fatigue syndrome [CFS] also known as myalgic encephalomyelitis/chronic fatigue syndrome [ME/CFS]; irritable bowel syndrome) are exacerbated just prior to or during menses. However, the symptoms expressed are not those typical of PMS, and the timing is not usually confined to the luteal phase.
These observations underscore the importance of using strict diagnostic criteria and prospective recording in assessing patients presenting with complaint of PMS or PMDD. (See 'Prospective monitoring with self-rating scale' above.)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Diagnosis and treatment of premenstrual dysphoric disorder".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Beyond the Basics topics (see "Patient education: Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●The premenstrual syndrome (PMS) is characterized by the presence of both physical and/or behavioral (including affective) symptoms that occur repetitively in the second half of the menstrual cycle and interfere with some aspects of the woman's life (figure 1). The American Psychiatric Association (APA) Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) defines premenstrual dysphoric disorder (PMDD) as a severe form of PMS in which symptoms of anger, irritability, and internal tension are prominent. (See 'Definitions' above and 'DSM-5 criteria' above.)
●The most common behavioral symptom of PMS is irritability. Other frequent behavioral complaints include labile mood, anxiety/tension, sad or depressed mood, increased appetite/food cravings, sensitivity to rejection, and diminished interest in activities. (See 'Most common symptoms' above.)
●The most common physical manifestations of PMS are abdominal bloating and an extreme sense of fatigue. Other common symptoms include breast tenderness, headaches, hot flashes, and dizziness. (See 'Most common symptoms' above.)
●The assessment of patients with possible PMS or PMDD should begin with the menstrual cycle history, and the relationship between symptom expression and menstrual cycle phase. The possibility that the symptoms are due to medications or hormone treatment rather than PMS or PMDD should be evaluated. (See 'General approach' above.)
Both hyper- and hypothyroidism need to be ruled out. This can be done by looking for the typical features of thyroid disease on history and exam and by measuring serum thyroid-stimulating hormone (TSH). (See 'Thyroid disorders' above.)
●If the patient's symptom history is consistent with PMS/PMDD and there is no evidence for other medical disorders, the patient should then record her symptoms prospectively for two months. (See 'General approach' above.)
●For symptom recording, we use the Daily Record of Severity of Problems (DRSP) form (table 2). It is important to use prospective recording and strict diagnostic criteria to diagnosis PMS. (See 'Prospective monitoring with self-rating scale' above.)
●We suggest using the DSM-5 criteria for diagnosis of PMDD, which requires prospective documentation of multiple recurrent symptoms that cause functional impairment. (See 'DSM-5 criteria' above.)
●Premenstrual disorders should always be differentiated from premenstrual exacerbation of an underlying major psychiatric disorder; the menopausal transition; thyroid disorders (hyper- or hypothyroidism); and mood disorders, such as major depressive disorder, minor depressive disorder, or dysthymic disorder. Women with significant symptoms in both the follicular and luteal phase are likely to have a mood disorder rather than a premenstrual disorder. (See 'Differential diagnosis' above.)
●In women who show a clear symptom-free interval in the follicular phase, those who meet either the DSM-5 criteria for PMDD for severe distress and/or psychosocial impairment are candidates for pharmacologic therapy. (See "Treatment of premenstrual syndrome and premenstrual dysphoric disorder".)
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