Approach
While premenstrual symptoms are common among most women, a diagnosis of PMS or PMDD is less common. PMS is characterised by repetitive, cyclical, physical, and behavioural symptoms occurring in the luteal phase of the menstrual cycle (the time period between ovulation and onset of menstruation). PMDD is a more severe variant that includes at least one affective symptom. The American College of Obstetricians and Gynecologists describes premenstrual disorders as a diagnosis of exclusion, advising that clinicians should rule out other potential causes of premenstrual symptoms, such as other mood disorders or general medical conditions.[1]
History and physical examination
A menstrual history is of paramount importance. Both regular and irregular cycles may be associated with PMS/PMDD, as long as they are ovulatory.[7] Perimenopausal women, premenopausal women who have undergone a hysterectomy, or women with a progestin-containing intrauterine contraceptive device or contraceptive implant may experience irregular or absent menstrual cycles, but still have PMS/PMDD. In all cases, the cyclicity of the symptoms should be assessed, as well as their effect on the woman's work, school, family life, and interpersonal relationships.
Healthcare professionals should elicit the woman's belief about the cause of the symptoms, previous treatments used, and whether symptoms improved with treatment. A full medical history, including medication, contraceptive history, and use of recreational drugs and alcohol should be part of the evaluation. A history of sexual abuse should be explored with every woman as some evidence suggests a relationship between prior abuse and increased sensitivity to hormonal changes and mood disorders.[54] In any woman with a history of current or past abuse, additional counselling may be warranted.
Physical examination should be performed as indicated by patient age and routine gynaecological and medical recommendations. There are no specific physical signs on examination for PMS/PMDD.
Symptom diary
Central to the diagnosis of PMS/PMDD is a patient’s recollection of symptoms having been present during most menstrual cycles in the preceding year, along with a prospective symptom diary, recommended for at least 1 cycle but ideally 2 to 4 cycles.[1][7] The woman should record and rate her symptoms every day. Various apps and symptom calendars are available, but the Daily Record of Severity of Problems (DRSP) form, consisting of 17 common symptoms, including the 11 listed in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), rated each day on a scale from 1 to 5, is the most commonly used. The DRSP has been validated as a prospectively self-administered questionnaire.[56] Each woman should also identify her most bothersome symptom, which may or may not score the highest on the DSRP.
For confirmation of PMS/PMDD, the symptom diary should reveal symptoms during the luteal phase, which resolve with the onset of menses, with at least 1 symptom-free week. The diary will differentiate PMS/PMDD from premenstrual exacerbations of other conditions and may identify chronic disorders unrelated to the menstrual cycle.[1]
Additional testing for depression or anxiety with validated questionnaires such as the Patient Health Questionnaire (PHQ-9), the Hospital Anxiety and Depression (HAD) Scale, or the Beck Depression Inventory should be utilised if these disorders are suggested by history or symptoms.
If diagnosis remains inconclusive following evaluation with a symptom diary, a 3-month trial of a gonadotrophin-releasing hormone (GnRH) agonist may be helpful, with resolution of symptoms after ovarian suppression considered diagnostic for the disorder.[1][7] This approach is inferred to be efficacious based on evidence in GnRH use for treatment but is an off-label indication and is not evidence-based. Initiation of other therapies, such as selective serotonin-reuptake inhibitors, may be considered before this diagnostic intervention.
Laboratory testing and imaging
Laboratory testing in the absence of physical findings is generally not recommended. Thyroid screening may be the exception as thyroid disease may cause mood disorders. Women who have irregular cycles may need further evaluation for causes of abnormal bleeding as indicated by general gynaecological practice. If pain is a significant symptom, a pelvic ultrasound might be considered.
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