Premenstrual syndrome and dysphoric disorder

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 90% of women.[1]American College of Obstetricians and Gynecologists. ACOG clinical practice guideline no. 7: management of premenstrual disorders. Dec 2023 [internet publication]. https://www.acog.org/clinical/clinical-guidance/clinical-practice-guideline/articles/2023/12/management-of-premenstrual-disorders ​ 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%.[2]Schoep ME, Nieboer TE, van der Zanden M, et al. The impact of menstrual symptoms on everyday life: a survey among 42,879 women. Am J Obstet Gynecol. 2019 Jun;220(6):569.e1-e7. http://www.ncbi.nlm.nih.gov/pubmed/30885768?tool=bestpractice.com

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.[3]Ismaili E, Walsh S, O'Brien PMS, et al; Consensus Group of the International Society for Premenstrual Disorders. Fourth consensus of the International Society for Premenstrual Disorders (ISPMD): auditable standards for diagnosis and management of premenstrual disorder. Arch Womens Ment Health. 2016 Dec;19(6):953-8. http://www.ncbi.nlm.nih.gov/pubmed/27378473?tool=bestpractice.com 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.[4]American College of Obstetricians and Gynecologists. Guidelines for women's health care: a resource manual. 4th ed. Washington, DC: American College of Obstetricians and Gynecologists; 2014:607-13.

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.[5]American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th ed., text revision (DSM-5-TR). Washington, DC: American Psychiatric Association; 2022.