Cyclical physical and mood symptoms in the luteal phase; PMDD is the severe form.
Also known as: PMS, PMDD, premenstrual dysphoric disorder, premenstrual syndrome
Overview
PMS is the cyclical occurrence of one or more bothersome physical, behavioral, or mood symptoms in the luteal phase, resolving within a few days of menses onset, with a symptom-free interval in the follicular phase. PMDD (DSM-5-TR diagnosis) requires >=5 symptoms with at least one being a mood symptom and causing significant impairment.
Epidemiology
Up to 80% of menstruating women report some premenstrual symptoms. PMS affects 20-30% with bothersome symptoms; PMDD affects 3-8%.
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Symptoms are triggered by normal cyclical changes in ovarian hormones (estradiol and progesterone) in genetically susceptible individuals with altered serotonergic and GABAergic responses. Allopregnanolone, a progesterone metabolite acting on GABA-A receptors, is implicated.
Clinical presentation
Symptoms
Mood: irritability, depression, anxiety, mood lability, anger, sense of being overwhelmed, decreased interest, difficulty concentrating
Physical: bloating, breast tenderness, headache, fatigue, joint/muscle aches, appetite/sleep changes
Symptoms appear in late luteal phase (~1-2 weeks before menses) and resolve within a few days of menses onset
Signs / physical exam
Physical exam is typically normal
Mental status exam may demonstrate dysphoria during luteal phase
Differential diagnosis
Major depressive disorder or anxiety disorder — Persistent symptoms NOT confined to luteal phase; prospective symptom diary distinguishes
Bipolar disorder — Mood symptoms not strictly cyclical; manic/hypomanic episodes
Thyroid disease — TSH and free T4 abnormal
Premenstrual exacerbation (PME) of an underlying disorder — Symptoms present throughout cycle but worsen premenstrually; treat the primary disorder
Perimenopause — Irregular cycles, vasomotor symptoms, age usually >40
Prospective symptom diary across at least 2 cycles documenting symptom timing and resolution. ACOG PMS criteria: >=1 affective or somatic symptom, in the 5 days before menses, in 3 consecutive cycles, with relief within 4 days of menses, no symptoms days 5-12 of cycle, and impairment. DSM-5-TR PMDD: >=5 symptoms with at least 1 from mood category, prospective documentation across 2 cycles, significant impairment.
Labs
Targeted to rule out medical mimics: TSH, CBC if fatigue, prolactin if galactorrhea/amenorrhea
For PMDD or severe PMS: SSRI (fluoxetine, sertraline, paroxetine, citalopram, escitalopram) — either continuous OR luteal-phase dosing (cycle days 14-28); rapid onset (often within days)
Combined oral contraceptive containing drospirenone with a 24/4 regimen (e.g., Yaz) — FDA-approved for PMDD
GnRH agonists (leuprolide) with add-back estrogen/progestin for severe refractory cases
Second-line / adjunct
Spironolactone 50-100 mg in luteal phase for bloating, mastalgia
Targeted symptom therapy: NSAIDs for dysmenorrhea/headache, diuretics for edema
Surgical: bilateral oophorectomy (with hysterectomy) — last resort for severe, refractory PMDD
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