Premenstrual Syndrome (PMS) and PMDD
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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Risk factors
- Personal or family history of mood disorders (depression, anxiety, PMDD)
- History of trauma, chronic stress
- Smoking, obesity, increased caffeine intake (weak associations)
- Genetic susceptibility (ESR1 gene variants)
Pathophysiology
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
- Endometriosis / dysmenorrhea — Pain predominates; dyspareunia, dyschezia; laparoscopy or imaging
Diagnostic workup
Diagnostic criteria
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
Imaging
- Not routinely indicated
Diagnostic algorithm
| Feature | PMS | PMDD |
|---|---|---|
| Symptom number | >=1 mood or somatic | >=5 symptoms (>=1 mood) |
| Impairment | Mild-moderate | Marked, interferes with function |
| Diagnosis source | ACOG clinical criteria | DSM-5-TR psychiatric criteria |
| First-line med tx | SSRI or OC if severe; supplements for mild | SSRI (continuous or luteal); drospirenone OC |
Treatment
First-line
- Lifestyle: aerobic exercise, regular sleep, stress reduction, smoking cessation, reduce caffeine/alcohol/sodium in luteal phase
- Supplements with modest evidence: calcium 1000-1200 mg/day, vitamin B6 (50-100 mg/day; >100 mg/day risks neuropathy), magnesium
- Cognitive behavioral therapy
- 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
Complications
- Functional impairment (work, school, relationships)
- Suicidality and self-harm (PMDD carries elevated risk)
- Comorbid depression, anxiety, substance use
PANCE pearls
- PMDD is a DSM-5-TR diagnosis with prospective symptom tracking required across 2 cycles — distinguishes from PME of other mood disorders.
- SSRIs work rapidly in PMDD (often within days), unlike in major depression — can be used continuously or only during the luteal phase.
- Drospirenone-containing combined OCs (Yaz) are FDA-approved for PMDD; other COCs less consistently studied.
- PMS/PMDD do not begin in the postmenopausal period — consider other diagnoses if onset is after menopause.
- Suicide risk is elevated in PMDD — screen and address active mood/safety concerns even in 'cyclical' presentations.
References
- ACOG PB 15 — ACOG Premenstrual Syndrome (Obstet Gynecol, multiple updates)
- DSM-5-TR — DSM-5-TR Diagnostic Criteria for Premenstrual Dysphoric Disorder (APA 2022)
- ISPMD 2011 — International Society for Premenstrual Disorders consensus on diagnosis
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