From American College of Obstetrics and Gynecology Practice Bulletin: Clinical management guidelines for obstetrician-gynecologists. Number 15, April 2000. Premenstrual syndrome. Obstet Gynecol 2000;95:1-9; and Kessel B: Premenstrual syndrome. Advances in diagnosis and treatment. Obstet Gynecol Clin North Am 2000;27:625-39.

PMDD is characterized by various combinations of marked mood swings, depressed mood, irritability, and anxiety, which may be accompanied by physical symptoms. These symptoms occur exclusively during the luteal phase of the menstrual cycle and generally resolve within 2 to 3 days after the onset of menses. The symptoms cause substantial impairment of personal functioning, generally more in social than occupational domains. A symptom-free period during the follicular phase of the menstrual cycle is essential in differentiating PMDD from preexisting anxiety or mood disorders.

Features of PMDD and depressive disorders overlap considerably. A family history of depression is common in women diagnosed with moderate to severe PMS. Despite the overlap between PMDD and depressive disorders, many patients with PMDD do not have depressive symptoms; therefore, PMDD should not be considered simply a variant of depressive disorder. The diagnostic criteria for PMDD from the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, are presented in Box 32-2.

Box 32-2. Research Criteria for Premenstrual Dysphoric Disorder

A. In most menstrual cycles during the past year, five (or more) of the following symptoms were present for most of the time during the last week of the luteal phase, began to remit within a few days after the onset of the follicular phase, and were absent in the week after menses, with as least one of the symptoms being 1, 2, 3, or 4:

1. Markedly depressed mood, feelings of hopelessness, or self-deprecating thoughts

2. Marked anxiety, tension, or feelings of being “keyed up” or “on edge”

3. Marked affective lability (e.g., feeling suddenly sad or tearful or increased sensitivity to rejection)

4. Persistent and marked anger or irritability or increased interpersonal conflicts

5. Decreased interest in usual activities (e.g., work, school, friends, hobbies)

6. Subjective sense of difficulty in concentrating

7. Lethargy, easy fatigability, or marked lack of energy

8. Marked change in appetite, overeating, or specific food cravings

9. Hypersomnia or insomnia

10. A subjective sense of being overwhelmed or out of control

11. Other physical symptoms, such as breast tenderness or swelling, headaches, joint or muscle pain, a sensation of “bloating,” or weight gain

B. The disturbance markedly interferes with work or school or with usual social activities and relationships with others (e.g., avoidance of social activities, decreased productivity and efficiency at work or school).

C. The disturbance is not merely an exacerbation of the symptoms of another disorder, such as major depressive disorder, panic disorder, dysthymic disorder, or a personality disorder (although it may be superimposed on any of these disorders).

D. Criteria A, B, and C must be confirmed by prospective daily ratings during at least two consecutive symptomatic cycles. (The diagnosis may be made provisionally before this confirmation.)

From American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association, 1994:717-718.

PMS and PMDD can be diagnosed only after physical and psychiatric disorders have been ruled out. This differential diagnosis is presented later in this chapter. PMS should be distinguished from simple premenstrual symptoms such as breast tenderness that does not interfere with daily functioning. The key elements of the diagnosis are symptoms consistent with PMS or PMDD, consistent occurrence of symptoms only during the luteal phase of the menstrual cycle, a relative absence of symptoms during the follicular phase of the menstrual cycle, and a negative impact of symptoms on function and lifestyle.

Medications Associated with Premenstrual Syndrome and Premenstrual Dysphoric Disorder

Oral contraceptives

Key Historical Features

✓ Duration of symptoms

✓ Interference with work, school, social activities, or relationships

✓ Affective or cognitive symptoms

• Affective lability (e.g., feeling suddenly sad or tearful or increased sensitivity to rejection)

• Aggression

• Anger

• Anxiety, tension, or feelings of being “keyed up” or “on edge”

• Decreased interest in usual activities (e.g., work, school, friends, hobbies)

• Depressed mood, feelings of hopelessness, or self-deprecating thoughts

• Fatigue

• Forgetfulness

• Hypersomnia or insomnia

• Irritability

• Panic attacks

• Poor concentration

• Reduced coping skills

• Subjective sense of difficulty in concentrating

• Marked change in appetite, overeating, or specific food cravings

✓ Other physical symptoms

• Acne

• Appetite change

• Bloating or fluid retention

• Breast tenderness or swelling

• Joint or muscle pain

• Muscle aches

• Nausea and vomiting

• Palpitations

• Pelvic heaviness or pressure

✓ Family medical history

✓ Social history

Key Physical Findings

A comprehensive physical examination should be performed to rule out other possible causes of the emotional and physical symptoms.

Important considerations include a thyroid examination and a cardiopulmonary examination. The patient should be evaluated for evidence of alcohol or substance abuse and also for evidence of anorexia or bulimia.

Suggested Work-Up

The timing of symptoms should be confirmed with a prospective symptom and menstrual period record kept by the patient for at least two or three menstrual cycles. In the Daily Symptom Report, a self-reporting scale presented in Figure 32-1, patients rate each symptom on a 5-point scale from 0 (none) to 4 (severe). The scale provides guidance for scoring the severity of each symptom and may be used in the office setting for the diagnosis and assessment of PMDD.

Figure 32-1. Daily symptom report.

(From Freeman EW, DeRubeis RJ, Rickels K: Reliability and validity of a daily diary for premenstrual syndrome. Psychiatry Res 1996;65:97-106.)

For both PMS and PMDD, symptoms begin any time in the 2 weeks before the onset of menstrual flow, continue to the onset of menses, and resolve within 2 to 3 days after the onset of bleeding.

Diagnostic criteria for PMS and PMDD are outlined in Boxes 32-1 and 32-2.

A laboratory workup is not necessary unless the history or physical examination results are suggestive of physical or psychiatric disorders that could cause the patient’s symptoms.

Additional Work-Up

Thyroid-stimulating hormone (TSH)	If a thyroid disorder is suspected
Complete blood cell count (CBC)	If anemia is suspected
Measurement of fasting blood glucose	If diabetes is suspected
Measurement of electrolytes, blood urea nitrogen (BUN), creatinine, calcium, magnesium, phosphorus, and albumin	If an eating disorder is suspected
Toxicology screen	If substance abuse is suspected
Abdominal ultrasonography, laparoscopy, or both	If endometriosis is suspected

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Premenstrual syndrome and premenstrual dysphoric disorder

National Institute of Mental Health

University of California at San Diego