Chapter 8: Premenstrual Syndrome and Premenstrual Dysphoric Disorder

LEARNING OBJECTIVES

1. Identify the signs and symptoms associated with premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD).

2. Explain the pathophysiologic theories associated with PMS and PMDD.

3. List criteria used for the diagnosis of PMD and PMDD.

4. Recommend nonpharmacologic and pharmacologic therapy for PMS and PMDD.

5. Educate women about PMS and PMDD and monitor their treatment efficacy and toxicity.

INTRODUCTION

In 1931, Robert Frank introduced the term “premenstrual tension” describing 15 women with a menstrual cyclical occurrence of negative symptoms that disappeared shortly after the onset of menstruation.¹ “Premenstrual tension” was used until the 1950s when the definition was broadened to premenstrual syndrome (PMS).^1,2 In 1994 the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) included the term premenstrual dysphoric disorder (PMDD) in place of late luteal dysphoric disorder.² In 2013, the fifth edition of the DSM (DSM-5) was released and included PMDD as a full diagnostic category under depressive disorders.³

No universally accepted definitions exist for PMS or PMDD; however, various organizations, such as the World Health Organization (WHO), American College of Obstetricians and Gynecologists (ACOG), and American Psychiatric Association (APA), have published definitions. PMS and PMDD are both under-recognized and under-diagnosed disorders.⁴ The WHO definition of premenstrual tension syndrome is an unspecified severity of tension, any headache, and/or molimen (abnormal strain or tension associated with a normal physiological function, especially menstruation) that occurs premenstrually and remits following menses. The ACOG defines PMS as having at least one related symptom associated with an identifiable dysfunction in social or economic performance that occurs 5 days before menses and remits within 4 days of the onset of menses in at least three consecutive menstrual cycles. The APA defines PMDD in the DSM-5 as having at least five symptoms with at least one being marked affective lability, irritability, depressed mood, or anxiety occurring during the last week before menses and remitting within a few days after the onset of menses.³ DSM-5 criteria state that PMDD is associated with marked interference with work, social activities, and/or relationships during the past year as compared with PMS.

A majority of women in adolescence and adulthood experience PMS symptoms.^5,6 According to the DSM-5, 1.8% of all reproductive age women meet the criteria for PMDD without functional impairment and 1.3% meet the criteria for PMDD with functional impairment without co-occurring symptoms.³ The prevalence of PMS and PMDD is consistent in the United States, European countries, India, Israel, and China.⁷ Approximately 8% to 16% of women miss work because of PMS each year, and of those, 5% to 8% miss over 14 work days.⁸

PMDD is viewed as a psychiatric and medical syndrome rather than an exacerbation of an underlying psychiatric disorder.⁵ It should be noted that depression, bipolar disorder, panic disorder, ...