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Essentials of Diagnosis

  • Symptoms include mood symptoms (irritability, mood swings, depression, anxiety), physical symptoms (bloating, breast tenderness, insomnia, fatigue, hot flushes, appetite changes), and cognitive changes (confusion and poor concentration).
  • Symptoms must occur in the second half of the menstrual cycle (luteal phase).
  • There must be a symptom-free period of at least 7 days in the first half of the cycle.
  • Symptoms must occur in at least 2 consecutive cycles.
  • Symptoms must be severe enough to require medical advice or treatment.

General Considerations

Premenstrual syndrome (PMS) has been defined as “the cyclic occurrence of symptoms that are of sufficient severity to interfere with some aspects of life and that appear with consistent and predictable relationship to the menses.” Although the symptoms themselves are not unique, the restriction of the symptoms to the luteal phase of the menstrual cycle is pathognomonic of PMS. It is a psychoneuroendocrine disorder with biologic, psychological, and social parameters that is both difficult to define adequately and quite controversial. One major difficulty in detailing whether PMS is a disease or a description of physiologic changes is its extraordinary prevalence. Up to 75% of women experience some recurrent PMS symptoms; 20–40% are mentally or physically incapacitated to some degree, and 5% experience severe distress. The highest incidence occurs in women in their late 20s to early 30s. PMS is rarely encountered in adolescents and resolves after menopause. Evidence suggests that women who have suffered with PMS and premenstrual dysphoric disorder are more likely to suffer from perimenopausal symptoms.

The symptoms of PMS may include headache, breast tenderness, pelvic pain, bloating, and premenstrual tension. More severe symptoms include irritability, dysphoria, and mood lability. When these symptoms disrupt daily functioning, they are clustered under the name premenstrual dysphoric disorder (PMDD).

Other symptoms commonly included in PMS are abdominal discomfort, clumsiness, lack of energy, sleep changes, and mood swings. Behavioral changes include social withdrawal, altered daily activities, marked change in appetite, increased crying, and changes in sexual desire. In all, more than 150 symptoms have been related to PMS. Thus the symptom complex of PMS has not been clearly defined.


The etiology of the symptom complex of PMS is not known, although several theories have been proposed, including estrogen–progesterone imbalance, excess aldosterone, hypoglycemia, hyperprolactinemia, and psychogenic factors. A hormonal imbalance previously was thought to be related to the clinical manifestations of PMS/PMDD, but in the most recent consensus, physiologic ovarian function is believed to be the trigger. This is supported by the efficacy of ovarian cyclicity suppression, either medically or surgically, in eliminating premenstrual complaints.

Further research has shown that serotonin (5-hydroxytryptamine [5-HT]), a neurotransmitter, is important in the pathogenesis of PMS/PMDD. Both estrogen and progesterone have been shown to influence the activity of serotonin and gamma-aminobutyric acid (GABA) centrally. Many of the symptoms of other ...

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