Retrospective data document a 20–30% prevalence for PMS, and a 5–8% prevalence for PMDD [2–5], although prospectively collected symptom reporting suggests a much lower prevalence of PMDD [6]. Less robust adolescent studies have documented similar, if not higher, prevalence rates of PMD with one study reporting over 60% of adolescents confirming symptoms consistent with the diagnosis of PMS [7]. The most commonly reported premenstrual symptoms for adolescents are psychological in nature with more than 85% reporting stress and anxiety [7]. Physical symptoms , including fatigue, abdominal bloating, breast tenderness, and dysmenorrhea, are also frequently described by adolescents, with two-thirds reporting abdominal bloating and pain in one study [7]. These symptoms result in a substantial negative functional impact on quality of life in teens, with 88% reporting their symptoms to be of at least moderate severity in one study [8] and another cross-sectional study identifying one in nine female high school students missing more than 1 day of school per month due to premenstrual symptoms [9].

The strongest risk factors for severe PMD such as PMDD include personal and/or family history of depression , suggesting a biological susceptibility to this illness [6]. The leading theory on the etiology of PMDD is that some women appear to have a biological vulnerability to the hormonal fluctuations associated with the menstrual cycle [10]. Specifically, they appear to have differential brain sensitivity to allopregnanolone, a metabolite of progesterone that acts in the central nervous system on GABA receptors implicated in mood disorders [11]. Neuroimaging studies also show evidence of differential brain serotonergic function in response to hormonal fluctuations [12]. It may be that serotonin reuptake inhibitors rapidly ameliorate symptoms of PMDD in some women because they allow for an acute repletion of serotonin in the brain. Hormone fluctuations may also impact other systems implicated in mood disorder etiology such as the hypothalamic-pituitary axis, brain-derived neurotrophic factor (BDNF), and immune function [10].

Two other strong clinical correlates of PMDD symptoms are early childhood sexual abuse [6] and daily life stress. This has led some to suggest that environmental experiences may influence the way that the brain responds to physiologic stimuli, increasing risk for a PMDD phenotype [13]. Early childhood trauma is associated with persistent neurophysiological changes that affect the ability to regulate emotional responses to various internal and external stimuli across the lifespan [14]. It could be that factors such as early childhood trauma sensitize the brain in a manner that makes it more difficult for some women to cope with the biological changes occurring over the menstrual cycle. Females with PMDD appear to more often rely on specific psychological mechanisms for coping with stress such as avoidance or wishful thinking, which are likely to be less effective than problem-focused action strategies such as stress management, lifestyle modification, and behavioral psychological techniques such as relaxation that are known to be effective in managing psychological symptoms associated with the menstrual cycle [15].

The diagnosis of both PMS and PMDD requires prospective evaluation of symptoms for at least two menstrual cycles since there is strong evidence that retrospective reporting of symptoms does not correlate with prospective evaluation in as many as half of women who report PMD symptoms [16]. The premenstrual symptoms screening tool for adolescents (PSST-A ), validated for use in adolescents, has been developed to help differentiate adolescents who warrant prospective evaluation, education, and possibly early initiation of treatment in severe cases [3]. PMDs are diagnoses of exclusion. It is important to ensure that the symptoms are not better conceptualized as an exacerbation of another psychiatric disorder such as depression or anxiety that requires a different approach to treatment and that the symptoms are not attributable to the physiological effects of a medication or drug of abuse, nor related to a medical condition requiring treatment such as hypothyroidism or an autoimmune condition [17].

Education plays a central role in the management of PMDs in adolescents. All adolescents, regardless of the severity of their symptoms, should be educated about PMD. This includes education about the menstrual cycle, PMS and PMDD symptoms and their potential impact on functioning, as well as the treatment options. Treatment preferences and potential barriers to treatment should be elucidated. One study showed a sustained reduction in PMS scores 3 months after an educational program involving secondary school students versus uneducated controls [18].

The approach to PMD treatment depends on the severity of symptoms and impact on function, with the least invasive management strategies attempted first [19]. Identified medical and psychiatric comorbidities should be treated and treatment preferences explored. Continued symptom tracking is helpful for assessing treatment response. Symptom trackers available electronically and on mobile devices may provide a more convenient means of symptom tracking for this population over conventional trackers, including the Daily Record of Severity of Problems (DRSP) [20]. While few PMD management strategies have been specifically evaluated in adolescents, with the exception of antidepressant medication use (see below), strategies evaluated in adults are usually applied.

For those with PMS or mild symptoms of PMDD, lifestyle modifications and self-care may be sufficient. Lifestyle modification includes a healthy diet and regular exercise, as well as self-care that includes good sleep hygiene and scheduling stressful activities outside of the premenstrual time period whenever possible. Experts recommend that diet includes adequate intake of fruits, vegetables, whole grains, and water, with reduction (or elimination) of sugar, salty foods, caffeine, red meat, and alcohol. Small, frequent meals high in carbohydrates may help with symptom reduction around the time of menstruation. There is some evidence for non-athlete adolescent girls that regular exercise can improve psychological and physical symptoms of PMS [21], although this has not been investigated among a group with diagnosed PMDD. Other non-pharmacological strategies with some RCT evidence for efficacy in PMS include calcium 600 mg twice daily and chasteberry, or Vitex agnus-castus [22]. Some evidence suggests that vitamin B6 (pyridoxine) supplementation (80 mg) reduces PMD symptoms, but this has not been studied in women with diagnosed PMDD. Supplementation with vitamins and other herbal treatments is not necessarily benign; for example, vitamin B6 supplementation has been associated with peripheral neuropathy at higher dosages.

For those with symptoms meeting diagnostic criteria for PMDD, cognitive behavior therapy (CBT ) is the most studied psychological treatment. CBT helps to address dysfunctional thinking patterns and enhance coping strategies and is delivered one on one or in groups by a trained therapist. Its effect size on psychological symptoms appears to be only in the small to medium range, but it may appear to have sustained effects over a longer term than medication treatment [23]. There has been increasing interest in behavioral techniques to reduce stress, with some evidence that relaxation therapy and mindfulness-based stress reduction (MBSR) may be helpful for psychological symptoms of PMDs; this requires confirmation in larger RCTs [24, 25].

For women who do not respond to non-pharmacological strategies, or who have more severe symptoms that need to be addressed more quickly, medication treatment may be required. Antidepressant medications such as selective serotonin reuptake inhibitors (SSRIs ) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are the mainstay of PMDD treatment in adult women—and in adult women SSRIs are recommended as first-line pharmacological therapy. There is evidence of a moderate to large effect size for daily dosing—with improvements seen within 2–3 menstrual cycles [26, 27]. Some studies also support the effect of luteal phase dosing (where antidepressants are taken in the luteal phase only) or “symptom onset” dosing (where antidepressants are taken with symptom onset and discontinued with menstruation) [28]. Women do not appear to have onset or withdrawal symptoms in intermittent dosing, although PMDD symptoms recur upon discontinuation. The use of antidepressant medication is, however, controversial in adolescents due to a lack of efficacy demonstrated in this population for major depressive disorder and due to an increased risk of side effects that can include increased rates of agitation and suicidal behavior [29]. In a recent large meta-analysis, only the SSRI fluoxetine was more effective than placebo for major depression in adolescents, with evidence of reasonable tolerability. Antidepressants have not been evaluated specifically for the treatment of PMDD in adolescents so they should only be used with extreme caution and likely in situations where symptoms are severe and where other treatments, including hormonal treatments, have been ineffective. If an antidepressant is used, fluoxetine is probably the most defendable choice [30, 31].