Introduction
Premenstrual disease (PMD) occurs from menarche to menopause, approximately ages 14–51. Severe symptoms in women with premenstrual dysphoric disorder (PMDD), usually last 6–7 days/cycle. In general, US women with PMDD will experience ∼8 years of severe symptoms during their reproductive years. Causes may include genetic vulnerability where complex altered interactions between central nervous system, gonadal hormones, and other modulators are responsible for unpleasant symptoms. Ovulation/gonadal hormones likely contribute to the symptoms; increased frequency and decreased amplitude of luteal-phase progesterone and luteinizing hormone pulses may be a cause. Neurotransmitters and neurohormonal systems contribute as well; serotonin abnormalities (abnormal 5-HT actions), g-aminobutyric acid (GABA) abnormalities, or the renin-angiotensin-aldosterone system (impaired interaction between estrogen and progesterone) may be at fault.
Practically every unpleasant symptom has been attributed to premenstrual syndrome (PMS). Symptoms should be distinguished from typical moliminal symptoms. The most commonly reported symptoms appear in Box 59.1.
The clinician’s task is complicated by the fact that many if not most patients arrive with a self-diagnosis or an unevaluated referral diagnosis. Patients and clinicians often misconstrue dysmenorrhea as a component of PMS. A prospective symptom calendar is perhaps the best way to differentiate common maladies from those which are specific to the luteal phase of the otherwise normal menstrual cycle.
Box 59.1 Common symptoms of premenstrual syndrome
- Anger
- Anxiety
- Bloating or weight gain
- Breast swelling or tenderness
- Depression, sadness, hopelessness
- Decreased alertness or concentration
- Decreased self-esteem
- Decreased interest in usual activities
- Fatigue or lethargy
- Food craving or overeating
- Gastrointestinal complaints
- Headache or migraine
- Impulsivity
- Irritability, agitation or listlessness
- Mood swings
- Muscle and joint pain
- Sleep disturbances (insomnia, hypersomnia)
- Tension
Two months of charting on any of the widely available self-reporting scales often used as research tools (e.g. Calendar of Premenstrual Experiences, University of California, Department of Reproductive Medicine) will allow the patient and physician to differentiate PMS from normal fluctuations in well-being. These tools can also help to differentiate those affective disorders which the patient may prefer to attribute to hormonal fluxes. Prospective diaries for 2–3 consecutive months should show≥1 affective or somatic symptom consistent with PMS and restriction of symptoms to the luteal phase. Exclusion of other disorders is necessary.
The persistence required to complete this task will help the clinician to establish the extent to which the patient is interested in treatment.
There are two methods of diagnostic assessment. One, used primarily by nonpsychiatrists, is described by the International classification of diseases 10 (ICD-10) as PMS and requires just a single symptom. The other more stringent diagnostic criteria are used mainly by mental health workers and require five of 11 defined symptoms and are associated with social dysfunction. Prospective charting is also required to achieve the diagnosis called PMDD in the Diagnostic and statistical manual of mental disorders IV (DSM-IV). Less than 5% of PMS sufferers are estimated to have this more severe form of the condition.
The American College of Obstetricians and Gynecologists (ACOG) diagnostic criteria for PMS included affective and somatic symptoms. The affective symptoms are:
- irritability, which is considered to be the hallmark affective symptom for premenstrual syndrome
- depression
- angry outbursts
- anxiety
- confusion
- social withdrawal
The somatic symptoms include:
- breast tenderness
- abdominal bloating
- headache
- swelling of extremities
Premenstrual dysphoric disorder is the most severe form of PMS.
The DSM-IV diagnostic criteria for PMDD also include both affective and somatic symptoms. For the DSM-IV diagnosis of PMDD, a patient must meet a minimum of five symptoms. One of the four core symptoms must be included. Any/all somatic symptoms count as one. The symptoms must be persistent for more than 1 year, and remit within a few days of the follicular phase. Symptoms are absent the week following menses. Symptoms are confirmed with prospective cycle diaries for at least two consecutive menstrual cycles. These symptoms must not be an exacerbation of any other disorder.
The core affective symptoms are:
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