Am Fam Physician. 2016 Aug 1;94(3):236-240.
Patient information: See related handout on premenstrual disorders.
Premenstrual disorders affect up to 12% of women. The subspecialties of psychiatry and gynecology have developed overlapping but distinct diagnoses that qualify as a premenstrual disorder; these include premenstrual syndrome and premenstrual dysphoric disorder. These conditions encompass psychological and physical symptoms that cause significant impairment during the luteal phase of the menstrual cycle, but resolve shortly after menstruation. Patient-directed prospective recording of symptoms is helpful to establish the cyclical nature of symptoms that differentiate premenstrual syndrome and premenstrual dysphoric disorder from other psychiatric and physical disorders. Physicians should tailor therapy to achieve the greatest functional improvement possible for their patients. Select serotonergic antidepressants are first-line treatments. They can be used continuously or only during the luteal phase. Oral contraceptives and calcium supplements may also be used. There is insufficient evidence to recommend treatment with vitamin D, herbal remedies, or acupuncture, but there are data to suggest benefit from cognitive behavior therapy.
Prospective questionnaires are the most accurate way to diagnose premenstrual syndrome and premenstrual dysphoric disorder because patients have been found to greatly overestimate the cyclical nature of symptoms, when realistically, they are erratic or simply exacerbated during the luteal cycle.
The Daily Record of Severity of Problems is a useful tool to help diagnose PMS and PMDD.
Selective serotonin reuptake inhibitors may be used as first-line treatment for severe symptoms of PMS and PMDD.
Oral contraceptives are effective for treatment of PMS and PMDD.
Calcium supplementation of 1,000 to 1,200 mg per day may improve PMS symptoms.
Cognitive behavior therapy may improve PMS and PMDD symptoms.
PMDD = premenstrual dysphoric disorder; PMS = premenstrual syndrome.
*—These symptoms must be relieved within four days of the onset of menses, without recurrence until at least day 13 of the cycle, and must be present in the absence of any pharmacologic therapy, hormone ingestion, or drug or alcohol use. The symptoms must occur reproducibly during two cycles of prospective recording. The patient must exhibit identifiable dysfunction in social, academic, or work performance.
Adapted with permission from American College of Obstetricians and Gynecologists. Guidelines for Women's Health Care: A Resource Manual. 4th ed. Washington, DC: American College of Obstetricians and Gynecologists; 2014:608.
A. In the majority of menstrual cycles, at least five symptoms must be present in the final week before the onset of menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week postmenses.
1. Marked affective lability (e.g., mood swings; feeling suddenly sad or tearful, or increased sensitivity to rejection).
7. Physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of “bloating,” or weight gain.
note: The symptoms in Criteria A–C must have been met for most menstrual cycles that occurred in the preceding year.
G. The symptoms are not attributable to the physiologic effects of a substance (e.g., a drug of abuse, a medication, other treatment) or another medical condition (e.g., hyperthyroidism).
Reprinted with permission from the American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013:171–172.
Establishing the timing of symptoms is essential when evaluating for PMS and PMDD. Symptoms must occur during the luteal phase and resolve shortly after the onset of menstruation. Other conditions, such as depression or anxiety, may worsen during the luteal phase, but these can be distinguished from PMS because they persist throughout the menstrual cycle. Migraines, anemia, endometriosis, and hypothyroidism may produce symptoms similar to PMS or PMDD and should also be considered. Diagnostic laboratory testing or imaging should be directed at ruling out alternative medical diagnoses.
note: Patients should record the score for each item on each day using the following scale: 1 = not at all, 2 = minimal, 3 = mild, 4 = moderate, 5 = severe, 6 = extreme. If during the mid-follicular phase (days 6 through 10) the patient has an average daily score greater than 3 for any symptom, an alternative diagnosis should be sought. Excused symptoms include appetite for obese patients, insomnia with good reasons, or pain from physical illness. The week before menses, the patient should score at least 4 for at least two days on five symptoms that correlate with premenstrual dysphoric disorder diagnostic criteria (Table 2). The week before menses, the patient should score at least 4 for at least two days on at least one impairment item. The patient must meet these criteria for two consecutive cycles or two out of three cycles. Clinical judgment should correlate with the assessment of daily ratings.
Information from Endicott J, Nee J, Harrison W. Daily Record of Severity of Problems (DRSP): reliability and validity. Arch Womens Ment Health. 2006;9(1):41–49.
Treatment of PMS and PMDD focuses on relieving physical and psychiatric symptoms. Many of the medications used address the body's hormonal activity through suppression of ovulation, whereas others affect the concentration of neurotransmitters such as serotonin, norepinephrine, or dopamine in the brain. A third group of complementary or alternative agents with varying mechanisms of action are also used. In the United States, selective serotonin reuptake inhibitors (SSRIs) are approved for primary treatment. Although SSRIs are considered psychiatric medications, when used to treat premenstrual disorders they improve physical and psychiatric symptoms in most patients.14 Physicians should tailor therapy based on patient tolerance and response to each medication.
Herbal Preparations and Acupuncture. Many small, poorly conducted studies have reviewed the effectiveness of Chinese herbal supplements and acupuncture in the treatment of premenstrual symptoms.27 This evidence is too limited and study quality is too poor to suggest benefit.27 A 2010 Cochrane review of Chinese herbal supplements for PMS also did not find evidence that was strong enough to support their use.28 The studies evaluated use of saffron, St. John's wort, ginkgo, vitex agnus-castus, peppermint, angelica root, dragon's teeth, turmeric, tangerine leaf, and bitter orange, among others.27,28 Larger, more extensive trials are needed to support the use of these agents as first-line treatment.
Cognitive Behavior Therapy. A 2009 meta-analysis analyzed seven trials, three of which were randomized controlled trials, and showed improvement in functioning and depression scores for patients with PMS or PMDD.29 The frequency and duration of therapy were not defined. However, the results suggest that mindfulness-based exercises and acceptance-based cognitive behavior therapy may be helpful for reducing symptoms. Further studies are needed to support the use of cognitive behavior therapy as first-line therapy.
Data Sources: Research was conducted in the PubMed and Cochrane databases using the terms PMS and PMDD, PMS and PMDD treatment, and PMS and PMDD definition. We also used articles located in an Essential Evidence Plus report on the topic premenstrual dysphoric disorder, topic 248. External sources such as the Diagnostic and Statistical Manual of Mental Disorders, 5th ed., and publications from the American Congress of Obstetricians and Gynecologists were accessed separately and directly through our institutional licensing agreement at the Medical College of Wisconsin. Search date: August 1, 2015.
SETH BODDEN, MD, is an assistant professor in the Department of Family and Community Medicine at the Medical College of Wisconsin.
Address correspondence to Sabrina Hofmeister, DO, Medical College of Wisconsin, 1121 E. North Ave., Milwaukee, WI 53212 (e-mail: shofmeister@mcw.edu). Reprints are not available from the authors.
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