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Managing Premenstrual Symptoms

(Published June 2008)

Diagnostic Approach

Changing and inconsistent diagnostic criteria for premenstrual disorders over the past few decades can make the diagnosis of PMS/PMDD a challenge. Patients should be counseled that it may take some time to complete the diagnostic process. They should be assured that various treatments can be tried until an effective and suitable approach is found.1 Immediate measures should be recommended to the patient to ameliorate symptoms while a definitive diagnosis is being sought. These include lifestyle modifications such as stress reduction, exercise, dietary changes, supplements, and psychosocial support.2,3

The Multiple-Visit Diagnostic Process

Diagnosis is best approached as a multiple-visit process.4 In general, the diagnosis of PMS is one of exclusion, and it is important to differentiate it from other conditions sharing similar characteristics. Almost two-thirds of women with PMS symptoms have a psychiatric disorder as well, thus complicating the evaluation of premenstrual symptoms.

To meet the criteria for PMS or PMDD, symptoms must:

  • Occur in the luteal phase of the menstrual cycle and resolve within a few days of the start of menstruation
  • Create problems or impairment for the patient
  • Not be better explained by another diagnosis

Obtaining prospective charting information for a 2-month period represents the best way to diagnose both PMS and PMDD.4 A symptom chart such as that shown in Figure 1 is provided to the patient, who marks the occurrence and severity of symptoms on each day of at least two consecutive months. The clinician can then assess the pattern of symptoms in relation to the entire cycle. A clear pattern of symptoms that occur throughout the entire luteal phase and stop within 3 days of the onset of menses is diagnostic of PMS.

Visit 1

Table 1. Differential Diagnosis of Premenstrual Disorders4-6

Angina

Asthma

Chronic fatigue syndrome

Cyclic mastalgia

Diabetes

Endometriosis

Genital herpes

Irritable bowel syndrome

Menstrual-associated migraine

Premenstrual molimina

Psychiatric disorders:

  • Anxiety
  • Bipolar disorder
  • Depression
  • Personality disorder
  • Posttraumatic stress disorder

Raynaud phenomenon

Seizure disorders

Substance use disorders

Thyroid disorders

During the first visit, a history of menstrual symptoms and the presenting complaint should be elicited from the patient and a differential diagnosis developed (Table 1).

  • A complete medical history should include menstrual history, history of gynecologic conditions (e.g., endometriosis, surgery), and obstetric history.
  • Treatment or psychotherapy for mental health problems, particularly mood disorders (anxiety, depression), should also be recorded and a psychiatric or psychotherapeutic referral considered as warranted.
  • Laboratory tests should be conducted to aid in the differential diagnosis:6
    • Chemistry profile to assess electrolyte disturbances
    • Complete blood cell count to rule out anemia
    • Thyroid-stimulating hormone level to rule out thyroid disorders

The affective symptoms of PMDD in particular may closely resemble those of premenstrual exacerbations of psychiatric disorders, especially depression and anxiety. If the patient reports no symptom-free period, it may be appropriate to refer her to a mental health professional.6

At the end of the first visit, the patient should be instructed in the use of a daily symptom rating chart (see “The Charting Interval” and ”Menstrual Symptoms Chart” ) and counseled about lifestyle changes, such as diet, exercise, and sleep habits that may ameliorate some symptoms until the next visit. A follow-up visit should be scheduled for 6–8 weeks.

The Charting Interval

In the interim between the first and second visits, the patient should keep a daily record of her symptoms and try the nonpharmacologic measures decided upon at the first visit.

Prospective charting of symptoms has been found to be an effective and accurate approach to the diagnosis of premenstrual disorders for a variety of reasons:

  • DSM-IV criteria require prospective information for a diagnosis of PMDD. More than half of women who present with “severe premenstrual symptoms” are found not to have a luteal-phase pattern according to prospective charting.4
  • Self-help strategies such as lifestyle changes can be initiated and evaluated during the charting period. Deferring pharmacologic treatment during this interval allows these measures to be objectively evaluated.
  • Many women benefit from charting by gaining the ability to see their individual menstrual patterns and plan their activities around the most difficult phases of their cycles.

The Second Visit

At the second visit, the laboratory test results and the patient’s daily charting should be reviewed. A diagnosis of PMS or PMDD requires the symptoms to occur throughout the luteal phase of the menstrual cycle and to abate with the onset of menses.

Most ob/gyns do not distinguish between PMS and PMDD. Patients whose mental and emotional symptoms are not responsive to the treatment approaches described here should be referred for psychiatric evaluation.

References

  1. Rapkin AJ. New treatment approaches for premenstrual disorders. Am J Manag Care. 2005;11(16 Suppl):S480–91.
  2. American College of Obstetricians and Gynecologists. Premenstrual Syndrome. ACOG Practice Bulletin No. 15. Washington, DC: American College of Obstetricians and Gynecologists, 2000.
  3. Dickerson LM, Mazyck PJ, Hunter MH. Premenstrual syndrome. Am Fam Physician. 2003;67(8):1743–52.
  4. Johnson SR. Premenstrual syndrome, premenstrual dysphoric disorder, and beyond: a clinical primer for practitioners. Obstet Gynecol. 2004;104(4):845–59.
  5. Guille C, Spencer S, Cavus I, Epperson CN. The role of sex steroids in catamenial epilepsy and premenstrual dysphoric disorder: implications for diagnosis and treatment. Epilepsy Behav. 2008; Mar 16.
  6. Kaur G, Gonsalves L, Thaker HL. Premenstrual dysphoric disorder: a review for the treating practitioner. Cleve Clin Med. 2004;71(4):303–21 passim.