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Managing Premenstrual Symptoms

(Published June 2008)

Signs and Symptoms

Symptoms of both PMS and PMDD occur during the luteal phase of the menstrual cycle (days 14–28 in a 28-day cycle) and notably subside within 2–3 days after menses begins. Some women experience positive symptoms, such as a sense of well-being, in the luteal phase of their cycles. More often, negative symptoms undermine a woman’s ability to function across multiple settings, including work, school, and home.1

Premenstrual Syndrome

Although more than 200 symptoms have been associated with PMS, common symptoms include the following:2

Physiological symptoms:
Behavioral symptoms:
Psychological symptoms:
Abdominal bloating
Back pain
Breast pain, tenderness, and/or swelling
Muscle aches
Weight gain
Changes in sexual interest
Food cravings or overeating
Crying and tearfulness
Decreased self-esteem
Depressed mood
Difficulty concentrating
Mood swings

The American College of Obstetricians and Gynecologists (ACOG) has developed the following diagnostic criteria for the diagnosis of PMS:3

ACOG Diagnostic Criteria for PMS

Patient reports at least one of each of the following affective and somatic symptoms during the 5 days before menses. Symptoms must appear in three consecutive menstrual cycles:

Affective: Depression, angry outbursts, irritability, anxiety, confusion, social withdrawal

Somatic: Breast tenderness, abdominal bloating, headache, swelling of extremities

Symptoms must also meet the following criteria:

  • Be relieved within 4 days of the onset of menses, without recurrence until at least cycle day 13
  • Be present in the absence of any pharmacologic therapy, hormone ingestion, or drug or alcohol use
  • Be causing identifiable dysfunction in social or economic performance
  • Occur reproducibly during two cycles of prospective recording

Premenstrual Dysphoric Disorder

Reproductive health professionals generally view PMDD as a particularly severe form of PMS with pronounced psychological and emotional symptoms.4 Unlike mental health professionals, most obstetrician/gynecologists (ob/gyns) do not distinguish between PMS and PMDD. The DSM criteria for the diagnosis of PMDD is listed in the chart below.5

DSM Criteria for Premenstrual Dysphoric Disorder5

A. In most menstrual cycles during the past year, five (or more) of the following symptoms were present for most of the time during the last week of the luteal phase, began to remit within a few days after the onset of the follicular phase, and were absent in the week postmenses, with at least one of the symptoms being 1, 2, 3, or 4:
  1. Markedly depressed mood, feelings of hopelessness, or self-deprecating thoughts
  2. Marked anxiety, tension, feelings of being “keyed up” or “on the edge”
  3. Marked affective lability (e.g., feeling suddenly sad or tearful or increased sensitivity to rejection)
  4. Persistent and marked anger or irritability or increased interpersonal conflicts
  5. Decreased interest in usual activities (e.g., work, school, friends, hobbies)
  6. Subjective sense of difficulty in concentrating
  7. Lethargy, easy fatigability, or marked lack of energy
  8. Marked change in appetite, overeating, or specific food cravings
  9. Hypersomnia or insomnia
  10. A subjective sense of being overwhelmed or out of control
  11. Other physical symptoms, such as breast tenderness or swelling, headaches, joint or muscle pain, a sensation of “bloating,” weight gain

B. The disturbance markedly interferes with work or school or with usual social activities and relationships with others (e.g., avoidance of social activities, decreased productivity and efficiency at work or school)

C. The disturbance is not merely an exacerbation of the symptoms of another disorder, such as Major Depressive Disorder, Panic Disorder, Dysthymic Disorder, or a Personality Disorder (although it may be superimposed on any of these disorders).

D. Criteria A, B, and C must be confirmed by prospective daily ratings during at least two consecutive somatic cycles. (The diagnosis may be made provisionally prior to this confirmation.)


  1. Malone DC. Managing the spectrum of premenstrual symptoms. Am J Manag Care. 2005:11(16):S471–2.
  2. Dickerson LM, Mazyck PJ, Hunter MH. Premenstrual syndrome. Am Fam Physician. 2003;67(8):1743–52.
  3. American College of Obstetricians and Gynecologists. Premenstrual Syndrome. ACOG Practice Bulletin No. 15. Washington, DC: American College of Obstetricians and Gynecologists, 2000.
  4. Rapkin A. A review of treatment of premenstrual syndrome and premenstrual dysphoric disorder. Psychoneuroendocrinology. 2003;28(Suppl 3):39–53.
  5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text Revision. Washington, DC: American Psychiatric Association, 2000.