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Managing Premenstrual Symptoms

(Published June 2008)

Definitions

Despite the familiarity of premenstrual symptoms to many women, there is no clear consensus on the definition of premenstrual disorders. Rather, these conditions make up a continuum of disorders that are defined according to the nature and severity of their symptoms.1

  • Premenstrual molimina are the symptoms, sensations, feelings, and observations, such as bloating, headaches, nausea, ovulatory pain, and breast tenderness, that many women experience during the premenstrual phase of their cycles. These symptoms are minor, do not cause functional impairment, and are minimally distressing. They predict impending ovulation and subsequent menstruation. If they occur within 3 days of the onset of menses and do not represent a patient’s chief presenting complaint, they are considered to be a normal part of a woman’s menstrual cycle.
  • The National Library of Medicine’s Medical Subject Headings (MeSH) terminology defines PMS as follows: “A combination of distressing physical, psychologic, or behavioral changes that occur during the luteal phase of the menstrual cycle. Symptoms of PMS are diverse (such as pain, water retention, anxiety, cravings, and depression) and they diminish markedly 2–3 days after the initiation of menses.”
    Premenstrual syndrome (PMS) is a term coined in 1931 to describe a constellation of physical and emotional symptoms unique to women during their childbearing years.2 Premenstrual symptoms in general are often described or referred to as PMS.3 Accepted definitions of the disorder require that symptoms must occur only during the luteal phase to be considered PMS.
  • Premenstrual dysphoric disorder (PMDD) is defined by diagnostic criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM).4 Both PMS and PMDD produce symptoms that are associated with the ovarian cycle of a woman of reproductive age. These disorders represent abnormal responses to normal endocrine changes associated with ovulation. The symptoms of these disorders may continue to occur during a woman’s menstrual cycle until she reaches menopause. (See “Signs and Symptoms” below for the DSM criteria required for a diagnosis of PMDD.)

In contrast to psychiatrists and other mental health professionals, most obstetrician/gynecologists (ob/gyns) and other women’s health care providers do not distinguish between PMS and PMDD. The approaches to diagnosis and management of these disorders are therefore addressed together in this guide.

Epidemiology of Premenstrual Disorders: Fast Facts
  • An estimated 43–55 million women experience some uncomfortable symptoms during the premenstrual phase of their cycles.5
  • The lifetime prevalence of PMS is estimated to be approximately 13–18% of women of reproductive age.6
  • PMS affects women throughout the reproductive years:
    • Occurs most often in women in their late 20s to early 40s.7
    • Also significant in adolescents.8
    • Average age of onset is 26 years.9
  • PMS occurs more often in women who:7
    • Have had at least one child.
    • Have a family history of depression.
    • Have a history of postpartum depression or mood disorder.
  • PMS symptoms tend to worsen over the course of the reproductive years.9
  • Approximately 12–25 million women have premenstrual symptoms that interfere with their daily lives:5
    • About 20–40% of women who have physical changes with menstruation experience symptoms of PMS.10,11
    • About 3–9% of women of reproductive age meet the criteria for PMDD.6
    • Approximately 2–5 million women have severe PMDD symptoms.12,13

Etiology of Premenstrual Disorders14,15

Although the etiology of premenstrual disorders is unclear, hypotheses abound and include the following:

  • Allergies
  • Catecholamine alterations
  • Endorphin withdrawal
  • Fluid retention
  • Hormonal alterations (high estrogen, falling estrogen, changes in estrogen-progesterone ratio, excess prolactin)
  • Hypoglycemia
  • Increased adrenal activity
  • Increased aldosterone activity
  • Increased renin-angiotensin activity
  • Nutritional deficiencies
  • Prostaglandin impact
  • Psychological or psychogenic effects

Additionally, there may be a concomitant overlay of other disorders such as stress, posttraumatic stress, anxiety disorder, and depression.

References

  1. Yonkers KA, Pearlstein T, Rosenheck RA. Premenstrual disorders: bridging research and clinical reality. Arch Womens Ment Health. 2003;6(4):287–92.
  2. Moline ML, Zendell SM. Evaluating and managing premenstrual syndrome. Medscape Womens Health 2000;5(2):1. Available at www.medscape.com/viewarticle/408913. Accessed March 25, 2008.
  3. Steiner M. Premenstrual syndrome and premenstrual dysphoric disorder: guidelines for management. J Psychiatry Neurosci. 2000;25(5):459–68.
  4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text Revision. Washington, DC: American Psychiatric Association, 2000.
  5. Mishell DR Jr. Premenstrual disorders: epidemiology and disease burden. Am J Manag Care. 2005;11(16 Suppl):S473–9.
  6. Halbreich U, Borenstein J, Pearlstein T, Kahn LS. The prevalence, impairment, impact, and burden of premenstrual dysphoric disorder (PMS/PMDD). Psychoneuroendocrinology. 2003;28(Suppl 3):1–23.
  7. U.S. Department of Health and Human Services, National Women’s Health Information Center. womenshealth.gov. Premenstrual Syndrome.  
  8. Rapkin AJ, Tsao JCI, Turk N, Anderson M, Zeltzer LK. Relationships among self-rated Tanner staging, hormones, and psychosocial factors in health female adolescents. J Pediatr Adolesc Gynecol. 2006;19:181–7.
  9. Steiner M. Premenstrual syndrome and premenstrual dysphoric disorder: guidelines for management. J Psychiatry Neurosci. 2000;25(5):459–68.
  10. American College of Obstetricians and Gynecologists. Premenstrual Syndrome. ACOG Practice Bulletin No. 15. Washington, DC: American College of Obstetricians and Gynecologists, 2000.
  11. Bhatia SC, Bhatia SK. Diagnosis and treatment of premenstrual dysphoric disorder. Am Fam Physician. 2002;66(7):1239–48.
  12. Ginsberg KA, Dinsay R. In: Ransom SB, ed. Practical Strategies in Obstetrics and Gynecology. Philadelphia: W.B. Saunders; 2000:684–9.
  13. U.S. Census Bureau. Annual estimates of the population by sex and five-year age groups for the United States: April 1, 2000 to July 1, 2004. U.S. Census Bureau, Population Division.
  14. Maxson WS, Rosenwaks Z. In: Copeland LJ, Jarrell JF, eds. Textbook of Gynecology, 2nd ed. Philadelphia: W.B. Saunders; 2000:513–4.
  15. Speroff L, Glass RH, Kase NG, eds. Menstrual Disorders in Gynecologic Endocrinology and Infertility, 6th Ed. Philadelphia, PA: Lippincott Williams & Wilkins, 1999:557–74.