Practice Essentials
Premenstrual syndrome (PMS) is a cyclical, luteal-phase condition characterized by physical, psychological, and/or behavioral changes of sufficient severity to interfere with normal activity. Premenstrual dysphoric disorder (PMDD) is considered a more severe and disabling form of PMS and is listed as a mental disorder in the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5), whereas PMS is not. [1, 2]
Signs and symptoms of premenstrual syndrome
The symptoms of PMS usually cluster around the luteal phase of ovulation and resolve when menses begin or shortly thereafter. PMS symptoms can be both affective (eg, anxiety, depression, irritability) and somatic (eg, bloating, headache, swelling). [3]
See Presentation for more detail.
Diagnosis of premenstrual syndrome
The diagnosis of PMS is typically made from the patient's history of symptoms and the luteal phase timing thereof. Therefore, physical examination findings are not typically helpful in establishing the diagnosis of PMS.
It is important to rule out other psychologic diagnoses that cause dysphoric behavior before diagnosing PMS.
See Workup for more detail.
Treatment of premenstrual syndrome
Medical care of PMS is primarily pharmacologic and behavioral, with an emphasis on relief of symptoms. Selective serotonin reuptake inhibitors (SSRIs) are considered suitable first-line therapy for premenstrual disorders, especially where psychological or behavioral symptoms are prominent. Because of the difficulty in treating PMS and the variations in response to treatments experienced by patients, complementary and alternative strategies have been explored for patients with PMS, and a multimodal approach may be useful.
See Treatment and Medication for more detail.
Pathophysiology and Etiology
The definitive cause of PMS is unknown and may be multifactorial. Some theories about the causes of PMS have fallen out of favor, including estrogen excess, estrogen withdrawal, pyridoxine (vitamin B6) deficiency, [4] alteration of glucose metabolism, and fluid-electrolyte imbalances. Current research provides some evidence supporting the following etiologies:
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Hormonal shifts are a factor in PMS given the timing of the symptoms. However, patients with and without PMS have similar hormone levels. PMS therefore may represent an exaggerated response to normal hormonal changes, producing more pronounced emotional and physical responses. [5]
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Serotonin deficiency is a potential contributor, as patients who are most affected by PMS may have decreased serotonin levels. Symptoms of PMS can respond to selective serotonin reuptake inhibitors (SSRIs), which increase the amount of available serotonin. [6]
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Magnesium and calcium deficiencies are postulated as nutritional factors in PMS, and studies evaluating supplementation show improvement in physical and emotional symptoms.
Epidemiology
United States statistics
Individual symptoms of PMS have been reported to affect as many as 90% of women of reproductive age sometime during their lives. An estimated 20-30% of women may meet criteria for PMS based on symptoms with 2-5% of women meeting symptomatic criteria for PMDD. [9] In adolescents, previous studies have demonstrated 50-100% experiencing at least one PMS symptom, with 13-89% reporting symptoms as moderate to severe. [10]
Two known risk factors for PMS are obesity and smoking. Research reveals that women with a body mass index (BMI) of 30 or above are nearly three times as likely to have PMS than women who are not obese. Women who smoke cigarettes are more than twice as likely to have more severe PMS symptoms. [11] [12, 13]
Life experiences may also be a risk factor for PMS. The results of a large longitudinal study carried out by Bertone-Johnson et al suggested that the experience of abuse (emotional, sexual, or physical) in early life places women at higher risk for PMS in the middle-to-late reproductive years. [14] Similarly, the experience of perceived discrimination (race, gender, etc) was associated with increased premenstrual symptoms for minority women. [15]
Age- and sex-related demographics
PMS affects women with ovulatory cycles. Older adolescents tend to have more severe symptoms than younger adolescents do. Women in their fourth decade of life tend to be affected most severely. PMS resolves completely at menopause. [16]
Prognosis
Inability to maintain normal activities is part of the definition of this condition; hence, morbidity is related to loss of function. Complications of PMS may include absenteeism from work and school, behavioral problems, and strain on interpersonal relationships. PMS and PMDD have been associated with a higher risk of bulimia nervosa. [17] PMS may also be associated with an increased risk of future hypertension. [18]
Most PMS symptoms worsen with the patient's age until menopause; thus, it is important to treat severely affected adolescents, as symptoms would not be expected to lessen over progression of time.
Patient Education
Because PMS may cause significant morbidity for affected individuals, providing patient education and identifying potential coping strategies may be an important part of holistic, patient-centered treatment. The American College of Obstetricians and Gynecologists (ACOG) suggests the provision of patient education about the etiology of PMS could be helpful as well as instruction on coping strategies that could include stress mitigation, relaxation strategies, physical activity, and dietary modifications. [9] Yoga, biofeedback, and self-hypnosis may be beneficial. Regular exercise can decrease PMS symptoms.
