PMS and Premenstrual Dysphoric Disorder
Erin Shankel
Definition
A.Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) are psychoneuroendocrine disorders with a constellation of symptoms that occur in the luteal phase, days 18 to 21, and interfere with a woman’s life. This is followed by a symptom-free period. PMS symptoms are primarily physical and behavioral, whereas patients with PMDD have significant affective symptoms as well.
Incidence
A.Virtually every menstruating woman experiences some symptoms at some time. Twenty percent of menstruating women have symptoms serious enough to interfere with their lives, but only a small percentage have disabling symptoms. Symptoms occur more commonly in women in their 30s and 40s.
Pathogenesis
The basis of PMS is presumably hormonal. During the luteal phase, progesterone levels increase and estrogen levels decrease, causing a shift in the ratio of these hormones; this contributes to causing symptoms experienced during PMS. These hormones are also known to interact with neurotransmitters in the brain, such as serotonin; these interactions are thought to cause some of the symptoms experienced, such as mood changes and pain thresholds, during PMS.
Predisposing Factors
A.Female of reproductive age.
Common Complaints
The following are Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) diagnostic criteria for PMDD:
A.Symptoms present for most of the past year.
B.Five or more symptoms (listed in the following) during the week before menses and resolving within a few days after menses begins.
C.Not simply an exacerbation of another psychological disorder, although they can coexist.
D.Symptoms must include at least one affective symptom:
1.Mood swings.
2.Anger or irritability.
3.Depression or hopelessness.
4.Anxiety or tension.
E.PLUS any of the following physical or behavioral symptoms to reach a minimum of five symptoms overall:
1.Difficulty concentrating.
2.Change in appetite.
3.Anhedonia.
4.Fatigue.
5.Feeling overwhelmed or out of control.
6.Change in sleeping habits.
7.Breast tenderness, bloating, weight gain, or muscle aches.
The following are American Congress of Obstetricians and Gynecologists (ACOG) diagnostic criteria for PMS:
A.One to four of the above mentioned physical, behavioral symptoms, or affective symptoms, OR
B.Five or more physical or behavioral symptoms, but no affective symptoms. If five or more physical, behavioral, and affective symptoms, PMDD is the more appropriate diagnosis.
Subjective Data
A.Obtain a complete menstrual history:
1.Menarche; frequency, duration, and regularity of periods.
2.Ask about premenstrual symptoms that are physical: weight gain, edema, acne, nausea, vomiting, constipation, backache, headache, migraine, syncope, breast tenderness, breast swelling, hot flashes, paresthesia of hands or feet, aggravation of convulsive disorder, increased appetite, food cravings (sweets, salt, or food in general), and fatigue.
3.Ask about premenstrual symptoms that are emotional: irritability, emotional lability, anxiety, depression, crying, palpitations, fatigue, aggression, lethargy, and sleep disturbances.
4.Ask particularly about the timing of the symptoms: When do the symptoms begin and end in relationship to the menstrual period? Has the patient kept a calendar of symptoms?
B.Ask about symptoms of dysmenorrhea. Some women confuse menstrual cramps and PMS.
C.Note type of contraception the patient uses.
D.Review her obstetric history, if applicable.
E.Elicit the types of treatment the patient has tried and efficacy of treatment.
F.Ask the patient about the amount and type of exercise she gets. Women with PMS often get little exercise.
Physical Examination
A.Check height, weight, and blood pressure (BP). Calculate body mass index (BMI).
B.Note overall appearance; inspect thyroid.
C.Palpate the neck, noting thyroid enlargement or nodules. Palpate the abdomen, noting enlargement, masses, or tenderness.
D.Auscultate the heart, lungs, and abdomen.
E.Pelvic examination:
1.Inspect the external genitalia for pubic hair pattern, lesions, or discharge.
2.Speculum examination: Check for discharge and lesions.
3.Bimanual examination: Check for size, mobility, shape, and tenderness of the uterus and adnexal area.
4.No physical abnormality or changes are consistent with PMS.
Diagnostic Tests
A.Consider Pap smear and screening for sexually transmitted infections (STIs).
B.Thyroid-stimulating hormone (TSH).
Differential Diagnoses
A.PMS.
B.PMDD.
C.Major depression.
D.Dysmenorrhea.
E.Substance abuse.
F.Perimenopausal symptoms.
G.Sexual dysfunction.
H.Fibromyalgia.
I.There are rarely major medical problems, but hypothyroidism, hyperthyroidism, anemia, and autoimmune disorders (such as systemic lupus erythematosus [SLE])) must be kept in mind.
Plan
A.General interventions:
1.Have the patient keep a menstrual calendar or diary for at least 3 months to document occurrence of symptoms in the luteal phase.
2.Symptomatic treatments: Treatment must be individualized.
B. 
See Section III: Patient Teaching Guide Premenstrual Syndrome:
1.Diet: Have the patient eat six small meals a day to even out glucose load. Have her avoid caffeine to decrease irritability and facilitate sleep. Encourage her to avoid simple sugars and eat complex carbohydrates to provide a slow, steady source of energy. She should avoid salt to
decrease edema.
2.Activity: Instruct the patient to increase exercise, preferably aerobic exercise. Suggest exercising every day (walking, swimming, and stretching). Encourage stress reduction activities such as imagery or yoga, as well as support or counseling groups. Encourage smoking cessation as well as adequate sleep and rest.
C.Pharmaceutical therapy:
1.Nonsteroidal anti-inflammatory drugs (NSAIDs) for relief of muscular aches, headaches, and menstrual cramps. Follow directions for the particular NSAIDs, whether over-the-counter (OTC) or prescription.
2.For PMDD, antidepressants are first line. Can be taken continually or only during luteal phase.
3.Oral contraceptives (OCPs) can be used as a secondline therapy. They induce anovulation and mitigate symptoms.
4.Should try all of the above mentioned treatments before danazol or alprazolam.
5.Adjunctive therapies:
a.Minerals:
i.Conflicting evidence exists regarding efficacy compared with placebo, but there is low risk of harm.
ii.Magnesium 360 mg/d for 14 days.
iii.Calcium 1,200 to 1,600 mg/d.
b.Vitamins used to decrease anxiety and irritability, food cravings, painful breasts, depression, fatigue, and lethargy:
i.Conflicting evidence exists regarding efficacy compared with placebo, but there is low risk of harm.
ii.Vitamin B6 (pyridoxine) 50 to 150 mg/d.
iii.Multiple vitamin one/d.
iv.Vitamin E 400 IUs/d.
6.See Table 17.10 for other therapies.
TABLE 17.10 Medications Used With PMS and PMDD
a Has drospirenone and ethinylestradiol.
PMDD, premenstrual dysphoric disorder; PMS, premenstrual syndrome.
Source: Steiner, M., & Li, T. (2014). Premenstrual syndromes. In M. Curtis, S. Linares, & T. Antoniewicz (Eds.) Glass’ office gynecology (pp. 143-54). Philadelphia, PA: Lippincott.
Follow-Up
A.Follow-up every 3 to 4 months to assess or alter treatment and/or therapy.
Consultation/Referral
A.Consult a physician if symptoms are severe or not relieved by first- or second-line therapies.
Individual Considerations
A.Partners: Encourage the patient to have her partner come to a visit. Partner education and support are helpful.