CHAPTER 15

Premenstrual
Syndrome/
Premenstrual
Dysphoric Disorder
Definition 212
Premenstrual Syndrome Diagnostic Criteria 212
Premenstrual Dysphoric Disorder Diagnostic Criteria 213
Tests 213
Treatment 213

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 Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD)
have many symptoms that overlap with anxiety and depression. A differentia-
Pathognomonic for PMS: tion should be made because each has a different treatment. PMS and
PMDD both have similar symptoms, but PMDD has markedly severe symp-
Symptoms during luteal
toms. The symptoms of PMS do not impair daily activities; however, the
phase. symptoms of PMDD do affect the activities of daily living. The symptoms oc-
cur in the luteal phase for both conditions.

DEFINITION

 Refers to a group of mild to moderate symptoms.

 Both physical and behavioral.
 Occur in luteal of the menstrual cycle.
 May interfere with work and personal relationships.
 Symptoms followed by a symptom-free period.
 Monitor for 2–3 months because symptoms can be variable month to
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month.

P R E M E N ST R UA L SY N D R O M E D I AG N O ST I C C R I T E R I A

A 26-year-old woman complains of feeling sad and confused before her

menses. She reports having headaches and breast pain. She feels better
when she is alone, but she is able to work and take care of her 2 children.
Once she begins menses, she no longer has these symptoms. What is the most
likely diagnosis. What is the best way to make the diagnosis?
Answer: PMS. This patient has affective and somatic complaints that resolve
Premenstrual Syndrome/

with menses. She is able to continue her daily activities despite the symptoms.
Dysphoric Disorder

Best diagnostic method is keeping a prospective symptom diary for 2 months.

 At least one of the following affective and somatic symptoms during the
5 days before menses:
 Affective symptoms:
 Depression
 Angry outburst
 Irritability
 Anxiety
 Confusion
 Social withdrawal
 Somatic symptoms:
 Breast tenderness
 Abdominal bloating
 Headache
 Extremity swelling
 Relieved within 4 days of onset of menses.
 No recurrence until cycle day 13.
 Symptoms occur in two prospectively monitored cycles.
 Exclude other diagnoses—depression and anxiety may present all
throughout the cycle.

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 P R E M E N ST R UA L DYS P H O R I C D I S O R D E R D IAG N O ST I C C R I T E R IA
( D S M- I V C R I T E R I A )

A 17-year-old G0 complains of being sad 4 days right before she starts

menstruating. She reports low energy, fatigue, hopelessness, anxiety,
mood swings, bloating, breast tenderness, headache, and sleep distur-
bances during these days. These symptoms disappear 2 days after the start of
menses. They occur on a monthly basis. She reports that she misses school on a
monthly basis because she cannot get out of bed for 3 days. What is the most
likely diagnosis? What is the best objective test to confirm the diagnosis?
Answer: PMDD. This patient has symptoms consistent with PMS, but with
markedly severe symptoms that affect daily activities. She should monitor her
symptoms in relation to her menses and record them prospectively.

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 Symptoms with prospectively monitored cycles.
 Five symptoms of PMS including one affective symptom:
 Feeling sad, hopeless, or having self-deprecating thoughts.
Diagnosis of PMS should be
 Anxiety or tension. made from recording
 Mood lability and crying. symptoms on a prospective
 Persistent irritability, anger, ↑ interpersonal conflicts. calendar.

T E STS

Prospective calendar of symptoms in relation to menses.

Premenstrual Syndrome/
Dysphoric Disorder
T R E AT M E N T

No drugs are currently FDA approved for the treatment of PMS or PMDD,
but several drugs are helpful when used off label. There are also some dietary
and lifestyle modifications that have been helpful. Treatment can be recom-
mended based on severity of symptoms. The therapy with most
evidence for effectiveness
 Supportive therapy: for PMS/PMDD: SSRIs and
 Reassurance and information counseling. ovulation blocking agents.
 Relaxation therapy for severe symptoms has been shown to help.
 Aerobic exercise reduces affective symptoms, especially depression.
 Dietary supplementation:
 Calcium is helpful.
 Vitamin E ↓ mastalgia.
 Carbohydrate-rich foods ↑ tryptophan, a precursor to serotonin.
 Selective serotonin reuptake inhibitors (SSRIs):
 Fluoxetine and sertraline have been well studied and shown to help. Calcium and aerobic
 Can be administered throughout the menstrual cycle or just with exercise help PMS/PMDD
symptoms during the last 2 weeks of the cycle. symptoms.
 Other:
 Spironolactone: Diuretic helps with the symptoms of fluid retention.
 Nonsteroidal anti-inflammatory drugs (NSAIDs).

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  Oral contraceptives:
 May help with physical symptoms, but not mood.
 Monophasic, continuous best.
 Gonadotropin-releasing hormone (GnRH) agonists: Severe PMS.
 Bilateral salpingo-oophorectomy: Reserved for those who are therapeu-
tic with GnRH agonists only, and do not want to continue taking GnRH
agonists on a daily basis, and want definitive treatment.
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Premenstrual Syndrome/
Dysphoric Disorder

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