Molimina, PMS and PMDD

Lynae M. Brayboy, MD
Learning Objectives

• You will understand the difference between

normal molimina, premenstrual syndrome,
and premenstrual dysphoric disorder.

• You will review PMDD treatment.

Molimina Definition

During the reproductive years, up to 80 % 90 % of menstruating

women will experience symptoms (breast pain, bloating, acne,
constipation) that forewarn them of impending menstruation, so-
called premenstrual molimina.
Premenstrual Syndrome (PMS) Definition

• PMS encompasses a wide range of severity with

more than 100 physical and psychological
symptoms reported.

• Over 60 % of women report swelling or bloating.

• Cyclic breast pain affect 70 % of women with 22

% reporting moderate to extreme discomfort.
Premenstrual Syndrome (PMS) Definition

• 30 % 40 % of these women are sufficiently

bothered to seek relief.

• PMS appears one to two weeks before

menstruation and resolves within one week of
the onset of menses.
Premenstrual Dysphoric Disorder (PMDD) Definition

This diagnosis should be reserved for a more severe constellation

of symptoms, mostly psychiatric, that lead to periodic interference
with day-to-day activities and interpersonal relationships.
Incidence of PMDD Epidemiology

Women with this degree of symptoms

probably comprise 3 5 % of
women in their reproductive years.
Causes of PMS/PMDD Etiology

PMS or PMDD

Ovarian steroid CNS Genetic

Social expectations
fluctuation neurotransmitters predisposition
DSM-5 Diagnostic Criteria for PMDD Diagnosis

A. Timing of symptoms

B. In the majority of menstrual cycles, at least 5 symptoms must be present in the final
week before the onset of menses, start to improve within a few days after the onset of
menses, and become minimal or absent in the week postmenses.
C.

D.

E.

F.

G.
DSM-5 Diagnostic Criteria for PMDD Diagnosis

1 or more

A. Timing of symptoms

B. Symptoms I

Marked affective lability (e. g., mood swings, feeling suddenly sad or
C. 1.
tearful, or increased sensitivity to rejection).
Marked irritability or anger that is often characterized by increased interpersonal
D. 2.
conflicts.

E. 3. Markedly depressed mood, feelings of hopelessness, or self-deprecating thoughts.

F. 4. Marked anxiety, tension, and/or feelings of being keyed up or on edge

G.
DSM-5 Diagnostic Criteria for PMDD Diagnosis

1 or more (5 with symptoms from B)

A. Timing of symptoms

B. Symptoms I

C. Symptoms II

D. 1. Decreased interest in usual activities

2. Subjective difficulty in concentration
E. 3. Lethargy, easy fatigability, or marked lack of energy
4. Marked change in appetite; overeating or specific food cravings
F.
5. Hypersomnia or insomnia
G. 6. A sense of being overwhelmed or out of control
7. Breast tenderness or swelling; joint or muscle pain, bloating or weight gain
DSM-5 Diagnostic Criteria for PMDD Diagnosis

1 or more (5 with symptoms from B)

A. Timing of symptoms

B. Symptoms I

C. Symptoms II

D. Severity

E. The symptoms are associated with clinically significant distress as well as

impairment with work, school, usual social activities, or relationships with others.
F.

G.
DSM-5 Diagnostic Criteria for PMDD Diagnosis

1 or more (5 with symptoms from B)

A. Timing of symptoms

B. Symptoms I

C. Symptoms II

D. Severity

E. Consider other psychiatric disorders

F. The disturbance is not merely an exacerbation of the symptoms of another psychiatric

disorder, such as major depressive disorder, panic disorder, persistent depressive
disorder or a personality disorder (although it may co-occur with any of these disorders).
G.
DSM-5 Diagnostic Criteria for PMDD Diagnosis

1 or more (5 with symptoms from B)

A. Timing of symptoms

B. Symptoms I

C. Symptoms II

D. Severity

E. Consider other psychiatric disorders

F. Confirmation of the disorder

G. Criterion A should be confirmed by prospective daily ratings during 2 symptomatic cycles

(although a provisional diagnosis may be made prior to this confirmation).
DSM-5 Diagnostic Criteria for PMDD Diagnosis

1 or more (5 with symptoms from B)

A. Timing of symptoms

B. Symptoms I

C. Symptoms II

D. Severity

E. Consider other psychiatric disorders

F. Confirmation of the disorder

G. Exclude other medical explanations

DSM-5 Diagnostic Criteria for PMDD Diagnosis

Key elements of a prospective symptom record used for the diagnosis of PMDD

I Daily listing of symptoms

II Ratings of symptom severity throughout the month

III Timing of symptoms in relation to menstruation

IV Rating of baseline symptom severity during the follicular phase

PRISM Menstrual Calendar Diagnosis

Days 1 2 3 4 5 6 7 8 9 10 11
Weight change
Symptoms
Irritable
Fatigue
A menstrual calendar allows Anxiety
women to record their
symptoms accurately. Appetite
Cramps
Lifestyle impact
Life events
Experiences
Medications
Laboratory Testing Diagnosis

Thyroid-stimulating hormone (TSH)

PMDD Treatment Conservative Treatment Options Management

Communication strategies Diet Exercise

PMDD Treatment Medical Therapeutic Options Management

Medical therapeutic options

• Medical ovarian suppression with:

• Oral contraceptive pills (continuous)
• Danazol 200 mg
• GnRH agonists

• SSRIs increase serotonin levels

PMS and PMDD

Remember to ask during a gyn history.

Rule out psychiatric disorders.

Rule out other medical causes.

Ask patient to keep a menstrual calendar.

Learning Outcomes

 You understand the difference between

normal molimina, premenstrual syndrome,
and pre-menstrual dysphoric disorder.

 You reviewed PMDD treatment.