PREMENSTRUAL

SYNDROME
EMINE ZEYNEP YILMAZ, MD, ASSISTANT PROFESSOR

MEDIPOL UNIVERSITY HEALTH CARE

PRACTICE & RESEARCH CENTER ESENLER HOSPITAL
DEFINITION

• Most women of reproductive age experience one or

more mild emotional or physical symptoms for one to
two days before the onset of menses. These symptoms
(such as breast soreness and bloating) are mild, do not
cause severe distress or functional impairment, and are
not considered to represent premenstrual syndrome
(PMS)
• In contrast, clinically significant PMS is defined by the
American College of Obstetricians and Gynecologists
(ACOG) as at least one symptom associated with
"economic or social dysfunction" that occurs during the
five days before the onset of menses and is present in at
least three consecutive menstrual cycles.
• Premenstrual dysphoric disorder (PMDD) is the most
severe form.
PMS
• Nearly 300 different symptoms have been reported and typically
include both psychiatric and physical complaints.
• For most women, these are self-limited. However, approximately 15
percent report moderate-to-severe complaints that cause some
impairment or require special consideration
• Current estimates are that 3 to 8 percent of menstruating women
meet the strict criteria for PMDD
SYMPTOMS
Most common symptoms — More than 150 physical,
behavioral, emotional, and cognitive symptoms have been
ascribed to PMS in the literature. However, the number of
symptoms seen in the vast majority of patients is much
more limited.
●The most common affective or behavioral symptom of
PMS is mood swings. Other frequent nonphysical
behavioral symptoms include irritability, anxiety/tension,
sad or depressed mood, increased appetite/food cravings,
sensitivity to rejection, and diminished interest in activities.
●The most common physical manifestations of PMS are
abdominal bloating and an extreme sense of fatigue. Other
common symptoms include breast tenderness, headaches,
hot flashes, and dizziness.
ETIOLOGY
• Still under investigation, PMDD is thought to spring
from genetic factors, psychosocial factors (particularly
stress), and an altered sensitivity to the normal
hormonal fluctuations that influence CNS functioning.
• Because of the timing of symptoms, current thinking is
that hormonal fluctuation is the key trigger.
DIAGNOSTIC
CRITERIA for
PMDD
DIFFERENTIAL DIAGNOSIS
• Mood and anxiety disorders 
• Menopausal transition — Unlike PMS symptoms, which occur during ovulatory cycles,
menopausal mood symptoms typically begin when menstrual cycles become
irregular/anovulatory.
• Thyroid disorders 
• Substance abuse — It has been suggested that women with PMS consume more alcohol than
controls, independent of cycle phase, and that women with a family history of alcoholism
experience more anxiety premenstrually. However, a firm link between alcoholism and PMS
has never been established.
• Other — A variety of medical disorders (eg, migraine; chronic fatigue syndrome [CFS] also
known as myalgic encephalomyelitis/chronic fatigue syndrome [ME/CFS]; irritable bowel
syndrome) are exacerbated just prior to or during menses. However, the symptoms expressed
are not those typical of PMS, and the timing is not usually confined to the luteal phase.
PMS
• Women without menstruation — The diagnosis of premenstrual
disorders is more challenging, but still possible, in women with normal
ovarian function and ovulation in the absence of menstruation. These
women experience the typical cyclic symptoms of PMS/PMDD but cannot
use menses as a reference point for their symptoms. Examples include:
• ●Women who have undergone hysterectomy (with ovarian conservation) or an
endometrial ablation, which results in amenorrhea in approximately 35 to 40
percent.
• ●Women using a LNG-IUD (for contraception or heavy menstrual bleeding).
Amenorrhea typically develops after six months of use, but ovulation persists in
approximately 75 percent of women.
TREATMENT –MILD
PMS
• Exercise and relaxation techniques 
• A number of vitamins and dietary
supplements, including primrose oil,
vitamin B6, vitamin E, calcium, and
magnesium, have been studied as
therapeutic agents for PMS; however,
evidence that any of these is more
effective than placebo, which has a 30
percent response rate, is inconsistent
• Vitex agnus castus, John’s wort
• Meditation, quality of sleep, decreased
caffein, alcohol and salt intake
TREATMENT – CONTRACEPTION OR
NOT?
• Selective serotonin reuptake inhibitors — Because of their proven
efficacy and safety profile, SSRIs for women with premenstrual symptoms
that include socioeconomic dysfunction is first choice.
• Clinical trials and systematic reviews of SSRIs for PMS and PMDD conclude
that these medications are effective.
• We typically start sertraline, citalopram, escitalopram or fluoxetine as these
are extensively studied. Paroxetine is also effective but is more likely to be
associated with weight gain. 
• A beneficial effect can be expected in the first cycle. If response is
suboptimal, the dose can be increased in the subsequent cycle. SSRI therapy
appears to be more effective for mood symptoms than somatic symptoms.
There are no strong predictors of response to SSRIs in women with PMDD.
TREATMENT – CONTRACEPTION OR
NOT?
• Combined estrogen-progestin contraception — For women with moderate to severe
nondepressive symptoms who are interested in hormonal contraception, we suggest
treatment with a COC. This is the simplest way to suppress the hypothalamic-pituitary-ovarian
axis and ovulation. We prefer monophasic pills, as multiphasic preparations can worsen mood
symptoms
• Cognitive behavioral therapy — Cognitive behavioral therapy (CBT) may provide some
benefit for women with PMDD. A meta-analysis of five randomized trials observed a reduction
in symptoms of anxiety and depression with CBT compared to other interventions. 
• GnRH agonists — In women with severe symptoms who have not responded to or cannot
tolerate SSRIs or COCs, we suggest gonadotropin-releasing hormone (GnRH) agonist therapy
with low-dose estrogen-progesterone "add back" therapy as the next step.However, GnRH
agonists should not be considered until the patient has first tried multiple SSRIs and a COC
with a shortened pill-free interval or continuous administration.
• Acupuncture 
• Surgery