Elsevier

The Lancet

Volume 371, Issue 9619, 5ā€“11 April 2008, Pages 1200-1210
The Lancet

Seminar
Premenstrual syndrome

https://doi.org/10.1016/S0140-6736(08)60527-9Get rights and content

Summary

Most women of reproductive age have some physical discomfort or dysphoria in the weeks before menstruation. Symptoms are often mild, but can be severe enough to substantially affect daily activities. About 5ā€“8% of women thus suffer from severe premenstrual syndrome (PMS); most of these women also meet criteria for premenstrual dysphoric disorder (PMDD). Mood and behavioural symptoms, including irritability, tension, depressed mood, tearfulness, and mood swings, are the most distressing, but somatic complaints, such as breast tenderness and bloating, can also be problematic. We outline theories for the underlying causes of severe PMS, and describe two main methods of treating it: one targeting the hypothalamus-pituitary-ovary axis, and the other targeting brain serotonergic synapses. Fluctuations in gonadal hormone levels trigger the symptoms, and thus interventions that abolish ovarian cyclicity, including long-acting analogues of gonadotropin-releasing hormone (GnRH) or oestradiol (administered as patches or implants), effectively reduce the symptoms, as can some oral contraceptives. The effectiveness of serotonin reuptake inhibitors, taken throughout the cycle or during luteal phases only, is also well established.

Introduction

Most women of reproductive age have one or more emotional or physical symptom in the premenstrual phase of the menstrual cycle. The symptoms are mild, but 5ā€“8% have moderate to severe symptoms that are associated with substantial distress or functional impairment. In early medical reports about this issue, clinically significant premenstrual symptoms were named premenstrual tension (PMT)1 or premenstrual syndrome (PMS).2 The WHO International Classification of Diseases (ICD) includes ā€œpremenstrual tension syndromeā€ under the heading ā€œDiseases of the Genitourinary Tractā€. However, like PMS and PMT, this description is not useful for the purpose of clinical diagnostics, drug labelling, or research, since it is not defined by specific criteria, and does not specify severity.

Section snippets

Diagnosis

In the mid-1980s, a multidisciplinary US National Institutes of Health consensus conference on PMS proposed criteria that were adopted by the Diagnostic and Statistical Manual III (DSM III)3 to define the severe form of this condition. Originally entitled ā€œlate luteal phase dysphoric disorderā€, it was later renamed ā€œpremenstrual dysphoric disorderā€ (PMDD). The diagnosis of PMDD stipulates (1) the presence of at least five luteal-phase symptoms (panel), at least one of which must be a mood

Prevalence

Most studies on the prevalence of premenstrual complaints are based on retrospective reports which, by their nature, can introduce recall bias.6, 7, 8, 9, 10, 11, 12 However, the findings of these studies are consistent with those from the few epidemiological studies that used prospective symptom ratings.13, 14 Findings of prospective and retrospective studies suggest that 5ā€“8% of women with hormonal cycles have moderate to severe symptoms. However, some studies suggest that up to 20% of all

Pattern of symptom expression

The length of symptom expression varies between a few days and 2 weeks (figure 1). Symptoms often worsen substantially 6 days before, and peak at about 2 days before, menses start.16, 17 Anger and irritability are the most severe complaints and start slightly earlier than other symptoms (figure 2).16 It is not uncommon for symptoms to linger into the next menstrual cycle16, 17, 18 but, by definition, there must be a symptom-free interval before ovulation. Typically, women have the same set of

Aetiology and pathophysiology

Since most women of reproductive age report at least mild premenstrual symptoms, a certain degree of discomfort during the luteal phase should probably be considered physiological rather than pathological. In evolutionary terms,29 luteal mood changes could be remnants of the oestrous cycle-related fluctuations in behaviour shown by lower species with the original purpose of promoting reproduction: sexual receptivity being increased and aggression decreased when oestrogen is high before

Treatment

Before pharmacological treatment is considered, the medical history of women with presumed PMS should be investigated for conditions such as depression, dysthymic disorder, anxiety disorders, and hypothyroidism. Given the possible links between PMS and sexual abuse, as well as with post-traumatic stress disorder,60 a history that assesses the presence of these factors, as well as domestic violence, should be obtained. Some individuals with anxiety and mood disorders, including PMS, attempt to

Conclusions

There is substantial empirical research to support the existence of a severe premenstrual disorder causing marked functional impairment. Severe PMS is consistently reported by about 5% of all women of fertile age. The management of PMS is complex. At the outset it is important to establish a precise diagnosis and not rely on the patient's own diagnosis. It is mandatory to separate PMS/PMDD from other diagnoses, particularly depression and anxiety disorders, premenstrual exacerbation of another

Search strategy and selection criteria

In this Seminar, we searched Medline (1950ā€“2006) with the subject heading ā€œpremenstrual syndromeā€ and keywords of ā€œpremenstrual syndromeā€ and ā€œpremenstrual dysphoric disorderā€. Of the 3138 publications that we identified, we selected the most up-to-date publications as well as key reports in the field relevant to the phenomenology, pathophysiology, and treatment of moderate to severe PMS and PMDD. To ensure that important publications were reviewed, we searched the reference lists of

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