Mini-ReviewPremenstrual Syndrome and Premenstrual Dysphoric Disorder
Introduction
Premenstrual symptoms are experienced by up to 90% of women of child bearing age. A smaller subset meet criteria for premenstrual syndrome (PMS) and less than 10% are diagnosed as having premenstrual dysphoric disorder (PMDD).1 This review will describe the epidemiology, etiology, and treatment of PMS and PMDD. When literature specifically applicable to adolescents is available, that will be noted. However, most of the research and literature has focused on adult women and this review will primarily reflect the adult literature.
Section snippets
Definition
PMS is used to describe an array of predictable physical, cognitive, affective, and behavioral symptoms that occur cyclically during the luteal phase of the menstrual cycle and resolve quickly at or within a few days of the onset of menstruation. To date, there is no universally accepted definition or diagnostic criteria for PMS. Over 200 premenstrual symptoms have been reported, although very few are confined to or only explained by changes in the menstrual cycle.2 With the work of Mortola,3, 4
Making the Diagnosis
Regardless of the definition used, there are several important findings that are usually needed to diagnosis PMS/PMDD.1, 2, 5
- 1.
Symptoms must occur in the luteal phase and resolve within a few days after onset of menstruation.
- 2.
The symptoms must be documented over several menstrual cycles and not be better explained by other physical or psychological conditions.
- 3.
Symptoms must be recurrent and severe enough to disrupt normal activities.
Because approximately one half of women with retrospective
Summary of Adult Studies
The exact prevalence of PMS/PMDD is unknown, but estimates are that 70–90% of menstruating women have some degree of symptoms before menses. Approximately 20–40% of women describe these symptoms as bothersome enough to impair daily functioning and are labeled as premenstrual syndrome. A further subset, representing 3–8% of women, have symptoms that are very severe, causing functional impairment that adversely affects quality of life and are classified as premenstrual dysphoric disorder.1, 6, 19
Impact on Quality of Life
The impact of PMS/PMDD on the quality of life is an important part of the definition of these disorders. One study included a sample of 18–45-yr-old women from a large medical group in Southern California. All women who were continuously enrolled as patients for the previous 18 months and did not decline contact were interviewed by phone to determine eligibility for the study. Inclusion criteria were a self-reported 26–32 day cycle length and willingness to keep a daily diary for 64 days. The
Risk Factors
Risk factors for PMS include advancing age (beyond 30 years) and genetic factors. However, as indicated above, PMS symptoms are identified in adolescents and can begin around age 14, or 2 years post-menarche, and persist until menopause.1 Some studies suggest that women whose mothers report PMS are more likely to develop PMS (70%, versus 37% of daughters of unaffected mothers).32, 33 In addition, concordance rates for PMS are significantly higher in monozygotic twins (93%) compared with
Pathophysiology
The exact etiology of PMS is currently unknown but it is probably a result of an interaction between sex steroids and central neurotransmitters.35 Alterations in neurotransmitters including endorphins, γ-aminobutyric (GABA), and serotonin have all been implicated, and women with PMS/PMDD are felt to be more sensitive to normal cyclical hormonal fluctuations.36
There is inconsistent evidence for differences (e.g., a drop) in circulating endorphins in symptomatic patients. Women with PMS and PMDD
Clinical Manifestations
More than 200 symptoms of PMS/PMDD have been described in literature, ranging from mild symptoms to those severe enough to interfere with normal activities.2 Common affective symptoms are irritability, anxiety/tension, mood lability, crying easily, depression, expressed anger, confusion, forgetfulness, hypersomnia/insomnia, and social isolation/withdrawal. Common physical symptoms include fatigue, abdominal bloating, breast tenderness, headache, swelling of extremities, joint or muscle pain,
Therapy
No single treatment is universally acceptable as effective. Studies have yielded conflicting results with most therapies, and many trials have not been well controlled. The various treatment modalities include the following:
Summary: Steps in the Treatment of PMS/PMDD
The following steps for treating PMS/PMDD are based on recommendations outlined in an ACOG Practice Bulletin6 and in a recent review by Johnson5:
Step 1: A. If mild/moderate symptoms: Recommend supportive therapy with good nutrition, complex carbohydrates, aerobic exercise, calcium supplements, and possibly magnesium or chasteberry fruit
B. If physical symptoms predominate: Try spironolactone or NSAIDs, or hormonal suppression with OCPs or medroxyprogesterone acetate.
Step 2: When mood symptoms
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