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Premenstrual Syndrome (PMS)

(Premenstrual Dysphoric Disorder; Premenstrual Tension)

By

JoAnn V. Pinkerton

, MD, University of Virginia Health System

Last review/revision Jan 2023
View Patient Education

Premenstrual syndrome (PMS) is a recurrent luteal-phase disorder characterized by irritability, anxiety, emotional lability, depression, edema, breast pain, and headaches, occurring during the 5 days before and usually ending a few hours after onset of menses. Premenstrual dysphoric disorder is a severe form of PMS. Diagnosis is clinical, often based on the patient’s daily recording of symptoms. Treatment is symptomatic and includes diet, medications, and counseling.

About 20 to 50% of women of reproductive age have PMS; about 5% have a severe form of PMS called premenstrual dysphoric disorder (PMDD).

Etiology of PMS

The cause of PMS is unclear.

Possible causes or contributing factors include

  • Multiple endocrine factors (eg, hypoglycemia, other changes in carbohydrate metabolism, hyperprolactinemia, fluctuations in levels of circulating estrogen and progesterone, abnormal responses to estrogen and progesterone, excess aldosterone or antidiuretic hormone [ADH])

  • Genetic predisposition

  • Serotonin deficiency

  • Possibly magnesium and calcium deficiencies

Estrogen and progesterone can cause transitory fluid retention, as can excess aldosterone or ADH.

Serotonin deficiency is thought to contribute because women who are most affected by PMS have lower serotonin levels and because selective serotonin reuptake inhibitors (SSRIs), which increase serotonin, sometimes relieve symptoms of PMS.

Magnesium and calcium deficiencies may contribute.

Symptoms and Signs of PMS

Type and intensity of PMS symptoms vary from woman to woman and from cycle to cycle. Symptoms typically start during the 5 days before menses and ending within a few hours of when menses begins. Symptoms may become more severe during stress or perimenopause. In perimenopausal women, symptoms may persist until after menses.

The most common symptoms are irritability, anxiety, agitation, anger, insomnia, difficulty concentrating, lethargy, depression, and severe fatigue. Fluid retention causes edema, transient weight gain, and breast fullness and pain. Pelvic heaviness or pressure and backache may occur. Some women, particularly younger ones, have dysmenorrhea when menses begins.

Other nonspecific symptoms may include headache, vertigo, paresthesias of the extremities, syncope, palpitations, constipation, nausea, vomiting, and changes in appetite. Acne and neurodermatitis may also occur.

Preexisting disorders may worsen while PMS symptoms are occurring. They include the following:

  • Skin disorders

  • Eye problems (eg, conjunctivitis)

  • Seizure disorders (increased seizures)

  • Connective tissue disorders (eg, systemic lupus erythematosus [SLE, or lupus], rheumatoid arthritis, with flare-ups)

  • Respiratory disorders (eg, allergies, infections)

  • Migraines

  • Mood disorders (eg, depression, anxiety)

  • Sleep disorders (eg, insomnia, hypersomnia)

Premenstrual dysphoric disorder (PMDD)

Some women have premenstrual dysphoric disorder (PMDD—see also Premenstrual dysphoric disorder under Symptoms and Signs of Depressive Disorders) Premenstrual dysphoric disorder Depressive disorders are characterized by sadness severe enough or persistent enough to interfere with function and often by decreased interest or pleasure in activities. Exact cause is unknown... read more , a severe form of PMS. In PMDD, symptoms occur regularly and only during the 2nd half of the menstrual cycle; symptoms end with menses or shortly after. Mood is markedly depressed, and anxiety, irritability, and emotional lability are pronounced. Suicidal thoughts may be present. Interest in daily activities is greatly decreased.

In contrast to PMS, PMDD causes symptoms that are severe enough to interfere with routine daily activities or overall functioning. PMDD is severely distressing, disabling, and often underdiagnosed.

Pearls & Pitfalls

  • Consider premenstrual dysphoric disorder if women have nonspecific but severe symptoms that affect their ability to function just before menses.

Diagnosis of PMS

  • For PMS, patient’s report of symptoms

  • Sometimes a depression inventory

  • For PMDD, clinical criteria

PMS is diagnosed based on physical symptoms (eg, bloating, weight gain, breast tenderness, swelling of hands and feet). Women may be asked to record their symptoms daily. Physical examination and laboratory testing are not helpful.

If PMDD is suspected, women are asked to rate their symptoms daily for 2 cycles to determine whether severe symptoms occur regularly.

For PMDD to be diagnosed, women must have 5 of the following symptoms for most of the week before menses, and symptoms must become minimal or absent during the week after menstruation. Symptoms must include ≥ 1 of the following:

  • Marked mood swings (eg, sudden sadness)

  • Marked irritability or anger or increased interpersonal conflicts

  • Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts

  • Marked anxiety, tension, or an on-edge feeling

In addition, ≥ 1 of the following must be present:

  • Decreased interest in usual activities, possibly causing withdrawal

  • Difficulty concentrating

  • Low energy or fatigue

  • Marked changes in appetite, overeating, or specific food cravings

  • Insomnia or hyperinsomnia

  • Feelings of being overwhelmed or out of control

  • Physical symptoms associated with PMS (eg, breast tenderness, edema)

Also, the symptom pattern must have occurred for most of the previous 12 months, and symptoms must be severe enough to interfere with daily activities and function.

Patients with symptoms of depression are evaluated using a depression inventory or are referred to a mental health care practitioner for formal evaluation.

Treatment of PMS

  • Sleep hygiene, exercise, and healthy diet

  • Sometimes selective serotonin reuptake inhibitors (SSRIs) or hormonal medications

PMS can be difficult to treat. No single treatment has proven efficacy for all women, and few woman have complete relief with any single type of treatment. Treatment can thus require trial and error, as well as patience.

General measures

Treatment of PMS is symptomatic, beginning with adequate rest and sleep, regular exercise, and activities that are relaxing. Regular exercise may help alleviate bloating as well as irritability, anxiety, and insomnia. Yoga helps some women.

Dietary changes—increasing protein, decreasing sugar, consuming complex carbohydrates, and eating smaller meals more frequently—may help, as may counseling, avoiding stressful activities, relaxation training, light therapy, sleep adjustments, and cognitive-behavioral therapy. Other possible strategies include avoiding certain foods and drinks (eg, cola, coffee, hot dogs, potato chips, canned goods) and eating more of others (eg, fruits, vegetables, milk, high-fiber foods, low-fat meats, foods high in calcium and vitamin D). Calcium supplements (600 mg twice a day) may lessen negative mood and somatic symptoms.

Some dietary supplements are mildly efficacious for reducing symptoms; they include chasteberry extract from the agnus castus fruit (which appears to lessen physical symptoms), vitamin B6 (no more than 100 mg a day), and vitamin E.

Medications

Selective serotonin release inhibitors (SSRIs) have been shown in randomized trials to improve mood and lessen physical symptoms such as breast tenderness and changes in appetite. SSRIs are the medications of choice for relief of anxiety, irritability, and other emotional symptoms, particularly if stress cannot be avoided. SSRIs (eg, fluoxetine 20 mg orally once a day) effectively relieve symptoms of PMS and PMDD. Continuous dosing is more effective than intermittent dosing. No SSRI appears to be more effective than another. Clinical trials have shown SSRIs to be effective for treatment of PMDD; those approved for PMDD include fluoxetine, sertraline and paroxetine. Additional SSRIs shown effective in clinical trials include citalopram, paroxetine and citalopram. These medications can be prescribed continuously or only during the 14-day luteal phase (second half) of the menstrual cycle or with a dose increase during the latter 14-day luteal phase.

Clomipramine, given for the full cycle or a half-cycle, effectively relieves emotional symptoms, as does nefazodone and venlafaxine, a serotonin-norepinephrine reuptake inhibitor (SNRI).

Anxiolytics may help but are usually less desirable because dependence or addiction is possible. Buspirone, which may be given throughout the cycle or during the late luteal phase, helps relieve symptoms of PMS and PMDD. Adverse effects include nausea, headache, anxiety, and dizziness.

For some women, hormonal manipulation is effective. Options include

  • Oral contraceptives

  • Progesterone by vaginal suppository (200 to 400 mg once a day)

  • An oral progestogen (eg, micronized progesterone 100 mg at bedtime) for 10 to 12 days before menses

  • A long-acting progestin (eg, medroxyprogesterone 200 mg IM every 2 to 3 months)

Women who choose to use an oral contraceptive for contraception can take drospirenone plus ethinyl estradiol. However, risk of venous thromboembolism may be increased.

Rarely, for very severe or refractory symptoms, a gonadotropin-releasing hormone (GnRH) agonist (eg, leuprolide 3.75 mg IM, goserelin 3.6 mg subcutaneously every month) with low-dose estrogen/progestin (eg, oral estradiol 0.5 mg once a day plus micronized progesterone 100 mg at bedtime) is given to minimize cyclic fluctuations.

Fluid retention may be relieved by reducing sodium intake and taking a diuretic (eg, spironolactone 100 mg orally once a day) just before symptoms are expected. However, minimizing fluid retention and taking a diuretic do not relieve all symptoms and may have no effect.

Bromocriptine and monoamine oxidase inhibitors are not useful. Danazol has significant adverse effects.

Surgery

In women with severe symptoms, bilateral oophorectomy may alleviate symptoms because it eliminates menstrual cycles; hormone replacement therapy is then indicated until about age 51 (the average for menopause).

Key Points

  • Symptoms of premenstrual syndrome (PMS) can be nonspecific and vary from woman to woman.

  • Diagnose PMS based on symptoms alone.

  • If symptoms seem severe and disabling, consider premenstrual dysphoric disorder (PMDD), which is often underdiagnosed, and ask patients to record symptoms for ≥ 2 cycles; for a diagnosis of PMDD, clinical criteria must be met.

  • Usually, treatment is a matter of trying various strategies to identify what helps a particular patient; start with lifestyle modifications, then SSRIs, oral contraceptives, or sometimes cognitive-behavioral therapy.

  • GnRH agonists and oophorectomy are reserved for severe cases.

More Information

The following English-language resource may be useful. Please note that THE MANUAL is not responsible for the content of this resource.

  • Lanza di Scalea T, Pearlstein T: Premenstrual dysphoric disorder. Med Clin North Am 103(4):613–628, 2019. doi: 10.1016/j.mcna.2019.02.007: This article discusses the definition, etiology, and treatment of premenstrual dysphoric disorder.

  • Appleton SM: Premenstrual syndrome: Evidence-based evaluation and treatment. Clin Obstet Gynecol (1):52–61, 2018. doi: 10.1097/GRF.0000000000000339: Evidence for diagnosis and treatment is reviewed.

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