Premenstrual disorders

Premenstrual disorders are common cyclical conditions affecting menstruating individuals of reproductive age. They comprise premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD). Both PMS and PMDD are marked by affective and somatic symptoms that start in the luteal phase and resolve following menstruation. Both conditions affect an individual's daily life, with symptoms of PMDD causing significant impairment that is comparable in intensity to other mood disorders (e.g., major depressive disorder, generalized anxiety disorder). Diagnosis is made clinically with history, prospective symptom documentation over ≥ 2 consecutive menstrual cycles, and for PMDD, DSM-5 criteria for PMDD. Management is tailored to the patient's symptoms and includes lifestyle changes (e.g., regular exercise, dietary modifications), behavioral therapy, and/or pharmacotherapy (e.g., SSRIs, oral contraceptives).

PMDD is classified as a depressive disorder and causes significant interference in daily life; ≥ 5 symptoms must be present for diagnosis. ^[1][3]

• Occurs in up to 12% of female individuals ^[2]
• Age of onset: 20–30 years of age ^[2]

Epidemiological data refers to the US, unless otherwise specified.

The following symptoms begin during the luteal phase, resolve following the onset of menses, and impact daily life. ^[1][2][3]

• Premenstrual affective symptoms
  • Mood swings or emotional lability
  • Irritability, anger, or increased conflicts
  • Depressed mood
  • Anxiety, tension, and/or feeling on edge
• Premenstrual somatic symptoms
  • Physical symptoms: joint pain, muscle pain, breast tenderness, fluid retention (e.g., bloating, weight gain, swelling of the extremities) ^[2]
  • Changes in appetite: overeating or cravings
  • Decreased interest in usual activities
  • Difficulty concentrating
  • Lethargy or lack of energy
  • Disordered sleep: hypersomnia or insomnia
  • Feeling overwhelmed or out of control
• Other associated symptoms ^[1][4]
  • Headaches, e.g., migraine
  • Gastrointestinal changes, e.g., abdominal pain

Approach ^[1][2]

• Exclude differential diagnoses of premenstrual disorders; consider testing based on clinical evaluation.
• Obtain prospective documentation of symptoms for at least 2 consecutive menstrual cycles. ^[1]
• Assess for DSM-5 criteria for PMDD.
  • Criteria met: Diagnose PMDD.
  • Criteria not met (e.g., only 1–4 symptoms): Diagnose PMS.

Prospective documentation (e.g., with a patient diary) verifies symptoms, timing, and severity. ^[1]

The lack of a symptom-free period between menses and the next ovulation cycle indicates an alternative diagnosis. ^[1]

DSM-5 criteria for PMDD ^[3]

Symptoms must meet all of the following criteria:

• Present during most menstrual cycles within the preceding year
• Documented over at least 2 cycles
• Start within 1 week before and resolve within 1 week after onset of menstruation
• Are not attributed to another mental disorder, medical condition, or substance or medication use
• Interfere with daily functioning
• Include ≥ 1 premenstrual affective symptom and ≥ 1 premenstrual somatic symptom for a total of ≥ 5 symptoms

PMDD may co-occur with other conditions (e.g., major depressive disorder). ^[3]

• Thyroid disorder
• Anemia
• Normal adolescent mood swings ^[1]
• Perimenopause ^[4]
• Another mood disorder, including premenstrual exacerbation of a mood disorder

The differential diagnoses listed here are not exhaustive.

Approach ^[1][5]

There is no standard treatment; use a multimodal approach tailored to the patient's symptoms.

• All patients
  • Lifestyle and dietary changes
  • Pain symptoms: over-the-counter NSAIDs (e.g., ibuprofen, naproxen)
  • Affective symptoms: Screen for suicidal thoughts and, if indicated, refer for counseling (e.g., cognitive behavioral therapy).
• Patients with PMDD or severe PMS symptoms
  • Initiate pharmacotherapy.
  • Severe refractory symptoms: specialist referral for possible GnRH agonists and/or bilateral oophorectomy with or without hysterectomy

Lifestyle and dietary changes ^[1][2]

The following recommendations are based on low-quality evidence; used shared-decision making.

• Regular exercise
• Calcium ^[2]
  • Adults: calcium supplementation (off-label) ^[1]
  • Adolescents: adequate dietary consumption of 1300–2000 mg of calcium per day ^[1]
• Acupuncture

Pharmacotherapy ^[1][2]

Monotherapy or combination therapy may be used based on individual symptom severity.

• Affective symptoms: SSRIs (first-line) ^[1]
  • Options ^[1][6]
    • Sertraline (off-label in PMS and adolescents with PMDD) ^[1][6]
    • Paroxetine (off-label in PMS and adolescents with PMDD) ^[1][6]
  • Administration: may be given continuously or only during the luteal phase ^[1]
• Somatic symptoms: combined oral contraceptives (COCs)
  • Options: drospirenone/ethinyl estradiol (off-label in PMS) for individuals also desiring contraception
  • Administration: typically given with a shortened placebo period (4 rather than 7 days) ^[1]
  • See “Contraindications to COCs.”

In contrast to individuals with other depressive disorders, individuals with PMDD show a clinical response to SSRIs within days rather than weeks. ^[1]