Premenstrual Syndrome and Premenstrual Dysphoric Disorder

 


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Am Fam Physician. 2016 Aug 1;94(3):236-240.

  Patient information: See related handout on premenstrual disorders.

Premenstrual disorders affect up to 12% of women. The subspecialties of psychiatry and gynecology have developed overlapping but distinct diagnoses that qualify as a premenstrual disorder; these include premenstrual syndrome and premenstrual dysphoric disorder. These conditions encompass psychological and physical symptoms that cause significant impairment during the luteal phase of the menstrual cycle, but resolve shortly after menstruation. Patient-directed prospective recording of symptoms is helpful to establish the cyclical nature of symptoms that differentiate premenstrual syndrome and premenstrual dysphoric disorder from other psychiatric and physical disorders. Physicians should tailor therapy to achieve the greatest functional improvement possible for their patients. Select serotonergic antidepressants are first-line treatments. They can be used continuously or only during the luteal phase. Oral contraceptives and calcium supplements may also be used. There is insufficient evidence to recommend treatment with vitamin D, herbal remedies, or acupuncture, but there are data to suggest benefit from cognitive behavior therapy.

Premenstrual disorders consist of psychiatric or somatic symptoms that develop within the luteal phase of the menstrual cycle, affect the patient's normal daily functioning, and resolve shortly after menstruation. The luteal phase begins after ovulation and ends with the start of menstruation. The subspecialties of psychiatry and gynecology have developed overlapping but distinct diagnoses that qualify as a premenstrual disorder.1  The American Congress of Obstetricians and Gynecologists (ACOG) includes psychiatric and physical symptoms in describing premenstrual syndrome (PMS; Table 1).2  The American Psychiatric Association (APA) focuses predominantly on psychiatric symptoms in its diagnostic criteria for premenstrual dysphoric disorder (PMDD; Table 2).3 Symptoms can occur anytime between menarche and menopause. The burden of disease can be high; women with PMS have higher rates of work absences, higher medical expenses, and lower health-related quality of life.4

WHAT IS NEW ON THIS TOPIC: PREMENSTRUAL SYNDROME AND PREMENSTRUAL DYSPHORIC DISORDER

Prospective questionnaires are the most accurate way to diagnose premenstrual syndrome and premenstrual dysphoric disorder because patients have been found to greatly overestimate the cyclical nature of symptoms, when realistically, they are erratic or simply exacerbated during the luteal cycle.

View/Print Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

The Daily Record of Severity of Problems is a useful tool to help diagnose PMS and PMDD.

C

12

Selective serotonin reuptake inhibitors may be used as first-line treatment for severe symptoms of PMS and PMDD.

A

14

Oral contraceptives are effective for treatment of PMS and PMDD.

A

1719

Calcium supplementation of 1,000 to 1,200 mg per day may improve PMS symptoms.

B

20, 21

Cognitive behavior therapy may improve PMS and PMDD symptoms.

B

29


PMDD = premenstrual dysphoric disorder; PMS = premenstrual syndrome.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

The Daily Record of Severity of Problems is a useful tool to help diagnose PMS and PMDD.

C

12

Selective serotonin reuptake inhibitors may be used as first-line treatment for severe symptoms of PMS and PMDD.

A

14

Oral contraceptives are effective for treatment of PMS and PMDD.

A

1719

Calcium supplementation of 1,000 to 1,200 mg per day may improve PMS symptoms.

B

20, 21

Cognitive behavior therapy may improve PMS and PMDD symptoms.

B

29


PMDD = premenstrual dysphoric disorder; PMS = premenstrual syndrome.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

View/Print Table

Table 1.

Diagnostic Criteria for Premenstrual Syndrome

Premenstrual syndrome can be diagnosed if the patient reports at least one of the following affective and somatic symptoms during the five days before menses in each of the three previous menstrual cycles*
Affective symptomsSomatic symptoms

Angry outbursts

Abdominal bloating

Anxiety

Breast tenderness or swelling

Confusion

Headache

Depression

Joint or muscle pain

Irritability

Swelling of extremities

Social withdrawal

Weight gain


*—These symptoms must be relieved within four days of the onset of menses, without recurrence until at least day 13 of the cycle, and must be present in the absence of any pharmacologic therapy, hormone ingestion, or drug or alcohol

The Authors

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SABRINA HOFMEISTER, DO, is an assistant professor in the Department of Family and Community Medicine at the Medical College of Wisconsin, Milwaukee....

SETH BODDEN, MD, is an assistant professor in the Department of Family and Community Medicine at the Medical College of Wisconsin.

Author disclosure: No relevant financial affiliations.

Address correspondence to Sabrina Hofmeister, DO, Medical College of Wisconsin, 1121 E. North Ave., Milwaukee, WI 53212 (e-mail: shofmeister@mcw.edu). Reprints are not available from the authors.

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