Premenstrual Syndrome and Premenstrual Dysphoric Disorder: Quality of Life and Burden of Illness

Andrea J. Rapkin; Sharon A. Winer


Expert Rev Pharmacoeconomics Outcomes Res. 2009;9(2):157-170. 

In This Article

Abstract and Introduction


Premenstrual symptoms are distressing for up to 20% of reproductive-aged women and are associated with impairment in interpersonal or workplace functioning for at least 3-8%. Typical symptoms of premenstrual syndrome and the severe form, premenstrual dysphoric disorder, include irritability, anger, mood swings, depression, tension/anxiety, abdominal bloating, breast pain and fatigue. The symptoms recur monthly and last for an average of 6 days per month for the majority of the reproductive years. For women with premenstrual dysphoric disorder, the symptoms can be as disabling as major depressive disorder. It has been estimated that affected women experience almost 3000 days of severe symptoms during the reproductive years. Until two decades ago, there were no effective treatments for severe premenstrual syndrome. Even in 2000, almost three-quarters of women in the USA with premenstrual disorders either did not seek help or sought treatment unsuccessfully from at least three clinicians for over 5 years. This review will focus on the epidemiology, diagnosis, treatment outcomes, quality of life and burden of illness for premenstrual disorders.


Distressing premenstrual symptoms have been recognized since antiquity. Many women experience a constellation of bothersome and even disabling psychological, somatic and behavioral premenstrual symptoms during a significant portion of their reproductive years. The cardinal symptoms are irritability and abdominal bloating, but mood swings, anger, anxiety/tension, depression or feeling 'blue', loss of control, fatigue, difficulty concentrating, food cravings, weight gain, headache and breast pain are also typically seen.[1] Substantial negative impact in personal, social and occupational domains has been documented.

The premenstrual symptoms are triggered by the rise and fall of ovarian sex steroids at the time of ovulation and do not remit until the onset of the next menstrual flow, often persisting until approximately day 5 of the following cycle. The phase of the menstrual cycle between ovulation and menses, the luteal phase, is physiologically determined to last between 12 and 14 days. Premenstrual symptoms, by definition, do not begin before ovulation and are most severe during the last few days of the luteal phase. Symptoms can occur throughout this phase; there is a relatively symptom-free interval in the late follicular phase of the menstrual cycle, between the end of menses and the onset of ovulation. Ovulatory menstrual cycles usually span 25-32 days, with ovulation generally occurring 14 days before menses; thus, for many women, there may be only 7-10 days each month without premenstrual symptoms.

The symptoms have a substantial negative impact on activities of daily living and quality of life.[2] Once they begin, unless treated, the cyclic symptoms recur monthly and persist with most cycles until the waning of ovulation with the menopausal transition. Symptoms recur within one to two cycles after discontinuation of treatment and spontaneous remission is unusual so, unlike depressive disorders, long-term therapy is needed.[3]


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