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

Definition and Prevalence

The type and severity of premenstrual symptoms is influenced by age, race, ethnicity and health status, particularly mental health[4] and, therefore, varies in the population, but symptoms are relatively constant within each woman over consecutive cycles, particularly for emotional symptoms. The degree of premenstrual symptoms represents a continuum with 90% of women experiencing minor symptoms termed premenstrual molimina. Frank described premenstrual tension as the clustering of more severe premenstrual symptoms in 1931, with Greene and Dalton creating the term premenstrual syndrome (PMS) in 1953. Mortola first recognized that depression occurred only during the luteal phase of women with PMS.[5]

In 2000, the American College of Obstetrics and Gynecology (ACOG) outlined objective criteria for PMS, requiring at least one affective and somatic symptom during the 5 days before menses in each of three prior menstrual cycles. Symptoms must cause identifiable dysfunction in social or economic performance ( Box 1 ).[6] This was a major step in recognizing the entity and facilitating diagnosis and treatment. It is estimated that 20-40% of reproductive women have recurrent moderate-to-severe luteal phase symptoms defined as PMS.[7]

The American Psychiatric Association recognized a premenstrual clustering of severe affective symptoms experienced only in the late luteal phase and, in 1987, the 'late luteal phase dysphoric disorder' (LLPDD) was introduced with diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). LLPDD has since been replaced with the term 'premenstrual dysphoric disorder' (PMDD).[8] The PMDD criteria require five or more symptoms, with at least one disabling affective symptom and also require impairment in functioning due to symptoms with most menstrual cycles in the past year ( Box 1 ). PMDD is thought to be a severe form of PMS, and PMDD is a subset of PMS. Both PMS by ACOG criteria and PMDD require prospective daily documentation of cyclic symptoms for two menstrual cycles or frequent assessment by a clinician over the course of the cycle to confirm relatively symptom-free interval after the cessation of menses. The general practice in the community is to start treatment for PMS before prospective recording of symptoms. Additionally, although the PMS/PMDD diagnoses can be superimposed on another medical or psychiatric diagnosis, they must not represent an exacerbation of an underlying disorder and should be present in the absence of any pharmacologic therapy, hormone ingestion or drug or alcohol use.[6] It is estimated that 3-8% of menstruating women meet the very strict DSM-IV criteria for PMDD.[7] Assessment of published reports suggests that the prevalence of clinically significant premenstrual dysphoric symptoms is probably higher, with 13-18% of reproductive women having dysphoric symptoms severe enough to result in distress and impairment.[9] These women may lack only one symptom to meet the arbitrary five symptom criteria required for the PMDD diagnosis.

Most European regulatory agencies do not accept the ACOG PMS or the DSM-IV PMDD diagnostic criteria, leaving only the ICD-10 definition for PMS which are too general and would confer the diagnosis on up to 90% of ovulatory women.[10] An ICD-10 diagnosis, requires only one of the following symptoms be experienced premenstrually: depressed mood, anger, irritability, confusion, loss of control, difficulty concentrating, abdominal bloating or swelling of the extremities, weight gain, breast pain, joint or muscle pain, sleep disturbances and changes in appetite.[10]

Premenstrual syndrome symptoms usually start to be problematic in the adolescent years[11] and decline in the climacteric. Symptoms are most severe in the 20s to mid-30s but women are most likely to seek treatment after the age of 30 years.[12] Pregnancy offers respite from PMS but there is an increased risk of postpartum depression.[13]

Contributing to the difficulty with formulating a diagnosis for clinical and research purposes is the absence of general consensus as to the specific diagnostic criteria for PMS and PMDD.[13] A biological marker is lacking and the diagnosis is based on luteal phase timing, not on the unique nature of the symptoms. To achieve a reliable diagnosis, the cyclicity of the symptoms is most accurately determined by prospective daily documentation for at least two menstrual cycles but this is not always enacted in clinical practice and is unrealistic for large epidemiologic studies. Without prospective recording, accurate diagnosis is hampered by confusion with other conditions that show premenstrual or menstrual exacerbation, termed 'menstrual magnification'. Premenstrual disorders must be distinguished from other conditions that are subject to menstrual magnification. Such perimenstrual exacerbation is typical with affective and anxiety disorders (depression, generalized anxiety and panic disorders), chronic pelvic pain and dysmenorrhea, menstrual migraines, irritable bowel syndrome, chronic fatigue syndrome, asthma, thyroid or adrenal disorders, and substance abuse.[6]


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