Table of contents
Premenstrual syndrome
Background
Overview
Definition
PMS is a collection of physical and emotional symptoms occurring in the luteal phase of the menstrual cycle and disappearing within a few days of menstruation. PMDD is a more severe form of PMS characterized by intense mood symptoms.
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Pathophysiology
The pathophysiology of PMS and PMDD is not fully understood, but hormonal changes that occur with the natural menstrual cycle, specifically the progesterone produced following ovulation, and serotonin deficits have been implicated. An aberrant response to these hormonal fluctuations is thought to underlie the symptoms of these conditions.
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Epidemiology
The prevalence of PMS and premenopausal dysphoric disorder in women of reproductive age is estimated at 12.2% and 5.8%, respectively.
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Risk factors
Risk factors for developing PMS and PMDD include a history of mood disorders, genetic predisposition, and high stress levels. Intensive physical activity before the first menstruation and consumption of alcohol and coffee have also been identified as risk factors.
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Disease course
The clinical course of PMS and PMDD is characterized by a cyclical pattern of symptoms that recur in the luteal phase of the menstrual cycle. Symptoms include mood swings, irritability, depression, anxiety, bloating, breast tenderness, and fatigue. Symptoms of PMDD can be debilitating and significantly impair daily life activities.
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Prognosis and risk of recurrence
PMS and PMDD are chronic conditions, but their symptoms can be managed with appropriate treatment.
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Guidelines
Key sources
The following summarized guidelines for the evaluation and management of premenstrual syndrome are prepared by our editorial team based on guidelines from the American College of Obstetricians and Gynecologists (ACOG 2023), the Royal College of Obstetricians and Gynaecologists (RCOG 2017), and the American Academy of Family Physicians (AAFP 2016).
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Diagnostic investigations
History and physical examination
As per RCOG 2017 guidelines:
Record symptoms prospectively over 2 cycles using a symptom diary when assessing for PMS, as retrospective recall of symptoms is unreliable.
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Advise completing a symptom diary by the patient before initiating treatment.
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GnRH analog trial
Medical management
General principles: as per ACOG 2023 guidelines, consider referring patients with premenstrual symptoms to a mental health professional if the diagnosis is unclear or an underlying mood disorder is suspected.
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SSRIs
Combined oral contraceptives
Estrogen patches and implants
Progesterone and progestins
GnRH agonists
Danazol
Spironolactone
NSAIDs
Nonpharmacologic interventions
Physical activity: as per ACOG 2023 guidelines, consider advising routine exercise to help manage physical and affective premenstrual symptoms.
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CBT
Calcium supplements
Alternative and complementary therapies
Therapeutic procedures
Surgical interventions
Hysterectomy and bilateral oophorectomy: as per ACOG 2023 guidelines, reserve bilateral oophorectomy with or without hysterectomy as an option for adult patients with severe premenstrual symptoms only when medical management has failed and patients have been counseled about the associated risks and irreversibility of the procedure. Offer a trial period of GnRH agonist therapy (with or without estrogen add-back treatment) before surgery to predict the response to surgical management.
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