Premenstrual Syndrome (PMS) and Premenstrual Dysphoric Disorder (PMDD)
Premenstrual syndrome (PMS) causes cyclical physical, psychological, and behavioural symptoms during the luteal phase of the menstrual cycle. Symptoms improve with menstruation and cause functional impairment. Premenstrual dysphoric disorder (PMDD) is a severe form of PMS with prominent mood symptoms and significant functional impairment.
This updated UKMLA guide to PMS and PMDD is based on NICE CKS, which covers definition, symptoms, diagnosis, and management.
Definition
PMS is characterised by cyclical and repetitive psychological, physical and behavioural symptoms
- Occurring in the luteal phase of the normal menstrual cycle (time between ovulation and the onset of menstruation)
- And is significant enough to cause functional impairment and/or affect day-to-day activities (work / school / performance / interpersonal relationships)
Premenstrual dysphoric disorder (PMDD) is a severe form of PMS.
If the woman experiences minor, transient premenstrual symptoms that do NOT cause impairment of activities of daily living or affect quality of life, these are more consistent with physiological premenstrual symptoms rather than PMS.
Risk Factors
Strongest risk factor: presence of ovulatory menstrual cycles
Other risk factors:
- Family history
- Mood disorders
- Smoking
- Alcohol consumption
- Sexual abuse and/or trauma
- Weight gain
- Stress
Clinical Features
| Psychological symptoms |
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| Physical symptoms |
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| Behavioural symptoms |
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Investigation and Diagnosis
Primary Care
Ask the woman to conduct a prospective daily symptom diary for 2-3 cycles
- Daily Record of Severity of Problems (DRSP) is a validated questionnaire
- RCOG recommends against retrospective reporting of symptoms
Diagnose PMS if symptom diary shows:
- Prominence of symptoms during the luteal phase, and
- Resolves with the onset of menses, and
- Followed by a symptom-free week
Symptoms should be significant enough to cause functional impairment and/or affect day-to-day activities (work / school / performance / interpersonal relationships).
Refer to secondary care if completed symptom diary alone is inconclusive.
PMDD is a severe form of PMS, diagnosis typically requires cyclical pre-menstrual symptoms (similar to PMS), but also:
- At least 1 significant mood-related symptom (e.g. low mood, irritability, anxiety, mood lability), and
- Causes significant impairment in daily functioning / relationships / quality of life
Secondary Care
Definitive test: GnRH agonist ovarian suppression test for 3 months
- Resolution of symptoms after ovarian suppression is diagnostic of PMS
Management
ALL Patients (Less Severe PMS)
| Category | Management |
|---|---|
| Lifestyle advice |
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| Pain management (headache / cramps / generalised aches and pains) |
|
| Breast pain management |
|
Advise that there is limited evidence to support the use of complementary treatments and dietary supplements (including reflexology, St John’s wort, calcium and vitamin D, ginkgo biloba, evening primrose oil, vitamin B6, and magnesium)
More Severe PMS
Consider the following if symptoms are more severe or the above management options are ineffective:
| Management / medication | Description / indications |
|---|---|
| COCP (e.g. drospirenone and ethinylestradiol) | Especially if the woman requires contraception |
| Refer for CBT | If the woman would benefit from psychological intervention (e.g. psychological symptoms predominate) |
| SSRI | Consider if:
|
If there are no underlying conditions and primary care management has failed, consider referral to a clinic with a specific interest in PMS or general gynaecology.
Secondary care management options include:
- Transdermal oestrogen
- Other antidepressants
- Diuretics
- Danazol
- Gonadotrophin-releasing hormone (GnRH) agonists
- Surgery (bilateral salpingo-oophorectomy with or without hysterectomy)