Definitions and Diagnosis of Premenstrual Syndrome

By Felise B. Milan, MD. Dr. Milan is Associate Professor of Clinical Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY; she reports no consultant, stockholder, speaker's bureau, research, or other financial relationships with companies having ties to this field of study.

While aspects of premenstrual mood changes were described by Hippocrates, premenstrual tension syndrome was first delineated as a disorder in the 1930s and the term premenstrual syndrome (PMS) was first defined in the 1950s.1 Although many recognized that a subset of the population suffered from a particularly severe form of PMS resulting in a significant level of dysfunction, clear clinical definitions were not outlined until recently. The American College of Obstetrics and Gynecology (ACOG) established clinical guidelines for PMS in 20002 and criteria for Premenstrual Dysphoric Disorder (PMDD) were included in DSM-IV.3 Both the ACOG criteria for PMS and the DSM-IV criteria for PMDD require confirmation of the luteal nature of the problem through the use of prospective symptom charts or a daily rating instrument for a minimum of two menstrual cycles.

A number of valid and reliable diagnostic instruments are available to document symptoms including the Calendar of Premenstrual Experiences,4 the Premenstrual Syndrome Diary,5 and the Daily Record of Severity of Problems.6 One expert recommends that women record daily the presence and severity of five of their most bothersome symptoms.7 The use of prospective symptom recording is important in both clinical and research settings as the literature shows that more than half of the women who present with complaints of "severe PMS" are found not to have a pure luteal phase pattern based on prospective charts.3,7

It is necessary to establish a diagnosis of either PMS or PMDD and rule out other psychiatric disorders. One study found that of 426 women recruited from primary care obstetrics and gynecology practices who reported having PMS, 22% (93) were found to have major depressive disorder and 14% (61) had panic disorder.8 Of the women in that study who charted their symptoms for a cycle, only 22% were confirmed to have PMS.8 The symptom diaries also can identify women who present with complaints of PMS but are found to have psychological symptoms present throughout their cycle that worsen between ovulation and menstruation. This phenomenon is referred to as "menstrual magnification."7 Many women find the information gleaned from charting their symptoms helpful in identifying potential triggers or lifestyle habits that may exacerbate them. Lastly, several experts7,9 have recommended that women try certain lifestyle changes or nutritional interventions during the cycles when they are recording their symptoms.

References

1. Rapkin A. A review of treatment of premenstrual syndrome and premenstrual dysphoric disorder. Psychoneuroendocrinology 2003;28:39-53.

2. American College of Obstetrics and Gynecologists. Premenstrual Syndrome. ACOG Practice Bulletin No. 15. 2000; April.

3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). 4th ed. Washington, DC: American Psychiatric Association; 1994:715-718.

4. Mortola JF, et al. Diagnosis of premenstrual syndrome by a simple, prospective, and reliable instrument: The calendar of premenstrual experiences. Obstet Gynecol 1990;76:302-307.

5. Thys-Jacobs S, et al. Comparative analysis of three PMS assessment instruments—the identification of premenstrual syndrome with core symptoms. Psychopharmacol Bull 1995;31:389-396.

6. Endicott J. Severe premenstrual dysphoria: Differential diagnosis and treatment. J Am Med Womens Assoc 1998;53:170-175.

7. Johnson SR. Premenstrual syndrome, premenstrual dysphoric disorder, and beyond: A clinical primer for practitioners. Obstet Gynecol 2004;104:845-859.

8. Yonkers KA, et al. Premenstrual disorders: Bridging research and clinical reality. Arch Womens Ment Health 2003;6:287-292.

9. Grady-Weliky TA. Clinical practice. Premenstrual dysphoric disorder. N Engl J Med 2003;348:433-438.