Premenstrual Dysphoric Disorder Clinical Presentation
- Author: Thwe T Htay, MD, FACP; Chief Editor: Iqbal Ahmed, MBBS, FRCPsych(UK) more...
The most common primary symptom of premenstrual dysphoric disorder (PMDD) is irritability. The common symptoms of breast pain and bloating differ from those of women with a major depressive disorder.
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), established 4 research criteria (A through D) for the diagnosis of PMDD.
Criterion A is that in most menstrual cycles during the past year, at least 5 of the following 11 symptoms (including at least 1 of the first 4 listed) were present:
Markedly depressed mood, feelings of hopelessness, or self-deprecating thoughts
Marked anxiety, tension, feelings of being “keyed up” or “on edge”
Marked affective lability (eg, feeling suddenly sad or tearful or experiencing increased sensitivity to rejection)
Persistent and marked anger or irritability or increased interpersonal conflicts
Decreased interest in usual activities (eg, work, school, friends, and hobbies)
Subjective sense of difficulty in concentrating
Lethargy, easy fatigability, or marked lack of energy
Marked change in appetite, overeating, or specific food cravings
Hypersomnia or insomnia
A subjective sense of being overwhelmed or out of control
Other physical symptoms, such as breast tenderness or swelling, headaches, joint or muscle pain, a sensation of bloating, or weight gain
The symptoms must have been present for most of the time during the last week of the luteal phase, must have begun to remit within a few days of the onset of menstrual flow, and must be absent in the week after menses.
Criterion B is that the symptoms must be severe enough to interfere significantly with social, occupational, sexual, or scholastic functioning. For example, the patient may avoid social activities or exhibit decreased productivity and efficiency at work or school.
Criterion C is that the symptoms must be discretely related to the menstrual cycle and must not merely represent an exacerbation of the symptoms of another disorder, such as major depressive disorder, panic disorder, dysthymic disorder, or a personality disorder (although the symptoms may be superimposed on those of any of these disorders).
Criterion D is that criteria A, B, and C must be confirmed by prospective daily ratings during at least 2 consecutive symptomatic menstrual cycles. The diagnosis may be made provisionally before this confirmation.
Of the 11 symptoms listed in DSM-5, 10 are emotional and behavioral in nature; only 1 includes multiple common physical symptoms. Thus, PMDD defines a narrow group of women with the most severe premenstrual emotional symptoms, with functional impairment, and without a concurrent Axis I or Axis II disorder that is exacerbated premenstrually.
Women who meet the PMDD criteria are coded on Axis I as depressive disorder not otherwise specified. Obviously, this classification excludes many women presenting with predominantly physical premenstrual symptoms or with premenstrual exacerbation of underlying Axis I or II disorders. The DSM-5 criteria do state that PMDD may be superimposed on Axis I or II disorders; however, it is not clear how to differentiate between exacerbation of an Axis I or II disorder and superimposition on the symptoms of such a disorder.
Because depression is a common symptom of PMDD, suicide is a risk. A case-control study of fertile females with regular menstrual cycles who attempted suicide (with blood donors used as controls) showed that attempts during the luteal phase were no more frequent in females with PMDD than in those without. However, PMDD was more prevalent in those who attempted suicide than in those who did not. This suggests that PMDD may not be associated with suicidal acts during the luteal phase, when premenstrual symptoms are present.
Several scoring systems are available for symptom quantification. It has been suggested that a within-cycle increase from follicular to luteal phase score (demonstrating “on-offness”) of at least 50% is necessary to confirm the diagnosis of PMDD and to warrant psychopharmacologic intervention. The within-cycle percentage change is calculated by subtracting the follicular score from the luteal score divided by the luteal score and multiplying the result by 100, as follows:
[Luteal score – (follicular score/luteal score)] × 100
More than 60 instruments have been used for symptom recording. Visual analog scales have been used in some studies. It is also common to score symptoms on a Likert scale ranging from “not present” to “severe.” A 24-item form called the Daily Record of Severity of Problems incorporates all of the DSM-5 symptoms of PMDD. As might have been expected from the large number of scoring instruments in use, a review of the scoring methods used in most studies did not find any of them to offer unique advantages.
The findings from the physical examination are usually unremarkable. Mild swelling of the ankles, feet, and fingers may occur secondary to fluid retention. Breast tenderness may be present.
A Mental Status Examination (MSE) may be abnormal only during the latter part of the luteal phase as described below. The following findings usually are not apparent during other phases of the menstrual cycle
General appearance may be affected; patients may appear anxious or frustrated
Behavior may be altered; patients may appear irritable
Orientation is normal
Memory is normal
Concentration may be affected
Impulse control may be normal or poor
Speech rate and flow may be slow if the depressive symptoms are predominant.
Mood and affect changes (eg, depression, anxiety, tension, self-depreciation, and anger) are common
Thoughts and perception are not affected
There is a theoretical danger of suicidal ideation and behaviors in patients with severe depression
Wyatt K, Dimmock P, O'Brien PMS. Premenstrual syndrome. Clin Evid. 2000. 4:1121-33.
Rickels K, Freeman E, Sondheimer S. Buspirone in treatment of premenstrual syndrome. Lancet. 1989 Apr 8. 1(8641):777. [Medline].
Endicott J. History, evolution, and diagnosis of premenstrual dysphoric disorder. J Clin Psychiatry. 2000. 61 Suppl 12:5-8. [Medline].
Frank RT. The hormonal causes of premenstrual tension. Arch Neurol Psych. 1931. 26:1053-57.
Klock SC. Premenstrual dysphoric disorder. Ryan KJ, ed. Kistner's Gynecology and Women's Health. 7th ed. 520-4.
Steiner M, Pearlstein T. Premenstrual dysphoria and the serotonin system: pathophysiology and treatment. J Clin Psychiatry. 2000. 61 Suppl 12:17-21. [Medline].
Mueller EA, Murphy DL, Sunderland T. Neuroendocrine effects of M-chlorophenylpiperazine, a serotonin agonist, in humans. J Clin Endocrinol Metab. 1985 Dec. 61(6):1179-84. [Medline].
Ling FW. Recognizing and treating premenstrual dysphoric disorder in the obstetric, gynecologic, and primary care practices. J Clin Psychiatry. 2000. 61 Suppl 12:9-16. [Medline].
Boyle CA, Berkowitz GS, Kelsey JL. Epidemiology of premenstrual symptoms. Am J Public Health. 1987 Mar. 77(3):349-50. [Medline].
Grady-Weliky TA. Clinical practice. Premenstrual dysphoric disorder. N Engl J Med. 2003 Jan 30. 348(5):433-8. [Medline].
Banerjee N, Roy KK, Takkar D. Premenstrual dysphoric disorder--a study from India. Int J Fertil Womens Med. 2000 Sep-Oct. 45(5):342-4. [Medline].
Tschudin S, Bertea PC, Zemp E. Prevalence and predictors of premenstrual syndrome and premenstrual dysphoric disorder in a population-based sample. Arch Womens Ment Health. 2010 Dec. 13(6):485-94. [Medline].
Issa BA, Yussuf AD, Olatinwo AW, Ighodalo M. Premenstrual dysphoric disorder among medical students of a Nigerian university. Ann Afr Med. 2010 Jul-Sep. 9(3):118-22. [Medline].
Stout AL, Grady TA, Steege JF, et al. Premenstrual symptoms in black and white community samples. Am J Psychiatry. 1986 Nov. 143(11):1436-9. [Medline].
Woods NF, Most A, Dery GK. Prevalene of perimenstrual symptoms. Am J Public Health. 1982 Nov. 72(11):1257-64. [Medline].
Chang AM, Holroyd E, Chau JP. Premenstrual syndrome in employed Chinese women in Hong Kong. Health Care Women Int. 1995 Nov-Dec. 16(6):551-61. [Medline].
The American Psychiatric Association. Diagnostic and statistical manual of mental disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000. 717-8.
Bhatia SC, Bhatia SK. Depression in women: diagnostic and treatment considerations. Am Fam Physician. 1999 Jul. 60(1):225-34, 239-40. [Medline].
Baca-Garcia E, Diaz-Sastre C, Ceverino A, García Resa E, Oquendo MA, Saiz-Ruiz J, et al. Premenstrual symptoms and luteal suicide attempts. Eur Arch Psychiatry Clin Neurosci. 2004 Oct. 254(5):326-9. [Medline].
Kim SY, Park HJ, Lee H, Lee H. Acupuncture for premenstrual syndrome: a systematic review and meta-analysis of randomised controlled trials. BJOG. 2011 Jul. 118(8):899-915. [Medline].
Jang SH, Kim DI, Choi MS. Effects and treatment methods of acupuncture and herbal medicine for premenstrual syndrome/premenstrual dysphoric disorder: systematic review. BMC Complement Altern Med. 2014 Jan 10. 14:11. [Medline].
Goodale IL, Domar AD, Benson H. Alleviation of premenstrual syndrome symptoms with the relaxation response. Obstet Gynecol. 1990 Apr. 75(4):649-55. [Medline].
Lam RW, Carter D, Misri S, et al. A controlled study of light therapy in women with late luteal phase dysphoric disorder. Psychiatry Res. 1999 Jun 30. 86(3):185-92. [Medline].
Krasnik C, Montori VM, Guyatt GH, Heels-Ansdell D, Busse JW. The effect of bright light therapy on depression associated with premenstrual dysphoric disorder. Am J Obstet Gynecol. 2005 Sep. 193(3 Pt 1):658-61. [Medline].
Parry BL, Cover H, Mostofi N, et al. Early versus late partial sleep deprivation in patients with premenstrual dysphoric disorder and normal comparison subjects. Am J Psychiatry. 1995 Mar. 152(3):404-12. [Medline].
Blake F, Salkovskis P, Gath D, et al. Cognitive therapy for premenstrual syndrome: a controlled trial. J Psychosom Res. 1998 Oct. 45(4):307-18. [Medline].
Busse JW, Montori VM, Krasnik C, Patelis-Siotis I, Guyatt GH. Psychological intervention for premenstrual syndrome: a meta-analysis of randomized controlled trials. Psychother Psychosom. 2009. 78(1):6-15. [Medline].
Lustyk MK, Gerrish WG, Shaver S, Keys SL. Cognitive-behavioral therapy for premenstrual syndrome and premenstrual dysphoric disorder: a systematic review. Arch Womens Ment Health. 2009 Apr. 12(2):85-96. [Medline].
drospirenone and ethinyl estradiol (YAZ®) [package insert]. Wayne, NJ: Bayer Health Care Phamaceuticals. 2007. Available at [Full Text].
Pearlstein T, Steiner M. Non-antidepressant treatment of premenstrual syndrome. J Clin Psychiatry. 2000. 61 Suppl 12:22-7. [Medline].
Andersen AN, Larsen JF, Steenstrup OR, Svendstrup B, Nielsen J. Effect of bromocriptine on the premenstrual syndrome. A double-blind clinical trial. Br J Obstet Gynaecol. 1977 May. 84(5):370-4. [Medline].
Kullander S, Svanberg L. Bromocriptine treatment of the premenstrual syndrome. Acta Obstet Gynecol Scand. 1979. 58(4):375-8. [Medline].
Graham JJ, Harding PE, Wise PH, Berriman H. Prolactin suppression in the treatment of premenstrual syndrome. Med J Aust. 1978 Nov 4. 2(3 Suppl):18-20. [Medline].
Werch A, Kane RE. Treatment of premenstrual tension with metolazone: a double-blind evaluation of a new diuretic. Curr Ther Res Clin Exp. 1976 Jun. 19(6):565-72. [Medline].
Harrison WM, Endicott J, Nee J. Treatment of premenstrual dysphoria with alprazolam. A controlled study. Arch Gen Psychiatry. 1990 Mar. 47(3):270-5. [Medline].
Schmidt PJ, Grover GN, Rubinow DR. Alprazolam in the treatment of premenstrual syndrome. A double-blind, placebo-controlled trial. Arch Gen Psychiatry. 1993 Jun. 50(6):467-73. [Medline].
Eriksson E. Serotonin reuptake inhibitors for the treatment of premenstrual dysphoria. Int Clin Psychopharmacol. 1999 May. 14 Suppl 2:S27-33. [Medline].
The Medical Letter. Which SSRI?. Med Lett Drugs Ther. 2003 Nov 24. 45(1170):93-5. [Medline].
Steiner M. Recognition of premenstrual dysphoric disorder and its treatment. Lancet. 2000 Sep 30. 356(9236):1126-7. [Medline].
Brown J, O' Brien PM, Marjoribanks J, Wyatt K. Selective serotonin reuptake inhibitors for premenstrual syndrome. Cochrane Database Syst Rev. 2009 Apr 15. CD001396. [Medline].
Steiner M, Steinberg S, Stewart D, et al. Fluoxetine in the treatment of premenstrual dysphoria. Canadian Fluoxetine/Premenstrual Dysphoria Collaborative Study Group. N Engl J Med. 1995 Jun 8. 332(23):1529-34. [Medline].
The Medical Letter. Fluoxetine (Sarafem) for premenstrual dysphoric disorder. Med Lett Drugs Ther. 2001 Jan 22. 43(1096):5-6. [Medline].
Yonkers KA, Halbreich U, Freeman E, et al. Symptomatic improvement of premenstrual dysphoric disorder with sertraline treatment. A randomized controlled trial. Sertraline Premenstrual Dysphoric Collaborative Study Group. JAMA. 1997 Sep 24. 278(12):983-8. [Medline].
Young SA, Hurt PH, Benedek DM, Howard RS. Treatment of premenstrual dysphoric disorder with sertraline during the luteal phase: a randomized, double-blind, placebo-controlled crossover trial. J Clin Psychiatry. 1998 Feb. 59(2):76-80. [Medline].
Steiner M, Hirschberg AL, Bergeron R, et al. Luteal phase dosing with paroxetine controlled release (CR) in the treatment of premenstrual dysphoric disorder. Am J Obstet Gynecol. 2005. 193:352-60. [Medline].
Steiner M, Ravindran AV, LeMelledo JM, Carter D, Huang JO, Anonychuk AM, et al. Luteal phase administration of paroxetine for the treatment of premenstrual dysphoric disorder: a randomized, double-blind, placebo-controlled trial in Canadian women. J Clin Psychiatry. 2008 Jun. 69(6):991-8. [Medline].
Freeman EW, Rickels K, Sondheimer SJ, et al. Nefazodone in the treatment of premenstrual syndrome: a preliminary study. J Clin Psychopharmacol. 1994 Jun. 14(3):180-6. [Medline].
Freeman EW, Rickels K, Yonkers KA, et al. Venlafaxine in the treatment of premenstrual dysphoric disorder. Obstet Gynecol. 2001 Nov. 98(5 Pt 1):737-44. [Medline].
Freeman EW, Sondheimer SJ, Sammel MD, et al. A preliminary study of luteal phase versus symptom-onset dosing with escitalopram for premenstrual dysphoric disorder. J Clin Psychiatry. 2005. 66:769-73. [Medline].
Shah NR, Jones JB, Aperi J, Shemtov R, Karne A, Borenstein J. Selective serotonin reuptake inhibitors for premenstrual syndrome and premenstrual dysphoric disorder: a meta-analysis. Obstet Gynecol. 2008 May. 111(5):1175-82. [Medline].
Kayatekin ZE, Sabo AN, Halbreich U. Levetiracetam for treatment of premenstrual dysphoric disorder: a pilot, open-label study. Arch Womens Ment Health. 2008 Jul. 11(3):207-11. [Medline].
Wyatt KM, Dimmock PW, Jones PW, Shaughn O''Brien PM. Efficacy of vitamin B-6 in the treatment of premenstrual syndrome: systematic review. BMJ. 1999 May 22. 318(7195):1375-81. [Medline].
Thys-Jacobs S, Starkey P, Bernstein D, Tian J. Calcium carbonate and the premenstrual syndrome: effects on premenstrual and menstrual symptoms. Premenstrual Syndrome Study Group. Am J Obstet Gynecol. 1998 Aug. 179(2):444-52. [Medline].
Facchinetti F, Borella P, Sances G, Fioroni L, Nappi RE, Genazzani AR. Oral magnesium successfully relieves premenstrual mood changes. Obstet Gynecol. 1991 Aug. 78(2):177-81. [Medline].
Walker AF, De Souza MC, Vickers MF, Abeyasekera S, Collins ML, Trinca LA. Magnesium supplementation alleviates premenstrual symptoms of fluid retention. J Womens Health. 1998 Nov. 7(9):1157-65. [Medline].
Budeiri D, Li Wan Po A, Dornan JC. Is evening primrose oil of value in the treatment of premenstrual syndrome?. Control Clin Trials. 1996 Feb. 17(1):60-8. [Medline].
Brauser D. Progesterone, Anxiety Affect Premenstrual Dysphoric Disorder. Available at http://www.medscape.com/viewarticle/812792. Accessed: October 28, 2013.
Dell DL. Premenstrual Syndrome, Premenstrual Dysphoric Disorder, and Premenstrual Exacerbation of Another Disorder. Clin Obstet Gynecol. 2004 Sep. 47(3):568-575. [Medline].
Gingnell M, Morell A, Bannbers E, Wikström J, Sundström Poromaa I. Menstrual cycle effects on amygdala reactivity to emotional stimulation in premenstrual dysphoric disorder. Horm Behav. 2012 Sep. 62(4):400-6. [Medline].