Diagnostic Considerations

Premenstrual dysphoric disorder (PMDD) is underdiagnosed and undertreated. No definitive laboratory or ancillary procedure aids in the diagnosis, and no definitive treatment is available for the symptoms associated with the syndrome; however, many options are available.

Identifying and treating PMDD is challenging for a primary care physician. On one hand, a patient with another mood disorder may have preconceptions that she has premenstrual syndrome (PMS) or PMDD, and consequently, the diagnosis of PMDD may be incorrect. On the other hand, a patient may not have intellectually connected her symptoms to her menstrual cycle, and the diagnosis of PMDD may be missed. The correct diagnosis depends on extended patient education and correction of previously received misinformation.

In addition to the conditions listed in the differential diagnosis (see below), other problems to be considered include the following:

Eating disorder
Disorders of adrenal system
Catamenial migraine
Catamenial epilepsy
Collagen-vascular disease

Differential Diagnoses

Workup

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. [QxMD MEDLINE Link].
Endicott J. History, evolution, and diagnosis of premenstrual dysphoric disorder. J Clin Psychiatry. 2000. 61 Suppl 12:5-8. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Boyle CA, Berkowitz GS, Kelsey JL. Epidemiology of premenstrual symptoms. Am J Public Health. 1987 Mar. 77(3):349-50. [QxMD MEDLINE Link].
Grady-Weliky TA. Clinical practice. Premenstrual dysphoric disorder. N Engl J Med. 2003 Jan 30. 348(5):433-8. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Woods NF, Most A, Dery GK. Prevalene of perimenstrual symptoms. Am J Public Health. 1982 Nov. 72(11):1257-64. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Yonkers KA, Simoni MK. Premenstrual disorders. Am J Obstet Gynecol. 2018 Jan. 218 (1):68-74. [QxMD MEDLINE Link].
Bhatia SC, Bhatia SK. Depression in women: diagnostic and treatment considerations. Am Fam Physician. 1999 Jul. 60(1):225-34, 239-40. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Goodale IL, Domar AD, Benson H. Alleviation of premenstrual syndrome symptoms with the relaxation response. Obstet Gynecol. 1990 Apr. 75(4):649-55. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Kullander S, Svanberg L. Bromocriptine treatment of the premenstrual syndrome. Acta Obstet Gynecol Scand. 1979. 58(4):375-8. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Harrison WM, Endicott J, Nee J. Treatment of premenstrual dysphoria with alprazolam. A controlled study. Arch Gen Psychiatry. 1990 Mar. 47(3):270-5. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Eriksson E. Serotonin reuptake inhibitors for the treatment of premenstrual dysphoria. Int Clin Psychopharmacol. 1999 May. 14 Suppl 2:S27-33. [QxMD MEDLINE Link].
The Medical Letter. Which SSRI?. Med Lett Drugs Ther. 2003 Nov 24. 45(1170):93-5. [QxMD MEDLINE Link].
Steiner M. Recognition of premenstrual dysphoric disorder and its treatment. Lancet. 2000 Sep 30. 356(9236):1126-7. [QxMD MEDLINE Link].
Brown J, O' Brien PM, Marjoribanks J, Wyatt K. Selective serotonin reuptake inhibitors for premenstrual syndrome. Cochrane Database Syst Rev. 2009 Apr 15. CD001396. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
The Medical Letter. Fluoxetine (Sarafem) for premenstrual dysphoric disorder. Med Lett Drugs Ther. 2001 Jan 22. 43(1096):5-6. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Management of Premenstrual Syndrome: Green-top Guideline No. 48. BJOG. 2017 Feb. 124 (3):e73-e105. [QxMD MEDLINE Link].
Steinberg EM, Cardoso GM, Martinez PE, Rubinow DR, Schmidt PJ. Rapid response to fluoxetine in women with premenstrual dysphoric disorder. Depress Anxiety. 2012 Jun. 29 (6):531-40. [QxMD MEDLINE Link].
Yonkers KA, Kornstein SG, Gueorguieva R, Merry B, Van Steenburgh K, Altemus M. Symptom-Onset Dosing of Sertraline for the Treatment of Premenstrual Dysphoric Disorder: A Randomized Clinical Trial. JAMA Psychiatry. 2015 Oct. 72 (10):1037-44. [QxMD MEDLINE Link].
Ozgoli G, Selselei EA, Mojab F, Majd HA. A randomized, placebo-controlled trial of Ginkgo biloba L. in treatment of premenstrual syndrome. J Altern Complement Med. 2009 Aug. 15 (8):845-51. [QxMD MEDLINE Link].
Verkaik S, Kamperman AM, van Westrhenen R, Schulte PFJ. The treatment of premenstrual syndrome with preparations of Vitex agnus castus: a systematic review and meta-analysis. Am J Obstet Gynecol. 2017 Aug. 217 (2):150-166. [QxMD MEDLINE Link].
Canning S, Waterman M, Orsi N, Ayres J, Simpson N, Dye L. The efficacy of Hypericum perforatum (St John's wort) for the treatment of premenstrual syndrome: a randomized, double-blind, placebo-controlled trial. CNS Drugs. 2010 Mar. 24 (3):207-25. [QxMD MEDLINE Link].
Cronje WH, Vashisht A, Studd JW. Hysterectomy and bilateral oophorectomy for severe premenstrual syndrome. Hum Reprod. 2004 Sep. 19 (9):2152-5. [QxMD MEDLINE Link].
Ismaili E, Walsh S, O'Brien PMS, Bäckström T, Brown C, Dennerstein L, et al. Fourth consensus of the International Society for Premenstrual Disorders (ISPMD): auditable standards for diagnosis and management of premenstrual disorder. Arch Womens Ment Health. 2016 Dec. 19 (6):953-958. [QxMD MEDLINE Link].

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Author

Thwe T Htay, MD, FACP Associate Professor of Medicine, Medical Skills Course Director, Department of Medical Education, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

Thwe T Htay, MD, FACP is a member of the following medical societies: American College of Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

Amy HoangAnh Doan, MD Resident Physician, Department of Pediatrics, University of Texas Health Science Center at Houston, McGovern Medical School

Amy HoangAnh Doan, MD is a member of the following medical societies: American Medical Association, National Med-Peds Residents' Association, Texas Medical Association

Disclosure: Nothing to disclose.

KoKo Aung, MD, MPH, FACP Professor of Internal Medicine and Associate Academic Dean, Vice President, Texas Tech University Health Sciences Center at El Paso, Paul L Foster School of Medicine

KoKo Aung, MD, MPH, FACP is a member of the following medical societies: American College of Physicians, Society of General Internal Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Ana Hategan, MD, FRCPC Associate Clinical Professor, Department of Psychiatry and Behavioral Neurosciences, Division of Geriatric Psychiatry, McMaster University School of Medicine; Geriatric Psychiatrist, St Joseph's Health Care Hamilton, Canada

Ana Hategan, MD, FRCPC is a member of the following medical societies: Canadian Academy of Geriatric Psychiatry, Canadian Coalition for Seniors' Mental Health, Canadian Psychiatric Association, International Psychogeriatric Association, Ontario Medical Association, Royal College of Physicians and Surgeons of Canada

Disclosure: Book royalties and/or honoraria for articles from American Psychiatric Publishing, Springer, and Current Psychiatry.

Acknowledgements

Ronald C Albucher, MD Chief Medical Officer, Westside Community Services; Consulting Staff, California Pacific Medical Center

Ronald C Albucher, MD is a member of the following medical societies: American Psychiatric Association

Disclosure: Nothing to disclose.

John Carrick, MD Consulting Staff, Department of Psychiatry, Flagstaff Medical Center

John Carrick, MD is a member of the following medical societies: American Association for Geriatric Psychiatry

Disclosure: Nothing to disclose.

Romeo Papica II MD Staff Physician, Premier Physicians

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Sections Premenstrual Dysphoric Disorder
Overview
Presentation
DDx
Workup
Treatment
Guidelines
Medication
References

Premenstrual Dysphoric Disorder Differential Diagnoses

Diagnostic Considerations

Differential Diagnoses

References

Tables

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