Premenstrual Syndrome

Updated: Feb 19, 2021
  • Author: Megan A Moreno, MD, MSEd, MPH; Chief Editor: Andrea L Zuckerman, MD  more...
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Practice Essentials

Premenstrual syndrome (PMS) is a recurrent luteal-phase condition characterized by physical, psychological, and behavioral changes of sufficient severity to result in deterioration of interpersonal relationships and normal activity. Premenstrual dysphoric disorder (PMDD) is considered a severe form of PMS. [1, 2]  PMDD is listed as a mental disorder in the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5), whereas PMS is not. [3]

Signs and symptoms of premenstrual syndrome

The symptoms of PMS usually cluster around the luteal phase of ovulation and resolve when menses begin. Symptoms may be divided into five basic categories—anxiety, craving, depression, hydration, and other.

See Presentation for more detail.

Diagnosis of premenstrual syndrome

Usually, no physical findings are specifically helpful in establishing the diagnosis of PMS. If an adolescent presents during the luteal phase, she may have mastalgia or edema of the breasts or legs.

It is important to rule out other conditions that cause erratic or dysphoric behavior before diagnosing PMS.

See Workup for more detail.

Treatment of premenstrual syndrome

Medical care of PMS is primarily pharmacologic and behavioral, with an emphasis on relief of symptoms. Selective serotonin reuptake inhibitors (SSRIs) are commonly considered suitable first-line therapy for premenstrual disorders. Because of the difficulty in treating PMS and the variations in response to treatments experienced by patients, complementary and alternative strategies have been explored for patients with PMS.

See Treatment and Medication for more detail.


Pathophysiology and Etiology

The definitive cause of PMS is unknown. Incorrect older theories about the causes of PMS include estrogen excess, estrogen withdrawal, progesterone deficiency, pyridoxine (vitamin B6) deficiency, [4] alteration of glucose metabolism, and fluid-electrolyte imbalances. Current research provides some evidence supporting the following etiologies:

  • Serotonin deficiency is postulated because patients who are most affected by PMS have differences in serotonin levels; the symptoms of PMS can respond to selective serotonin reuptake inhibitors (SSRIs), which increase the amount of circulating serotonin
  • Magnesium and calcium deficiencies are postulated as nutritional causes of PMS; studies evaluating supplementation show improvement in physical and emotional symptoms
  • Women with PMS often have an exaggerated response to normal hormonal changes; although their levels of estrogen and progesterone are similar to those of women without PMS, rapid shifts in levels of these hormones promote pronounced emotional and physical responses
  • Other theories under investigation include increased endorphins, alterations in the gamma-aminobutyric acid (GABA) system, and hypoprolactinemia [5, 6, 7]
  • The results of a large longitudinal study carried out by Bertone-Johnson et al suggested that the experience of abuse (emotional, sexual, or physical) in early life places women at higher risk for PMS in the middle-to-late reproductive years [8]


United States statistics

Symptoms of PMS have been reported to affect as many as 90% of women of reproductive age sometime during their lives. Nearly 20% of women experience PMS; approximately 10% are affected severely. Studies indicate that 14-88% of adolescent girls have moderate-to-severe symptoms. Another 3-5% of women meet the criteria for PMDD. PMDD is reported to affect 3-8% of women of reproductive age.

Two risk factors for PMS are obesity and smoking. Research reveals that women with a body mass index (BMI) of 30 or above are nearly three times as likely to have PMS than women who are not obese. Women who smoke cigarettes are more than twice as likely to have more severe PMS symptoms. [9, 10, 11, 12, 13]

Age- and sex-related demographics

By definition, only females are affected. PMS affects women with ovulatory cycles. Older adolescents tend to have more severe symptoms than younger adolescents do. Women in their fourth decade of life tend to be affected most severely. PMS resolves completely at menopause. [14]



Inability to maintain normal activities is part of the definition of this condition; hence, morbidity is related to loss of function. Complications of PMS may include school absence and behavioral problems. PMS and PMDD have been associated with a higher risk of bulimia nervosa. [15]  PMS may also be associated with an increased risk of future hypertension. [16]

Most PMS symptoms worsen with the patient's age until menopause; thus, little good news can be given to severely affected adolescents.


Patient Education

Because PMS may cause major morbidity for the adolescent, providing patient education regarding alternative therapies that may alleviate some symptoms is important.

Behavioral counseling and stress management may help the patients regain control during times of high emotionalism. Relaxation techniques may also help. Areas of stress should be identified. Relaxation techniques such as yoga, biofeedback, and self-hypnosis may be beneficial. Regular exercise often decreases the symptoms of PMS. Patients should be counseled to avoid salt, caffeine, alcohol, and simple carbohydrates.

For patient education resources, see the Women's Health Center, as well as Premenstrual Syndrome (PMS).