Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD): Clinical sciences

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Introduction0:00–0:57

Premenstrual syndrome, or PMS and premenstrual dysphoric disorder, or PMDD are disorders that are characterized by cyclically occurring physical and affective symptoms that impair daily functioning.
PMS is associated with symptoms such as irritability, mood swings, lethargy, and bloating, that occur during the luteal phase of the menstrual cycle, and resolve during or shortly after menstruation.
On the other hand, PMDD is a type of depressive disorder characterized by severe and sometimes disabling changes in affect, like mood lability, irritability, dysphoria, and anxiety, that also occurs during the luteal phase and resolves with onset of menses.
While the pathophysiology is not entirely understood, it’s likely multifactorial, and could be explained by an increased sensitivity to normal fluctuations in estrogen and progesterone levels that occur during the menstrual cycle.
Now, when a patient presents with a chief concern suggesting PMS or PMDD, your first step is to obtain a focused history and physical examination.

Focused H&P0:57–1:38

Keep in mind that diagnosis of these premenstrual disorders is by exclusion, so before making your diagnosis, be sure to rule out other possible causes of your patient’s symptoms such as other mood disorders or medical conditions, such as thyroid disorders, anemia, depression, anxiety, and substance use.
In addition, your patient should have experienced symptoms during most of their menstrual cycles over the past year, and ideally confirmed with at least two months of prospective monitoring with a symptom diary or calendar.

Premenstrual syndrome1:38–3:49

Okay, let’s start with PMS. Your patient will typically report symptoms that are cyclic in nature, because they typically follow their monthly cycle that begins with the luteal phase and ends with the onset of menstruation.
Symptoms are both physical and affective, and include bloating, breast tenderness, irritability, mood swings, lethargy, anxiety and tension, and feelings of rejection.
With these findings, you can diagnose PMS. Treating PMS requires a blended, holistic approach that best meets the needs of your patient through shared decision-making, and should be based on individual goals of care.
To start, offer education about the condition; and provide dietary counseling, including calcium supplementation, which is especially important in adolescent patients; and discuss the benefits of regular physical activity such as aerobic exercise, yoga, or Pilates.
Also recommend cognitive behavioral therapy, which is beneficial in addressing symptoms through relaxation techniques, problem-solving skills, and stress management.
As far as pharmacotherapy goes, physical symptoms of PMS can be treated with over the counter non-steroidal anti-inflammatory drugs, or NSAIDs, such as ibuprofen.
If moderate to severe affective symptoms are present, selective serotonin reuptake inhibitors, or SSRIs, such as sertraline, paroxetine, and fluoxetine can be used.
For the treatment of overall symptoms, combined oral contraceptives, or COCs are typically used. These can be taken either cyclically starting with the luteal phase or taken continuously throughout their cycle.
Now, here’s a clinical pearl! COCs have added beneficial effects, such as reducing menstrual bleeding and cramping, and improving acne.
Remember, though, that COCs are a form of contraception, so their use should be limited to those who desire protection against pregnancy.
Additionally, while COCs can reduce symptom severity and functional impairment, they may not be effective in decreasing mood symptoms.
Okay, now let’s discuss PMDD. Like PMS, patients with PMDD will typically report a cyclic recurrence of symptoms beginning with the luteal phase and resolving with the onset of menses.

Premenstrual dysphoric disorder3:49–7:26

In contrast to PMS, however, patients with PMDD report severe, sometimes disabling symptoms, which can have profound effects on daily function.
Now, to meet the criteria for diagnosis, your patient must have at least one of the following marked symptoms: affective lability that includes mood swings, feeling suddenly sad or tearful, or experiencing an increased sensitivity to rejection; irritability, anger, or interpersonal conflicts; depressed mood, feelings of hopelessness, or self-deprecating thoughts; and anxiety, tension, or feeling like they are on-edge.
In addition, one or more of the following symptoms must also be present, to reach a total of five symptoms when combined to the previous list of symptoms.
These include a decreased interest in usual daily activities; subjective difficulty with concentration; lethargy, easy fatigability, or a lack of energy; marked changes in appetite, including overeating or specific food cravings; hypersomnia or insomnia; sense of being overwhelmed or out of control; and physical symptoms including breast tenderness or swelling; joint or muscle pain; and a sensation of bloating or weight gain.
If your patient meets these criteria, you can diagnose PMDD. As with PMS, treatment for PMDD requires a blended, holistic approach that best meets the needs of your patient through shared decision-making, and should be based on individual goals of care.
So, offer education on premenstrual symptoms; provide dietary counseling, including calcium supplementation; and provide counseling on the benefits of regular physical activity and cognitive behavioral therapy.
Also like PMS, physical symptoms of PMDD can be treated with over the counter NSAIDs, such as ibuprofen; and affective symptoms can be treated with SSRIs.
SSRIs can be taken continuously, cyclically, or a combined approach where the SSRI is taken daily with an increased dose the week prior to menstruation.
Additionally, COCs can help with most symptoms, except for depressed mood. Here’s another clinical pearl!
The most abundant and highest quality evidence supports COCs over other hormonal options like the patch, vaginal ring, and progesterone only choices.
While the only FDA-approved COC for treatment of PMDD are drospirenone-containing COCs, many non-drospirenone-containing COCs are also effective.
Now, for severe, refractory cases in adult patients, a gonadotropin-releasing-hormone, or GnRH, agonist is an option. If used, it should be combined with hormonal add back therapy to address the adverse hypoestrogenic effects on bone mineral density and vasomotor symptoms.
Keep in mind that this treatment is not recommended for adolescents due to concerns about long-term effects on bone health.
Another treatment option is a bilateral salpingo-oophorectomy, or BSO, with or without a hysterectomy. This option should be reserved for those who have failed medical management and have been counseled on the risks and irreversibility of the procedure.
In addition, a trial of a GnRH agonist is advised prior to surgery to help predict your patient's response to a BSO. Alright, as a quick recap… PMS and PMDD are both characterized by cyclical physical and affective symptoms that can cause interruption in daily functions.

Review7:26–8:03

These symptoms start in the luteal phase of the menstrual cycle, and resolve during or shortly after menstruation. Treatment options include education about the condition, dietary counseling, including calcium supplementation, physical activity, cognitive-behavioral therapy, NSAIDs, SSRIs, and COCs.
In refractory cases, GnRH agonists or BSO can also be