• Credits
  - Section Writer: Dr. Om J Lakhani
  - Section Editor: Dr. Om J Lakhani

• Q. What are the components of Premenstrual syndrome (PMS)?

  • Physical characteristics
  • Psychological characteristics
  • It must be severe enough to interfere with day to day life

• Q. When does Premenstrual syndrome (PMS) occur?

  • It occurs in the second half of the menstrual cycle

• Q. What is premenstrual dysphoric disorder?

  • Severe form of Premenstrual syndrome (PMS) in which psychological characteristics predominate
  • Generally, if the symptoms are mainly behavioral/psychological- the diagnosis of PMDD is more likely than PMS

graph TD
		A[Premenstrual syndrome]
		A --> B1[Physical features]
		A --> B2[Psychological features]
		B2 --> |Severe|C[premenstrual dysphoric disorder]

• Q. Is it common for all women to experience some distress during this menstrual phase?

  • Yes
  • All women do experience some degree of discomfort
  • However, it should be labeled as PMS only if it is severe enough to cause economic and/or social dysfunction

• Q. According to ACOG, what are the criteria for PMS?

  • 1. It should occur circa 5 days before the menstrual bleed (Luteal phase)
  • 2. Must last for 3 or more consecutive cycles
  • 3. Includes physical and psychological (behavioral) component
  • 4. Must be severe enough to cause economic and/or social dysfunction

• Q. What is the diagnostic criteria for PMS?

  • At least one each of the Physical or Behavioural symptoms listed below must be present
  • Must be present at least 5 days before the menses
  • And must be present for at least 3 consecutive cycles
  • Must be severe enough to cause economic and/or social dysfunction
  • Affective symptoms
    • Angry outbursts
    • Anxiety
    • Confusion
    • Depression
    • Irritability
    • Social withdrawal
  • Physical symptoms
    • Abdominal bloating
    • Breast tenderness or swelling
    • Headache
    • Joint or muscle pain
    • Swelling of extremities
    • Weight gain

• Q. What is the DSM-5 criteria for the diagnosis of PMDD?

  • Timing of symptoms
    • A) In the majority of menstrual cycles, at least 5 symptoms must be present in the final week before the onset of menses, start to improve within a few days after the beginning of menses, and become minimal or absent in the week post menses
  • Symptoms
    • B)One or more of the following symptoms must be present:
      • 1. Marked affective lability (e.g., mood swings, feeling suddenly sad or tearful, or increased sensitivity to rejection)
      • 2. Marked irritability or anger or increased interpersonal conflicts
      • 3. Markedly depressed mood, feelings of hopelessness, or self-deprecating thoughts
      • 4. Marked anxiety, tension, and/or feelings of being keyed up or on edge
    • C) One (or more) of the following symptoms must additionally be present to reach a total of 5 symptoms when combined with symptoms from Criterion B above
      • 1. Decreased interest in usual activities
      • 2. Subjective difficulty in concentration
      • 3. Lethargy, easy fatigability, or marked lack of energy
      • 4. Marked change in appetite; overeating or specific food cravings
      • 5. Hypersomnia or insomnia
      • 6. A sense of being overwhelmed or out of control
      • 7. Physical symptoms such as breast tenderness or swelling; joint or muscle pain, a sensation of "bloating," or weight gain
  • Severity
    • D) The symptoms are associated with clinically significant distress or interference with work, school, usual social activities, or relationships with others.
    • E) Consider Other Psychiatric Disorders The disturbance is not merely an exacerbation of the symptoms of another disorder, such as major depressive disorder, panic disorder, persistent depressive disorder (dysthymia) or a personality disorder (although it may co-occur with any of these disorders).
  • Confirmation of the disorder
    • F) Criterion A should be confirmed by prospective daily ratings during at least 2 symptomatic cycles (although a provisional diagnosis may be made prior to this confirmation). Exclude other Medical Explanations
    • G) The symptoms are not attributable to the physiological effects of a substance (e.g., drug abuse, medication, or other treatment) or another medical condition (e.g., hyperthyroidism).

• Q. Is there a genetic component of Premenstrual syndrome (PMS)?

  • Yes, it is believed to be due to the involvement of the ESR1 gene - estrogen receptor alpha 1 gene

• Q. Biologically, what is the reason for PMS?

  • It occurs in the Luteal phase of the menstrual cycle
  • Earlier, it was believed to occur due to changes in the estrogen and progesterone
  • However, it is now believed to occur because of changes in the neurotransmitter response (especially serotonin) in response to the hormones
  • Hence SSRI tend to be the most effective therapy for PMS

• Q. Treatment with which vitamin is helpful in the management of PMS?

  • Vitamin B6

• Clinical Features and diagnosis

• Q. Which are the typical behavioral or psychological symptoms of PMS?

  • Mood swings and irritability are the most common behavioral symptom of PMS
  • Others include
    • anxiety/tension
    • sad or depressed mood
    • increased appetite/food cravings
    • sensitivity to rejection
    • diminished interest in activities

• Q. What are the physical manifestations of PMS?

  • The most common are abdominal bloating and extreme fatigue
  • The others are
    • breast tenderness
    • headaches
    • hot flashes
    • dizziness

• Q. Are hot flashes also seen?

  • Yes.
  • PMS is the most common cause of hot flashes outside of Perimenopausal syndrome
  • Hence this must be included in the differential diagnosis of Hot flashes

• Q. Which endocrine disorder must be ruled out in patients with PMS?

  • Both hyperthyroidism and hypothyroidism need to be ruled out

• Q. How will you differentiate PMS from other mood disorders?

  • General mood disorder will occur irrespective of the menstrual cycle phase
  • PMS tends to occur mainly in the luteal phase
  • However, some mood disorders tend to worsen in the premenstrual/luteal period, and hence sometimes differentiation is difficult

• Q. At what age do these symptoms develop?

  • The symptoms of PMS can start right at the time of menarche and continue throughout the reproductive period, often ending during menopause
  • They are also more likely to have symptoms during the menopause transition
  • The symptoms may resolve during pregnancy as well.

• Q. Is there any laboratory test for establishing the diagnosis of PMS?

  • No
  • However, a thyroid function test must be done to rule out thyroid dysfunction

• Q. Are the menstrual cycles regular in women with PMS?

  • They are generally normal
  • However, they are more likely to experience irregular menses during the menopause transition period

• Q. What is the relation between OCP and PMS?

  • OCPs are sometimes used to treat PMS. However, they are not the first-line therapy
  • OCP can induce PMS like symptoms in some women

• Q. What questionnaire is used for diagnosis and monitoring of PMS?

  • Daily record of severity problem (DRSP) form
  • {{pdf: https://firebasestorage.googleapis.com/v0/b/firescript-577a2.appspot.com/o/imgs%2Fapp%2FMedical_learning%2FC5eXKgIWhe.pdf?alt=media&token=dcb7c24a-b008-4fe0-bb3f-27a96caa0654}}

• Q. How is the DRSP used to make the diagnosis of PMS?

  • Record the score for each item 1 on each day using the following scale of 1 to 6: 1 = not at all, 2 = minimal, 3 = mild, 4 = moderate, 5 = severe, 6 = extreme.
  • Add the scores in the column for the first day of menses. If the total score is less than 50, consider a diagnosis other than premenstrual syndrome.
  • If the total score is greater than 50, record two cycles of symptoms.
  • If more than three items have an average score of more than 3 (mild) during the luteal phase, add the scores of five-day intervals during the luteal and follicular phases.
  • A luteal phase score that is 30 percent greater than the follicular phase score indicates a diagnosis of premenstrual syndrome.

• Q. Enlist the differential diagnosis of PMS?

  • 1. Underlying mood disorder
  • 2. Hypothyroidism
  • 3. Hyperthyroidism
  • 4. Menopausal transition
  • 5. Substance abuse

• Treatment

• Q. Broadly, what are the treatment options for PMS?

  • 1. Lifestyle measure
    • Stress reduction
    • Meditation
    • Exercise
  • 2. SSRI
  • 3. OC pills (OCP)
  • 4. GnRH agonist with hormone addback

• Q. When are medicines given, and when are lifestyle measures alone considered?

  • Medications are given if the symptoms are severe enough to cause social and economic disturbances
  • Mild cases can be treated with lifestyle measures alone

• Q. How are the SSRI given in these cases?

  • The options for giving SSRI include:
    • 1. Daily
    • 2. Only during the luteal phase
      • Starting on day 14 of the menstrual cycle
    • 3. On SOS basis

• Q. What type of OC pills (OCP) are preferred in these cases?

  • Drospirenone-containing OCP are preferred in cases of PMS
  • In India brands are CRISANTA, YAMINI (Drospirenone 3mg, ethinylestradiol 30mcg) etc
  • Brands containing a low dose of Ethinyl estradiol (EE) in the dose of 20 mcg may also be considered. (CRISTANTA-LS, YAMINI-LS)
  • OCP are second-line after SSRI and can be used in patients desirous of contraception and/or not responding to SSRI
  • Generally, a shorter interval period of 4 days instead of 7 days has been suggested for PMS

• Q. What is done in severe cases not responding to the above therapies?

  • In severe cases, GnRH agonist therapy with adding back of hormones can be done

• Q. Which vitamin supplement is useful?

  • Vitamin B6

• Q. Which herbal supplement is useful?

  • Vitex Agnus-Castus (Chasteberry)

• Q. Which SSRI can potentially cause weight gain?

  • Paroxetine

• Q. Which drug of the above group can cause severe withdrawal symptoms?

  • Venlafaxine can cause withdrawal symptoms