Obstetrics & Gynecology & Family Medicine
Premenstrual Syndrome (PMS) and Premenstrual Dysphoric Disorder (PMDD)
Premenstrual syndrome (PMS) refers to a set of recurring physical, behavioral, and psychological symptoms that occur cyclically during the luteal phase of the menstrual cycle (7 to 14 days before menstruation) and disappear within the first few days of menstruation; these symptoms are severe enough to interfere with daily activities and interpersonal relationships, with no underlying psychiatric or somatic cause that can fully explain them. With a prevalence of 30–40% of women of childbearing age for mild to moderate forms, and 3–8% for severe forms (premenstrual dysphoric disorder—PMDD), PMS is one of the most common gynecological complaints in primary care. Its pathophysiology is multifactorial and not yet fully understood: fluctuations in estrogen and progesterone levels during the menstrual cycle—which are normal in all women—interact with central (primarily the serotonergic system and the GABAergic system via the neurosteroid metabolites of progesterone—allopregnanolone) in an abnormally amplified manner in predisposed women, leading to changes in mood, pain sensitivity, and autonomic regulation. The severity of symptoms is independent of measured hormone levels (hormone levels are normal in PMS—it is the brain’s sensitivity to these normal fluctuations that is altered). Premenstrual Dysphoric Disorder (PMDD)—recognized as a distinct diagnostic entity in the DSM-5 since 2013 — represents the most severe form of the PMS spectrum and is characterized by predominant dysphoria (severe depression + anxiety + emotional lability + severe irritability) that significantly impairs social and occupational functioning, requiring active medical management.
Clinical symptoms
- Psychological and behavioral symptoms: Irritability + anger + emotional lability (crying + mood swings) + anxiety + inner tension + feeling overwhelmed + difficulty concentrating + depression + guilt + loss of interest in usual activities + hypersomnia or insomnia + changes in appetite (cravings + desire for sweets + salt)
- Physical symptoms: Breast pain and tenderness (cyclical mastalgia) + abdominal bloating + water retention + lower limb edema + pelvic pain + headaches + migraines (catamenial migraines) + joint and muscle pain + acne + fatigue + bowel transit issues
- Characteristic temporal nature: Spotting during the luteal phase (7–14 days before menstruation) + progressive worsening until menstruation + rapid improvement within 2–4 days after the onset of menstruation + absence of symptoms during the follicular phase (symptom-free period post-menstrually)
Diagnostic Criteria for PMDD (DSM-5)
- Criterion A — Temporality: In the majority of menstrual cycles, at least 5 symptoms must be present during the last week before menstruation, disappear within the first few days of menstruation, and be absent during the week after menstruation.
- Criterion B - At least 1 predominant affective symptom: Marked emotional lability (tears + sensitivity to rejection) + irritability + marked anger + depressed mood + feeling of hopelessness + anxiety + tension + feeling at the end of one's rope + at least 1 of these 4 symptoms must be present
- Criterion C — Additional symptoms: At least 5 symptoms in total, including the following: decreased interest in usual activities + difficulty concentrating + fatigue + change in appetite + hypersomnia or insomnia + feeling overwhelmed + physical symptoms (breast tenderness + bloating + headaches + joint pain)
- Criterion D — Impact: symptoms associated with clinically significant distress or impairment in social, occupational, or school functioning
- Criterion E — Prospective Confirmation: Symptoms must be prospectively documented over at least 2 symptomatic cycles (daily symptom diary) to confirm cyclicity + DRSP (Daily Record of Severity of Problems) or PMTS questionnaires are validated tools
ℙ️
The daily symptom journal over 2 consecutive menstrual cycles is the essential diagnostic tool for confirming PMS/PMDD. It allows for the establishment of luteal cyclicity of symptoms (gradual increase premenstrually + free interval postmenstrually) and the elimination of chronic depressive or anxious disorders that would worsen in the premenstrual period rather than true PMS. Underlying chronic depression that worsens in the luteal phase does not constitute PMDD—the treatment will be different.
Treatment — Phased Approach
| Bearing | Treatment | Efficiency and comments |
|---|---|---|
| First line — Hygiene and dietary measures | Regular physical activity (150 min/week) + caffeine reduction + alcohol + salt + refined sugar + diet rich in complex carbohydrates + relaxation techniques + stress management + regular sleep + psychoeducation | Moderate improvement + limited evidence but no adverse effects + should be continued in combination with any pharmacological treatment + aerobic exercise is the best-documented intervention (20–30% reduction in symptoms) |
| 1st line — Supplements (light forms) | Calcium carbonate 1,000–1,200 mg/day (best evidence) + vitamin D 1,000 IU/day + magnesium 200–400 mg/day (luteal phase) + vitamin B6 50–100 mg/day | Calcium: 48% reduction in symptoms (Thys-Jacobs study) + particularly breast tenderness + depression + bloating + magnesium: reduces water retention + headaches + vitamin B6: moderate improvement in mood symptoms (Cochrane meta-analysis) + safe at these doses |
| Second line - SSRIs (moderate to severe forms - SPM + TDPM) | Sertraline 50–150 mg/day + or fluoxetine 10–20 mg/day (Sarafem® — FDA-approved for PMDD) + or escitalopram 10–20 mg/day + or paroxetine CR 12.5–25 mg/day continuously or intermittently (luteal phase only — day 14 to menses) | Most effective treatment for PMDD + 60–70% reduction in emotional symptoms + response often seen as early as the first cycle (faster than for depression — different mechanism) + intermittent dosing (luteal phase) as effective as continuous dosing for certain SSRIs (sertraline + fluoxetine) + fewer side effects with intermittent dosing + side effects: nausea + sexual dysfunction + insomnia |
| 2nd line — Oral contraceptives | Drospirenone + ethinyl estradiol 20 mcg (Yaz® + Yazmin® — 20/4 formulation — 24 active days + 4 placebo days) → drospirenone has antimineralocorticoid (reduces water retention) and antiandrogenic properties + FDA approved for PMDD | Proven effectiveness on physical symptoms (bloating + breast tenderness) + moderately improved mood symptoms + option if contraception is desired simultaneously + conventional oral contraceptives can worsen or improve PMS depending on the individual → 3-cycle trial |
| 3rd line — GnRH agonists (very severe refractory forms) | Leuprolide (Lupron®) + or nafarelin + or goserelin → ovarian suppression → medical amenorrhea → disappearance of PMS symptoms + hormone add-back (estrogen + progesterone) recommended after 6 months to prevent bone loss | Highly effective (nearly 100% %) + but associated with side effects of artificial menopause (hot flashes + vaginal dryness + bone loss) + high cost + use limited to 6 months + used on an ad hoc basis to confirm the diagnosis or in preparation for surgical oophorectomy |
| Other options | Spironolactone 25–100 mg/day during the luteal phase (water retention + bloating) + alprazolam 0.25 mg PRN during the luteal phase (severe anxiety — risk of dependence + cautious use) + buspirone 10–30 mg/day (anxiety without risk of dependence) | Spironolactone: effective on physical symptoms + little impact on affective symptoms + alprazolam: reserved for forms with severe anxiety + strict intermittent use + risk of dependence if used daily |
Differential diagnosis
- Major depression with premenstrual worsening Depression present throughout the cycle + worsened in the luteal phase -> NO free window in post-menstrual -> continuous antidepressant treatment
- Generalized Anxiety Disorder Chronic non-cyclic anxiety: Symptom diary shows absence of characteristic cyclicity
- Endometriosis: Pelvic pain + dyspareunia + severe dysmenorrhea → can overlap with PMS → gynecological examination + ultrasound + laparoscopy if suspected
- Primary dysmenorrhea Menstrual pain starting with menstruation (not before) → NSAIDs + contraceptives + not to be confused with PMS pelvic pain starting in the luteal phase
- Thyroid pathologies: Hypothyroidism + hyperthyroidism → can mimic or worsen PMS symptoms → systematic TSH in the workup
Medical consultation recommended
Consult a doctor if premenstrual symptoms significantly interfere with work, interpersonal relationships, daily activities, or if thoughts of self-harm appear during the premenstrual phase. PMDD is associated with an increased risk of self-destructive behaviors during the luteal phase and requires active medical management, including SSRIs. For the diagnosis of PMS/PMDD, symptom journal prescription, and initiation of appropriate treatment (calcium, SSRIs, contraceptives), Clinique Omicron offers medical consultations at its service points in Quebec and via telemedicine. To make an appointment, visit cliniqueomicron.ca.
Consult at Clinique Omicron
Clinique Omicron's doctors and Nurse Practitioners (NPs) diagnose PMS and PMDD through detailed medical history and prospective symptom journaling over 2 cycles. They differentiate PMDD from underlying chronic depression, initiate lifestyle and dietary measures, and supplements (calcium + magnesium + B6) for mild forms. They prescribe SSRIs for moderate to severe forms (PMDD), suggest oral contraceptives (drospirenone) if contraception is desired, and refer to gynecology or psychiatry for refractory forms or those with significant psychiatric comorbidities. Consultations are available at multiple service points in Quebec and via telemedicine. To book an appointment, visit cliniqueomicron.ca.
The content of this page is for informational purposes only and is not a substitute for medical advice from a doctor or gynecologist. A diagnosis of PMS/PMDD is based on prospective symptom documentation over at least 2 cycles—a diagnosis based solely on retrospective symptom recall is insufficient. If thoughts of self-harm emerge premenstrually, consult a doctor without delay.
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