Understanding Premenstrual Disorders

In my practice it is quite frequent that I hear women reporting various levels of emotional and physical discomfort around their periods. Severity of symptoms may differ from cycle to cycle, and so does the ability to function at a regular, so-called base level. Indeed, during reproductive years women go through various hormonal fluctuations, not just within their monthly cycle, but also after pregnancy as well towards the end of the reproductive stage, in perimenopause.

Levels of main sex hormones: estrogen, progesterone, and their biproducts fluctuate within a menstrual cycle and are thought to be responsible for physical and psychological disturbances reported within a month. The link between phases of menstrual cycle, ovarian function and physical and psychological disturbances was first described in the early 20th century as “tension with emotional symptoms and worsening of medical conditions premenstrually.” Yet there is still a debate over the nomenclature of these conditions. It appears that sensitivity to hormonal fluctuations in a subset of women, rather than the absolute level of hormones, is responsible for triggering symptoms.

Nowadays we tend to categorize premenstrual disorders in the following groups:

Mild premenstrual molimina: Normative
Premenstrual Syndrome (PMS): Present in 20-30% of women
Premenstrual Dysphoric Disorder (PMDD): Present in 1.2%-6.1% women

Some physical and emotional discomfort is present in most women and is not pathological nor does it lead to functional impairment. However, when symptoms are more severe, PMS or PMDD may be diagnosed.

PMS (much more common) is categorized by several physical and/or emotional symptoms that are present 10-14 days before the menstruation and abate as menstruation begins. Those symptoms lead to some impairment during those couple of weeks, but women deny any symptoms during at least one week in a month. PMS can be diagnosed only based on physical symptoms present.

PMDD (rarer) leads to a higher level of impairment. As per criteria listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM 5), a woman has to experience at least one symptom from the following list:

  • Marked affective lability (e.g. mood swings; feeling suddenly sad or tearful; increased sensitivity to rejection)
  • Marked irritability or anger or increased interpersonal conflicts
  • Marked depressed mood, feelings of hopelessness, or self-deprecating thoughts
  • Marked anxiety, tension, feelings of being “keyed up,” or “on edge”

In addition, one (or more) of these symptoms must be present for diagnosis, to reach a total of five symptoms when combined with symptoms listed above:

  • Decreased interest in usual activities
  • Subjective difficulty in concentration
  • Lethargy, easy fatigability, or marked lack of energy
  • Marked change in appetite; overeating; or specific food cravings
  • Hypersomnia or insomnia
  • A sense of being overwhelmed or out of control
  • Physical symptoms such as breast tenderness or swelling, joint or muscle pain, a sensation of bloating, or weight gain

Self report is not sufficient in order to establish a diagnosis. Mood and/or physical symptoms recordings have to be done during at least 2 consecutive cycles (and symptoms severity should be scored 1-5).
Symptoms that are more commonly reported are: bloating, breast tenderness, food carving, mood swings, lethargy, irritability and anger, anxiety and tension. Those recordings are then analyzed and discussed with a provider in order to establish a diagnosis.

It appears that PMS and PMDD have been more common in Caucasian women, and those with history of obesity, or significant weight fluctuations, nicotine use, and specific dietary habits (low intake of potassium, zinc, iron).

Various lines of treatments have been suggested and applied.


  • Exercise (little evidence)
  • CBT (cognitive behavioral therapy)
  • Consumption of complex carbohydrates in premenstrual phase.


  • Vit B6 100mg/day
  • Vitex Agnus (chasteberry) 20-40mg/daily
  • Calcium supplements 500-1000mg daily
  • Vit D3 2000 IU daily


  • Serotonin reuptake inhibitors (SSRIs): administration either throughout the cycle, or only for 10-14 days during the luteal phase (before menstruation)
  • Oral contraceptive pills with at least 24 days (not 21 days as usually prescribed) of active ingredients and 4 days of placebo

On order to be diagnosed, both PMS and PMDD should stand alone, and not be a part of another psychiatric condition. Approach to treatment should be individualized, meeting women’s needs and expectations and and at times conducted in collaboration with a gynecologist.

Note to patients: The information included in this article is for educational purposes only and is not intended to be a substitute for medical treatment by a health care professional. Because of unique individual needs, the reader should consult his or her personal physician to determine the appropriateness of the information for the reader’s situation.